Untapped resources


Yesterday I received a notice when I tried to access DynaMed on my iPhone – apparently the license will be expiring soon. This morning I contacted the librarian in the university that I work in to request for two registration codes to renew my subscription on both my iPhone and iPad.

To my horror, the librarian said she could only offer me ONE code because almost all the codes have been snapped up by medical students. That got me a little hot and bothered but then again, beggar can’t be chooser. I thanked her and promptly updated the subscription on my iPhone since it’s the device that I carry most often with me.

During the ward round this morning, I instructed a few medical students to look up a condition on their smart-devices and I casually mentioned “Try looking in DynaMed”.

Some students looked at me blankly as if I just spoke Martian! I then asked, “have you not heard of DynaMed”?

One of the student grinned at me sheepishly and said, “I have heard of it, I got the registration code…..(silence)..but I haven’t activated it!”

A few other students nodded in agreement.

After the round, I shot off an email to the librarian relating my experience. That got her hot and bothered.

I felt a little angry inside me because the registration codes are expensive and the university has spent a fortune to procure them but the recipients evidently do not realize the value of these codes that they possess!

I checked on the DynaMed website and here is the annual cost of a DynaMed license:

Physician: USD 395.00

Residence: USD 149.95

Licensed Medical Practitioner: USD 199.95

Student: USD 99.95

DynaMed has been ranked top point-of-care-tool in a number of studies, surpassing even the favourite-among-physicians which is Uptodate!

So, to all my students who have DynaMed registration codes and have not activated their accounts, please do so – because I have a list of your names (and your codes!) and I will track you down for not tapping into this precious resource!

PS: One of you won’t be able to activate your account because your code has been used for my iPad. :)

Case #102: The man with the foot ulcer


It has been a long time since I last produced an article containing a radiographic images. Here is one to add to the other 101 cases:

A 60-year-old man with diabetes mellitus presented with a non-healing ulcer on his left foot. Below are two images that belonged to him:

20120523-081427.jpg

20120523-081436.jpg

Questions:

1. What radiographic imaging was done for this patient?

2. What is the abnormality detected in the imaging scans?

230512 @ 0820

Anything but the truth


Not too long ago, a student asked me how do I know whether my patients are telling the truth during history taking.

Truth of the matter is, I don’t.

But experience has taught me to look out for certain tell-tale signs that a person may not have been entirely truthful. This is especially pertinent in HIV-medicine because the disease, 30 years on, is still very much a stigmata and taboo subject.

People want to avoid the truth because it is unpleasant.

I can recognize at least 4 types of half-truth or plain-lies tellers:

1. The vividly-detailed-story

Usually, in a crisis situation, things would happen so fast that the typical response of a person who has undergone the situation will be “It was all a blur”.

Not so for this patient whom I saw many years ago. This was how he told his story:

“I was at the parking lot of this (sic) shopping mall when suddenly a man in his late 30s appeared out of nowhere! He asked me for money and in his right hand, he was holding a 5 cc syringe with a 25 gauge needle. In the syringe was blood which the man claimed to be his blood and that he has HIV infection. When I refused him money, the man assaulted me and stabbed me with the needle which poked my left elbow before fleeing the scene! I could not retrieve the needle and syringe because he took it with him before fleeing!”.

Yeah, right…..

2. The coached-to-tell-a-story type

Sometimes the words that come out of the mouth of a patient are so incredulous, it’s impossible to be the truth. Like the words of a young underage girl who presented in advance pregnancy:

“Before you start your examination, I want to say clearly that I had sex with my father and I did it willingly!”, she said in a well-rehearsed poker face!

Yeah, right….

3. The in-denial-type

A patient, anxious to hide the truth, might offer more than necessary information, even information that is unasked for. Like the young man who was fairly recently diagnosed with HIV-infection from blood donation.

He came into my clinic room and before I could ask him anything, he blurted out:

“Doctor, I really don’t know how I got this infection. It’s impossible! I mean, I have never had sex. I have never had any blood transfusions and I never ever do drugs!I think maybe I got it from other people’s blood because I like to help victims of road traffic accidents.”

Yeah, right….

4. The fantasy-weaver

This type is simply not from this world. Like the guy who was diagnosed with both syphilis and HIV-infection during a routine health check who, without a hint of being aware of how ridiculous he sounds, said this:

“I believe I contracted these disease from the polluted air around me”!!

Yeah, right….

But really, whatever was the cause or origin of their infections, to me it does not matter. My job is not to dwell on HOW they got it but HOW to get them well and to keep them healthy.

