Durians

It’s that season again!!! With all the rain in the earlier part of the year, I would think that there would not be any durians this year. I am, thankfully, wrong.

I used to be a big fan of this stinky fruit but some where along the line, when I was studying in India for 6 years, I lost the craving for it (replaced by cravings for Alfonso mangoes!!!). I remember my dad used to buy a whole basket load of them for us and we would be eating it for breakfast, lunch, tea, dinner and supper; for days!

Not anymore, the fruit has become an expensive commodity.

I still buy them, occasionally, mainly for my wife and kids who seem to love it. It’s a joy seeing them enjoying the delicacy. Nowadays all I can eat are perhaps 2 or 3 seeds of them. No worries, they polish off the rest soon enough.

Sat, 300607 @ 0712; thank you Lord, for the weekend.

Hung on Hung Up

I did a non-randomised, non-controlled study on the “hung up” answer I got from the students in the exam yesterday. What I did was, I asked the present Semester 6 students here (meaning a couple of months ago, they were in Semester 5, just like the students in the exam yesterday) the same question I asked in the exam…

And voila! Everyone answered correctly!

I asked if they have ever heard of the answer “hung up” and one student said it was NOT learnt from a book or the teaching video; rather it was from notes passed down from seniors!

Whoever the senior was, he did a lot of damage. And I bet not a few are cursing him!

Yesterday, I asked the last student in the exam the same question (secretly hoping that I would get the desired correct answer). He answered:

“HANG UP”.

Yes, I think I will do just that…

Fri, 290607 @ 1720; and Hallelujah, the weekend is HERE!!!!

Exam Bloopers 6

Disclaimer: The following entry is not meant to ridicule; rather it is meant to educate and for some light hearted banter. If you disagree, kindly press Alt-F4.

Day 2 of exams saw me in a station where a ‘simulated patient’ has a thyroid problem and the task of the students was to elicit the following:

1. Features suggestive of thyroid problems on general inspection.

2. Look for lid lag.

3. Look for fine tremor.

4. Elicit the biceps reflex.

5. Tell me what kind of reflex to expect in hypothyroidism.

Let me write the bloopers according to the structure above.

Introduction

Student: What is your name?

Patient: Beng* (name changed to protect patient’s identity)

Student: Can I call you Ah-Beng ah? Can?

Sad to say, almost all the students failed to address the patient properly. Most simply called him ‘Beng’; only one or two respectly addressed him as ‘Mr. Beng’.

Another student said:

“I am going to examine you and YOUR neck”. (as if the patient and his neck has disconnected)

General Inspection

Like a programmed robot, almost all students began their presentation with the following words:

“The patient is alert, conscious, communicative, not in obvious pain, not in respiratory distress, no discoloration… (actually a lot of students had no idea we were asking for features consistent with thyroid problems)

Of course others were more creative, in addition to the above, they also mentioned:

“the patient also has no discharge, ulcerations, sinuses, dilated veins”

“the patient has no gadgets attached” (I wonder what gadgets the student had in mind?)

“the patient looks a bit shy”

“the patient is not cold intolerant…because he did not button his shirt”

“he does not look agitated, angry, annoyed, anxious, depressed, excited…”

“he looks slightly bored” (ho hum….how true)

“there is no frightening facies”

“he doesn’t look scared”

“he is not frightening”

“he does not appear to be suffering from any discoloration” (Hard to imagine anyone actually suffering from discoloration!)

“he has no thinning of hair (and proceeded to play with the patient’s hair!)”

Looking for Lid Lag

For some reasons, a lot of students used the ‘H’ test to look for lid lag. As far as I know, the ‘H’ test is used to look for ophthalmoplegia.

One student gave this instruction:

“I want you to look at my finger and follow my eyes” (ooo, multitasking!!!)

Looking for fine tremor

One student asked the patient to stretch out his hands, placed a paper on the fingers of both hands and proceeded to stare at his watch (because they were instructed to wait 15 seconds). I asked him if he was looking for tremors in his watch.

