Ruffled feathers

Today, in the clinic a couple ruffled my feathers, metaphorically speaking. They were a discordant couple (meaning one is HIV positive while the other is not). The one who is positive was diagnosed with HIV about 10 years ago and subsequently was started on HAART (Highly Active Anti-retroviral Therapy) a few years later. Those days, HAART was not free and so, after about a year, she decided to stop.

Recently she came back to the clinic and asked to be started back on HAART. Some one saw her last week and started her on a normally used regimen. Unfortunately after taking the medications for 2 days, she decided to stop as she could not bear the side effects of the medications.

I was asked by the MO to see the patient and because she has had experience with HAART before, I had to ask her why did she stop her medications the last time. In the course of the conversation, her hubby who was beside her, decided to speak as well. Here are parts of the conversation:

Me: Do you remember which medications you were prescribed?
Wife (HIV+): No, I don’t remember.
Hubby (HIV-): I also don’t know, it was so long ago.
Me: Why did you stop your medications?
Hubby: Because the doctor told her to stop.
Me: Really? It’s hard to believe because no doctor will ask a HIV patient to stop his/her medication
Hubby: Yes, I am sure of it. It was in this clinic!
Me: Really? Here? What is the name of the doctor who asked you to stop?
Hubby: I can’t quite remember the name but I think it was Dr. XXX!!

All this while the wife was quiet. What really dissed me off was the fact that ‘Dr. XXX’ happens to be MY NAME! And this person who freely said my name didn’t even recognize who I am!

Me: Are you sure it is Dr. XXX?
Hubby: Yes, he told her to stop taking medicine.
Me: Don’t talk nonsense here. I AM Dr. XXX and I have been treating patients for the last 10 years and not once have I ever asked anyone to stop medications!
Hubby: Oh…..errrr…..well, it was so long ago! I can’t really remember..
Me: If you can’t remember, then do not simply say all kinds of untruthful things. I know every single patient I have treated either by name or face and I do not remember your wife.
Hubby: Err…ummm..

Later we discovered that the wife has decided to stop medications on her own accord and they made up the story just to cover up. They couldn’t care less whose name they maligned in the process!

Keeping my anger in check, I made some adjustments to her HAART regimen and after a bit of firm counseling, they left, by which time they were quite apologetic.

I just hope her new regimen works, otherwise, the going’s gonna get really tough.

There are many things a physician wants to know or expect from their patients. For me, one of them is complete truthfulness.

Fri, 300410 @ 1330

Climb with me?

I haven’t done much climbing this year and my legs are getting restless. So, if you are free on 8th May 2010 and would like to be ‘on top of the world’, join me and climb Gunung Datuk, at Rembau. The last time I was there and blogged about it was way back in July 2009, so it’s about time I go again.

Here are the details:

Date: 8 May 2010 (Saturday)
Time: 7.30 am, meet at IMU Seremban Foyer
What to bring: Click here.

Want to read up on what climbing Gunung Datuk is like? Click here.

So? What are you waiting for?

JOIN ME!!!

Thurs, 290410 @ 0700

Case #99: A man with diabetes

This 32-year-old man was recently diagnosed with Diabetes mellitus.

Here is his AXR:

Questions:

1. Identify the abnormality.
2. Name 3 causes for this abnormality.

Wed, 280410 @ 1630

9th Kg Angkat Mobile Clinic

Two Saturdays ago, I revisited the Orang Asli village (Kg Tekir, Labu , Negeri Sembilan) that IMU adopted way back in 2007, together with 40 students (31 medical and 9 nursing) to provide free health checks and education to the folks there.

This is the 4th year that I am heading this activity and planning each them have been a constant source of stress (so far I haven’t perforated my gut yet, so it’s ok).

I am putting up some photos here in a slide show, a new feature of WordPress that I want to try out. Hope it works.

This slideshow requires JavaScript.

Sometimes I feel I would be better off without having to plan these mobile clinics every 3-4 months but each time, at the conclusion of yet another well executed event, and seeing the tired but satisfied faces of my students and the happy faces of the villagers makes it all worthwhile.

Tues, 270410 @ 0700

An ethical issue

Last week I faced a similar situation faced by Dr Chase in the current season of HOUSE. If you are a follower of the medical series, you would know that Dr Robert Chase (Jesse Spenser) made a medical decision that would directly result in the death of a tyrannic dictator which would prevent the latter from committing genocide in his country, should he recover from a mysterious illness.