So, whenever I get stories like these from patients, I don’t even raise an eyebrow. I simply nod my head and move on. :)

Gunung Berlumut


Uploaded from the Photobucket iPhone App
View from the peak of Gunung Berlumut

It has been a long while since I last blogged about mountain climbing. It wasn’t because I have not been climbing since I came back from Melbourne but it was because I was regularly climbing mountains that I have climbed before – Ledang, Angsi and Datuk; and really, there wasn’t much that one can write about repeatedly.

Until last week, that is.

Last weekend, together with a group of 19 people (6 from IMU), we conquered Gunung Berlumut (Berlumut: Moss) located in Kluang, Johor. Rising to a height of 1010 meters above sea level, it is the 195th tallest mountain in Malaysia according to Malaysian Traveller. This mountain is little known – a search on the internet revealed precious little. The recreational park at the foot of the mountain and the mountain are managed by the Forestry Department of the State of Johor. It’s also expensive to climb this mountain. We had to pay RM 150 for a permit and RM 120 for a guide (for every 25 climbers). Toll charges from Seremban to Ayer Hitam and back was RM 50 and the petrol cost RM 82.

We pushed off at an unearthly hour of 4.00 am in the morning last Saturday and drove on the PLUS highway heading south and exited the Ayer Hitam exit 2 hours later. We headed straight to Kluang town which took another 20-25 minutes of driving and stopped at the deserted Kluang Railway station, one of the oldest railway stations in the country.

Uploaded from the Photobucket iPhone App

Uploaded from the Photobucket iPhone AppUploaded from the Photobucket iPhone App

We then had to wait another 30 minutes for the famous Kluang Rail Coffee to open business. The wait was well worth it as the offerings there (awesome Kluang coffee, half boiled kampung eggs, toast layered with rich kaya and butter that melts in your mouth, simple and delicious nasi lemak and pulut himpit) was cheap and to-die-for!

The drive from the railway station to the base of the mountain was to take another 30 minutes. Consequently, we only started our climb at 9.00 am. The target was to reach the peak within 4 hours with a turn-around time at 1.00 pm.

Uploaded from the Photobucket iPhone App
The gateway to the mountain.

Uploaded from the Photobucket iPhone App
The hanging bridge which marked the starting of the trail.

896ead59, Uploaded from the Photobucket iPhone App
All the climbers, minus one who was taking a prolonged toilet break.

I’d like to write down my statistics for this climb (for future reference):

Ascend time: 3 hours 25 minutes.
Descend time: 2 hours 35 minutes.
Food eaten: A pack of fried rice, 2 bananas, 1 wafer, a pack of sunflower seeds.
Water consumed: 3000 ml + 500 ml of 100+
Total distance: About 12 km
Total height: 1010 meters

And for the record, contrary to what other blogs seem to imply, I found climbing Berlumut to be quite challenging. While the initial 2 km was like a walk in the park, the next 1 km of the climb was quite taxing as the slope inclined at a constant 45 degrees. Although the trail was well demarcated, it was made up of mostly exposed roots of big trees and because it rained earlier, the trail was also slippery.

Uploaded from the Photobucket iPhone App

At the 3 km point, we had a short reprieve. There are 2 rocks here with jutting edges. The locals called them Batu Bergigi (Rocks with Teeth).

Uploaded from the Photobucket iPhone App

After the 3 km, the trail eased a little but it wasn’t long before we had to ascend a long series of steep inclines, most of them over 80 degrees! This part of the trail was the hardest for me. It felt like an eternity before it finally ended. This part of the trail took up more than an hour and by then I was exhausted. While ascending this part of the trail, I was reminded of another torturous mountain I had climbed a few years ago because of the similarity of both trails, Gunung Nuang, which I swore I would never ever climb again!

d4202703, Uploaded from the Photobucket iPhone App

The steep trail terminated into a broad area devoid of vegetation. The place reminded me of Bukit Botak (Botak: Bald) on Gunung Ledang (Mount Ophir). This was the false peak (Gunung Nuang also had a heart-breaking false peak). One of my students, probably fearing that I might lose my way, drew a sign on the ground pointing to the start of the final ascend. :)

Uploaded from the Photobucket iPhone App

Unlike the trail before, the final trail to the peak was not well maintained. There were plenty of undergrowth and some parts were obscure and one could easily get lost if one was not careful. The beautiful thing about this final trail to the peak was that almost the entire trail was covered in a thick and luxurious layer of green moss! It’s really quite a sight to behold. :)

Uploaded from the Photobucket iPhone App

Uploaded from the Photobucket iPhone App

When the peak was finally reached (30 minutes hike from the false peak), I was sore and sorely disappointed. The area was small and cramped with many people (there was also a team of 20 climbers from Singapore on that day). To actually see anything, one has to climb up a sorry-looking boulder jutting out from the ground. From here, I admit the view was breathtaking! Unfortunately, since the boulder could only hold around 6 people at a time, one has to be patient to wait his/her turn for 5-10 minutes of breathtaking splendour!