Another student gave this instruction:

“I want you to stretch out your hands, and close your mouth” (the student wanted to say “close your eyes”)

Eliciting the Biceps Reflex

“it won’t hurt because you see the hammer is made out of rubber”

“I am going to hit you with this”

Many students continued to hit the tendon over and over again when they did not get the desired reflex. A few were clever enough to use ‘reinforcement’ by asking the patient to clench his teeth. Still, there were some who continued to whack and whack even after they have obtained the reflex! I just want to say that reflex being a reflex, it will diminish with each subsequent whacking, so whacking till the skin is bruised isn’t going to help.

Naming the reflex in hypothyroidism

The correct answer was “slow relaxing reflex” or “delayed relaxation”

There seemed to be a lot of Madonna fans among the students, as one after another boldly proclaimed the answer is a “HUNG UP REFLEX“. Frankly I have never heard of this term before. The students, when asked, told me that they learnt it either from their seniors, their friends, a book (but they cannot tell me which book) and finally, the video in the teaching session. Hmm, I must inquire about this video, maybe it does feature Madonna!!!

Still, I gave marks to those to explained correctly what they meant by ‘hung up’. Some thought it meant the arm will be hunged in mid-air after a whacking, others thought both the contraction and relaxation phase are slow, still others thought that only the contraction is slow. Many stated that the reflex will be absent in hypothyroidism which may be true but definitely not unique to just this condition.

Funnily a number of students didn’t even know who Madonna was when I mentioned her! Gosh, I feel so old (and I don’t even like Madonna!).

And that was Day 2.

But the biggest blooper of all is this…there is a Day 3 (gasp!!!), because the Day 1 exam had to be declared null and void due to some ‘discrepancies’.

Fri, 290607 @ 0805; so glad to be back doing clinical work.

Exam Bloopers 5

Disclaimer: The following entry is not meant to ridicule; rather it is meant to educate and for some light hearted banter. If you disagree, kindly press Alt-F4.

I was in KL yesterday as an examiner for the Sem 5 exams. The scenario was simple. The patient is a young man who complains of pain in his left hip. The student’s task was to measure the lower limbs to look for ‘true shortening’. This is done by first squaring the patient’s pelvis (aligning the pelvis so that there will not be any tilt) and then the measurement is taken from the Anterior Superior Iliac Spine (ASIS – the front most knob of your hip bone if you are to touch yourself) to the medial malleolus (or the bony prominence in the inner aspect of your ankle).

Most of the students performed the task easily. Most of them had difficulty in locating the ASIS, mainly because the ‘patient’ was wearing a pair of shorts and another pair of boxers inside. Because of shyness or whatever, most students did not tug the pants low enough to get a good feel of the ASIS, or they did, the boxers stayed stubbornly on!

As a result, we have these scenarios:

1. The patient’s limb length was anything between 92 cm to 102 cm as measured by the students, depending on how much of the pants and boxers were caught in between the measuring tape! A discrepancy of 10 cm! It was actually a bit hilarious to see the patient ‘growing’ either taller or shorter with each subsequent student!

2. One student tugged the pants (and boxers) so hard, we saw the…., you know, briefly; and the ‘patient’ jumped, pulled up his pants and said “I think that will be enough!”.

3. Another student forgot to get the ‘patient’s  name during introduction and ended the examination by saying “Thank you patient!”.

Other bloopers I overheard other examiners commenting about were:

1. A student forgot to bring his watch and he was asked to count the pulse rate. So, in desperation, he grabbed hold of the patient’s hand and used the patient’s watch to time the heart rate! Creative and quick thinking indeed but not very professional I’m afraid.