Two episodes down the line and we see Dr Chase grappling with a badly affected guilty conscience that began to sap all his energy and make him lose focus on his work. He tried to seek some kind of solace by asking for forgiveness from a Catholic priest in a confession box, only to be told by the latter to surrender to the police; something which Dr Chase refused to consider because he felt that what he did was right and justified. Still, his conscience pricked him every moment that he lived.

Now, I am not saying I killed anyone, intentionally nor do I need to rush to the nearest confession box to spill the beans to the sympathetic ears of a priest.

Last week I learned from a very reliable source that one of my HIV patient on treatment has decided to stop therapy (again) as he felt well and healthy. What was worst is that he now has a new girlfriend! Previously I have treated this man for tuberculosis, PCP, multiple genital ulcers and warts and he has been put on HAART (Highly Active Anti-retroviral Therapy) which he defaulted once or twice but we managed to get him back on track. Once his genital ulcers were so bad, you could see his nuts inside the scrotum! He also has a number of girlfriends whom he was having unprotected sex with, despite knowing his own status. I have seen his girlfriends, they were gorgeous!

The last time I saw this chick-magnet, he swore that he would be good.

Obviously swearing is overrated.

Hearing the news made me angry inside. I am treating a HIV+ man so that he can remain healthy and he uses his regained health to infect others!

Oh Gosh!!!

What do I do? Leave him to die, the next time he comes (as he will surely come) with another opportunistic infection or scrotal ulcer? That would be against the Hippocratic oath I took. Or should I treat this scum-bag and he gets well enough to go infect even more women? That would weigh heavily on my conscience.

Sigh….

What do I do?

Mon, 260410 @ 1400

Doctors who can’t read

Another thing that irks me, besides doctors who use coffee mugs to do fungal farming, are doctors who cannot read simple instructions, like this one pasted on the curtains (!) of a certain on call room:

The sign says ‘KINDLY DO NOT LEAVE ANY CLINICAL LINEN (BLUE ATTIRE) IN THIS ROOM. PLEASE SEND IT BACK TO THE PLACE YOU TOOK IT FROM’.

Unfortunately, the message failed to get through, for right below the sign was this pile of used clinical blue attire (actually it’s called Surgical Scrubs):

Some one even cheekily wrote, “No way Mary”, under the sign (I have no idea who Mary is).

Some on call doctors have a habit of taking surgical scrubs from the Operation Theater (OT), wear them throughout the night while on call (because they didn’t want to bring their own clothes) all over the hospital and just dump them in the on call room the next day. It’s a bad habit.

Personally, I feel that surgical scrubs should stay where they are supposed to be, namely the OT. What irks me even more are fellow doctors who come out of the OT wearing the scrubs to attend to patients in the ward or see referrals and then go back into the OT still wearing the same attire! God knows what infectious agents they have carried out from the OT into the wards and vice versa.

But then again, no one bothers. Sigh…

Fri, 230410 @ 0700

Culture & Insensitivity

It irks me greatly to find fellow doctors having the severe disability of being unable to clean up after themselves.

Take this for instance:

Last Tuesday, while hunting for a mug to have my morning dose of caffeine, I chanced upon this mug being left at the sink. I was told that the mug has been left there since the previous Friday and no one has bothered to clean it up.

Looking inside the mug, this was what I saw:

EeeeeewwwwWWW!!!!

The left-over beverage (coffee I think) has become culture media for a number of fungal colonies. Yuck!

Memo to self: Bring my own mug and hide it in a safe place so others can’t use it for growing fungus.

Thurs, 220410 @ 0755

S.I.

The other day a group of us, lecturers , were going through parts of the medical curriculum with the aim of improving it. One of the topic given to us on that day to improve upon was Surgical Infection.

The original author who penned the curriculum related to Surgical Infections decided to just shorten the 2 words to the 2 letter abbreviation: S.I.

Seated in the committee that day were lecturers from a number of medical disciplines. When we came to the question:

“What is the adverse effect of S.I.?”, a few of us could no longer suppress ourselves and burst out laughing like insane hyenas.

Why?

Because the abbreviation, S.I. means different things to different doctors.

To a physician, S.I. could mean either Subcutaneous Insulin or Sexual Intercourse!  Therefore, the adverse effect of S.I. to a physician could be hypoglycemia or a baby (or even sexually transmitted infections), respectively!

To an emergency medicine doctor, S.I. could stand for Self Inflicted (injury).

To a Rheumatologist, S.I. could stand for Sacro-iliac (joint).

A surgeon could take S.I. also to mean Serious Injury or Small Intestine.

In fact, if you care to look it up in the dictionary, S.I. could mean a whole lot of other things! LOL!

So, what does S.I. mean to you? Leave a comment here!