Uploaded from the Photobucket iPhone App

I’m happy to say that all 19 of us reached the peak safely within the 4 hour period.

After a quick lunch and some photo-taking, we made a hasty descend, starting at 2 pm. Any delay might mean hiking down the steep slopes in failing light or darkness! After 2 hours and 35 minutes, my team reached the base. The others made it down safely not too long after (one team member tripped and fell several meters but thankfully only sustained superficial injuries).

Uploaded from the Photobucket iPhone App

Uploaded from the Photobucket iPhone App

Personally, I think the trail was really nice and very challenging. The flora and fauna along the way was fantastic.

Unfortunately the experience was marred by some things typically encountered in Malaysia:

1. The toilet facilities were awful and woefully inadequate. There were male and female sections. I can’t speak for the females but in the male toilet, there were only 3 stalls, one of which was blocked (read: overflowing with excrement!). The three urinals were smelly and dirty. There was no running water. The only source of water was from a large water tank which has sediments and cigarette butts inside! I had no choice but to shower using water from this tank. Some of my team members chose to bathe in the river instead.

2. The male Muslim prayer room was unkempt and again, had no running water for the ablution rites. The prayer room for females was locked.

3. There were flies everywhere! The two stalls which sold food and drinks were making a roaring business selling beverages and foods at exorbitant prices. The foods were exposed to the elements and there were plenty of flies on them! Monkeys were seen everywhere scavenging for food.

4. The entire area was ill-kept. The dustbins were overflowing with rubbish. Even the trail was littered with empty water bottles and food wrappers.

With the kind of money they charge for the climb, I would expect them to provide at least the clean basic necessities. I wonder where all the money collected went to!

So, was it a good climb? Yes! Definitely!

Would I go back again? Probably not. There are better mountains to climb with better facilities and at a cheaper rate.

One little heart beat at a time


I’m sharing with you a beautiful song sung by one of my favourite gospel singers.

The song got me all teary-eyed.

Mum, I hope that what I am today have made all the your sacrifices all worth while. And I hope my kids would grow up to be people who will make a difference, and make their mum proud.

Excuse me while I go wash my face. :)

Kept in the dark


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This morning, during the ward round, the daughter-in-law of a man repeated implored me to not tell the latter that he has hepatocellular carcinoma which has spread to his spine. He was admitted for progressively enlarging abdomen causing him much discomfort, the result of fluid accumulation in the peritoneal cavity because his liver no longer produce adequate amount of albumin to keep the fluid in the blood vessels from ‘leaking’ into the abdomen.

Earlier on, I had reviewed the patient and on hearing from the Medical Officer that the patient does not know his diagnosis, I took the daughter-in-law (DIL) aside and explained to her that I’d rather the patient knows his diagnosis AND the grave prognosis. This, in my opinion, would make his management a lot easier as he would know that he has a terminal illness and may want to make the most of what is left of his time on earth. In addition, he wouldn’t have to keep wondering why on earth the doctors cannot seem to make a diagnosis or possibly even vent his frustrations on the health personnel.

The DIL said she understood my concerns but she also said that the entire family knew about his condition but they have all made a pact to keep the man in the dark because “he has high blood pressure and may not be able to take the bad news”.

I went back to the patient and asked him a few question to gauge the extend of his knowledge of his condition. He said that he had been having abdominal distension for the last few months and he had been unwell. His appetite has diminished considerably and he has lost some weight. He also mentioned he was seen by a doctor not too long ago and after a scan, all he was told by the doctor was that he has a “small growth in the liver”. Beyond that he was clueless regarding the late-stage cancer that he has.

The DIL, fearing that I would spill the beans, followed me from bed to bed throughout the morning round (I wished my nurses would do what the DIL does!) and at the end of the round, approached me again, this time with the determined mission to extract a promise out of me that I will not tell her father-in-law the diagnosis! She even asked if I can cure her father-in-law! (She probably thought I’m a faith-healer or something).

I didn’t promise her anything but I did tell her that it is unlikely the condition can be cured.

I have always practiced the principle that the right of knowledge of the diagnosis belongs solely to the patient and whoever he chooses to reveal to. Unfortunately, what I have described here is the norm in Asian communities. Typically, everyone is aware of the diagnosis except the patient. This is sad.