2. One student was heard swearing “Oh Sh*t!! Oh Sh*t” repeatedly when he could not put on a pair of surgical gloves.

In my station, after measuring the limbs, the students were then asked to check on the mobility of the lower limbs. One student performed the task very well but her language pronounciation needs some work. She went:

“I am going to ezamine you now okay? Can you prease rift your light reg over your reft reg. Gud. Now rift yor reft reg over yor light reg. Ok, now frex yor light reg to your chest. The lange is geelo to wan hanrud twenty deglee. Now frex the reft reg too. Okay. The lange oso geelo to wan hanrud twenty deglee. Now prease open yor light reg. It is geelo to forty fai deglee. Now open yor reft reg also. Lange oso same. Now prease frex yor reg. I turn now the reg to inside. Extelal lotation is geelo to thirty deglee. Now I turn out. Intelal lotation also thirty deglee. Now I do other reg oso. Same. Now prease turn over. Now rift yor reg high up. Extension is geelo to forty deglee. Same also other reg. Gud! Gud!”

That’s it for day one. I wonder if I should talk about Day 2. Scared people get offended!

Thurs, 280607 @ 1530; the exams are over. Time to head on home.

HIV Bloopers – The Facts

After my HIV Bloopers entry yesterday, I did a bit of googling to look for some facts regarding the HIV situation in Malaysia. The first site I went to was the Malaysian AIDS Council website but I was disappointed that there was hardly any data on Malaysia! Sheesh!

I got more information from the Department of Public Health, Ministry of Health’s website. As of 2006, Malaysia has 58,300 HIV + patients, 18,400 with AIDS and 9,760 deaths due to AIDS. Another good site to read would be the United Nations Development Programme website.

An outdated, but still valid, report from WHO states that the first HIV patient in Malaysia was diagnosed in 1986. In that report, 96% of HIV patients were males, 73% were intravenous drug users, and 73% of HIV patients belong to the Malay ethnic group.

And finally, a good site to check out is the AVERT website but unfortunately it has no information on Malaysia (but Thailand, Laos and Vietnam are featured).

Rural Wonders

These pics were taken during my recent trip to Batu Pahat for the IMU Community Health Project there. One thing that I enjoy in a ‘kampung’ surrounding are the sights, sounds and the air feels a lot fresher than the pollution choked stuff we breathe inhale in the city.

Of course there were flies, lots of it! And it contributed to a lot of us coming down with acute gasteroenteritis!

And there were other insects as well.

And water lilies growing in the ‘parit‘ (trench). The village was called Parit Simpang Enam. Every other village’s name starts with the word ‘Parit’ and not surprising too because thes trenches were everywhere.

The water in these trenches is typically a clear brown fluid, probably from the dark brown soil that Johor is famous for. This soil (tanah gambut) is especially ideal for planting pineapples.

A pineapple field.

Juicy succulent pineapple!

I am told this fruit is called ‘Pulasan’ which is related to rambutans. I am told it turns a shade of red when it ripens and the flesh is much sweeter than rambutans.

The flower pod of a tree (which I do not know the name!).

Flowers upon a tall, tall tree.

More of the same flowers…

Which eventually will become ‘petai’!!! I love petai!!! Unfortunately I can’t indulge in it often as it makes the breath and other bodily waste products stink to high heavens! It is reputed to have ‘kidneys cleansing effects’.

It was mid-day when I took this pic. Rain clouds were already gathering by then. Thankfully, it only poured in the night, thus not jeopardising the health camp.

Thurs, 280607 @ 1005; still in KL for another day of exams.

HIV Bloopers

From the VIP’s mouth at the recently held event I went to:

“I am an expert in HIV. I’ve been invited to so many international meetings. In fact, I just came back from Geneva. In Malaysia, the HIV situation is very serious. From 4 cases in 1974, now it has reached 200,000 cases. I don’t know what the scenario will be like in 2020 if nothing is done!”

From my patient’s mouth:

“I am HIV positive. I was tested in 1984 and diagnosed with the disease. I swear to God I am positive!!!”

Can you spot the bull?

Wed, 270607 @ 1356; lunch break is over and the exam starts again!

Update: You can read more about HIV/AIDS and ‘Patient Zero’ here: Patient Zero.