Wed, 210410 @ 1325

What if…

Over the weekend, one of the oldest member of my church was admitted for a stroke. Apparently he went to bed well but woke up the next day unable to move the right side of his body. He also lost the ability to speak and swallow.

I looked in on him this morning. While he could open his eyes when called, he could not respond verbally. His eyes were looking away to his left, the side of the lesion in his brain. His breathing was laboured as he could not bring out the phlegm accumulated inside his airways properly as he has lost the ability to cough. The right side of his body lays motionless.

I placed my fingers at his wrist. His pulse was strong but irregular. He was running a temperature and his pupils were pin-point size. Upon listening to his chest, I found his heart to be bigger than normal which was confirmed by an Xray.

An ECG quickly confirmed that he has atrial fibrillation, the condition where the heart’s rhythm is no longer regular. How long he had this problem is anyone’s guess. The CT brain confirmed a massive stroke on the left side of his brain, affecting the Broca’s area which controls verbal expression, thus robbing him of his speech. Not only that, because of the size of the stroke, half his vision has been taken away as well.

The diagnosis is fairly simple: His irregularly beating heart caused blood clots to form within the heart chambers and these clots were then sent right into the vessels supplying blood and oxygen to the brain. One particularly large clot must have occluded the middle cerebral artery, one of the major blood vessel supplying the brain, thus annihilating the entire area in the brain supplied by this vital vessel.

The road to recovery, if any, would be long, tedious and fraught with many dangers. If he survives the infection that he has now, we have to work at rehabilitating him, preventing bed sores, preventing future infections, preventing stiffness of the now-lifeless limbs, preventing malnutrition and many many other things.

I spoke to his family members, laying before them a very realistic possible outcome, to the best of my knowledge. They listened and took it all in, probably still too stunned to say anything beyond asking the few questions that came to their minds.

I see him every Sunday in church, even spoke to him a few times. I remember the steamed dumplings he served us when we went to sing carols in his house 2 Christmases ago.

Now he is reduced to being an invalid, unable to voice his needs and concerns, unable to attend to his personal needs; unable even to smile or speak.

I wish with all my heart I could undo what has happened.

I feel really really angry because I could have done something for him before this calamity struck.

What if I had the opportunity to feel his pulse, even for a moment, in the many Sundays that we met in church? I would have been able to diagnose the irregular rhythm and given his something to take which would reduce the risk of a stroke.

What if…what if…what if…..

Damn! What’s the point of a diagnosis if I cannot reverse it?

And now it’s too late.

Mon, 190410 @ 1936

Sarcasm

I am a sarcastic person. Some (my more diplomatic friends) call it razor-sharp wit but I know sarcasm is sarcasm, no hiding the truth.

I used to be worst. Marriage and age has mellowed me some what.

Still, there are times, especially when I am tired from being on call, when the old sarcastic self resurface and leave a trail of destruction…!!!

I exaggerated just now. There were no trails of destruction.

Take yesterday for example. The on-call duty the night before left me feeling quite tired and my senses a little dulled. Still, I had to do the morning rounds, see some referrals and then take 2 clinical teaching sessions with medical students, followed by a quick lunch and then another classroom teaching.

By the 2nd clinical teaching session, I was feeling very tired and it being past lunch time was no help. It was during this session that I discovered that some students shy from taking history or examining a patient with HIV infection mainly because they are afraid of catching something infectious from them!!! It got me a little riled up.

And so one of the student blurted out this question:

Student: Sir, what kind of precautions should we take when taking history from HIV patients?

And I, with my mind already on auto-pilot, replied (rather sarcastically, I think, now in retrospect):

Me: Well, don’t kiss the patient. And not having sex with the patient would certainly help!

Strangely, the student was unperturbed. She went on to ask:

Student: But what if the patient has tuberculosis?
Me: Well, in that case, you should consider not breathing.

I can almost hear you say: Walaoyeh! So darn sarcastic la!
Yeah, I know. Sigh…

A little further on in the discussion, another student asked about the risk of getting sexually transmitted infections from oral sex.

Me: A person can get other STIs from oral sex such as syphilis and herpes simplex infections.
Student: What if the person has gonorrhoea?
Me: Frankly I really would not consider oral sex with some one who has a genital organ oozing with pus! Unless of course, the lights are off and you couldn’t see a darn thing!

I know, I know…double walaoyeh!

Since I can’t marry more, I guess I need to age more to mellow more.

To my students, sorry guys. Hope I didn’t offend anyone and if I did, it was because my morning caffeine fix did not kick in in time!

Fri, 160410 @ 0700