I feel angry that, in the name of ‘concern’ or ‘love’, his family members have formed a conspiracy of silence and consequently deprived the man of some possibly meaningful last days. To me, this is not love or concern. It’s disguised cowardice.

Inwardly, I curse the initial doctor who pussy-footed with the diagnosis and helped create the conspiracy of silence.

I will not be part of this conspiracy. When I have a chance, I will gently ask the patient this question: 

“Would you like to know what is the matter with you? If yes, I’d like to explain it to you and help you go through it.”

Personally, if I have a terminal illness, I‘d like to know my condition and its prognosis. I’d like to make full use of my last days on this side of heaven in a meaningful way, and not spending it in bewildering frustrations.

Under the coconut


During a lull in my clinic last Friday (my patients tend to take their own sweet time coming to the clinic), I had a little chat with a few medical students who was in the room with me. The topic of conversation eventually drifted to politics – specifically Malaysian politics (read: DIRTY).

I was dismayed to discover that almost all of them had not registered themselves as voters! When asked why they have not registered, my dismay turned into disbelief!

One said, “I don’t need to vote because the guy who is in my hometown will sure win the election!”

Another said, “I do not have transport to go and register myself”.

Yet another said, “I don’t know where to register”.

One of them lamented, “Actually, we IMU students are not in touch with politics”.

That’s really sad.

I think my political awakening started when my ‘kertas am’ teacher back in secondary school said this to me:

“Be careful….for the day will come when the land you stand on will be taken away from you and you have no place to call home”!

As a student, I have always been very attuned to the local politics as well as international politics. When I was a medical student in India, I could name you the chief ministers of almost every Indian state, their political ideologies and their hanky-panky stuff.

While I was in Melbourne last year, I was keenly following the politics in Victoria – I could even engage in politic-talk with any Aussies there. I knew who was who and what they do or did.

Why? Because, politics, whether you like it or not, will impact our lives, sometimes and eventually in ways beyond our control. If bad politics are not nipped at the bud, it can grow into a 56-year-old uncontrolled corrupt beast!

Over the weekend, in Malaysia, we had the largest act ofAhimsasimilar to the non-violent resistance practiced by Mahatma Gandhi. Malaysians from all walks of life gathered in large numbers in many major cities in Malaysia and around the world, demanding for electoral reforms and a clean election. Unfortunately, the Bersih 3.0 sit-in-and-protest took a violent turn in the end. (At this point, politicians are doing everything from blaming everyone else to scrambling at damage-control). Ironically, the mainstream media hardly breathed a word about the event!

The crux of the issue is this: why would decent folks (about 250,000 of them, according to some sources), spend a Saturday weekend, all dressed in gaudy yellow, go for a sit-in-protest (and get gassed and shot at with tear gas canisters and chemical-laced dirty water)?

It’s because these people care about what is happening around them. They want a better future, if not for themselves, then, for the next generation to come. They want to see a better Malaysia.

One vote may be insignificant.

But many one-votes can become a formidable force.

Therefore, I urge you, my students, exercise your right as a citizen of this country. Do not allow apathy to rob you of a better future. You cannot stay under the coconut forever!

Differential diagnoses of a dirty toilet seat


Dear People-contemplating-to-visit-Malaysia,

To my eternal shame, a common sight, regardless of where you go, which will greet you in my country (if you happen to stop over in the land between Singapore and Thailand) is this:

20120426-214728.jpg

My differential diagnoses for the drops of urine on the toilet seat are:

A. Hypospadias
B. Benign Prostatic Hypertrophy
C. Vertical Diplopia (seeing double vision making it hard to aim straight)
D. Micturition-induced-seizure
E. Urinary incontinence

But the underlying sinister pathology for this malady is really this:

DEEP APATHY AND SELFISHNESS!

People who can’t clean up their own mess should just pee at a tree outside or use a rubber band.

Condoms online


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If some one was to, say lean over, and look at the computer monitor in my cubicle, he may immediately jump to the conclusion that I am up to no good!

Why else would people send me emails regarding supply of condoms?!

I confess that I have solicited for condoms via email – in fact, I asked for about 1500 of them!

And no, I do not have such a healthy libido as to consume that many prophylactics (I wish!).

Rest assured that the request, directed to the Malaysian AIDS Council, was for a good cause. These condoms are to be distributed (discreetly and upon request only) to some of the eligible patients in the Infectious Diseases Clinic. We have been doing this for years and the last consignment from the MAC is almost used up (it took us close to 1.5 years to distribute about 1000 condoms).

So, the next time you see me lugging a huge bag of condoms in the hospital, don’t stare and don’t ask. :)