Pride

Over the weekend I was in Batu Pahat to participate in the IMU Community Health Project there held at one of the Javanese village there which has been ‘adopted’ by IMU. Actually ‘participate’ is probably not the best word to use as my involvement this time was limited to just observing and also to contribute in terms of ideas, unlike the last time. The reason being that the students were evidently totally in control of the whole thing; from the planning to setting up the health camp to the actual day programs!

I felt a bit redundant really but being there helped me assess how my own project, which will take off next month, would be like and also helped me gather some ideas on how to run the latter as well as to anticipate potential problems.

Most of all, I felt really proud as I watched all the pre-doctors (they will graduate in a couple of weeks) go about interacting with the villagers, talking to them, counselling, giving health talks, participating in communal games, staying overnight with the assigned adopted families and soldiering on despite the acute gastroenteritis that most of them (including me) suffered due to food prepared in less than ideal settings. (Many of themspent the night visiting the toilets in the dark! One student told me he felt something fell on his back as he was going about his business in the dark but he didn’t dare look at what it was!)

I would say the event was a great success.

 You can view a slide show here

Wed, 270607 @ 1310; in KL to take students for exam and wondering if I should blog about it.

Soya Bean Monsters

I’ve been inundated with work for the last 2 weeks, even with work overlapping into 2 weekends. I feel totally exhausted. There are lots to do some more. It’s the end of the day and I’ve had a long day; ward rounds in the morning preceded by a long meeting, 2 teaching sessions stretching well into the lunch break, a short quick lunch followed by another teaching session. Phew…

I’d wanted to blog about the recent Community Health Project I was involved in last weekend in Batu Pahat but the photos were taking too long to load (I really really hate Streamyx); so that will have to wait.

Let me share these pics with you. My son, Ryan, is at an age where he is totally mesmerised by superheroes and evil monsters. I took a peek at what he has been drawing and I saw these drawings of his.

I know, they look more like cute mutated soya bean monsters than evil ogres but hey, so what, I think they look real grand!

Tues, 260607 @ 1748; I need a holiday….

First Do No Harm

I took 2 students for their end of posting exam. It was a sudden decision as I saw my schedule and was dismayed to discover that my schedule is packed till the end of the month. So I broke the unexpected news to my students and told them the exam will be held today.

I hate to be caught by the unexpected and I expect my students to have felt the same too. One thing I learnt at the Team Building Training that I went to recently was this: Expect the unexpected! And my mentors used to tell me in my MMed days: “If you are not ready by the exam date, then you are not ready“. A few more days of reading up or even an hour spent trying to cramp last minute info into the poor brain isn’t going to help.

One of my student reads this blog often. Let me say that I have no intention to discredit the student nor do I harbour any malice with what I am about to write.

The patient assigned to this student was simple enough. A young man who, because of some problem with his fiancee, first thought of jumping off the Penang bridge and then eventually swallowed 30 tablets of paracetamol (PCM).

The student did very well, taking a very detailed and relevant history and was able to correlate the physical and laboratory findings well (with minimal prompting); until I asked him this:

Me: So, how would you manage this patient?

Student: I would lavage his stomach.

Me: Even after 16 hours of ingestion?

Student: Yes, because by doing the lavage, it will traumatise him so much that he would think twice before taking PCM again.

Me: Is that in the textbook?

Student: No

Me: Then where did you learn this from?

Student: From some doctors.

I was ashamed when I heard his reply, not at the student, but at the things we, senior people, knowingly or unknowingly teach these young minds. To teach a medical student to inflict pain on a patient so that the patient will refrain from repeating the same ‘mistake’ is unacceptable.

I told the student that I would let the comment pass. I reminded him that as doctors, our job is to heal, not to inflict harm to the patient. We are to love our patients. So what if he is scared of taking PCM next time as a result of an unpleasant gastric lavage? He would just as soon try another method to end his life, as long as the root of his problem is not settled.

I always remember the words of a wise old sage:

FIRST DO NO HARM

Mon, 250607 @ 1817; it’s been a long day. 4 more days to the weekend! I need a break.