Piercings

I had a bad morning. First it was the son who, as usual, was a pain to wake up and to get him ready for school – it’s enough to drive any loving parent into having homicidal thoughts and wishing I’d got a dachshund instead 8 years ago.

And then there’s the ward rounds which raised my temperature another few degrees. Because of the shift system that has been implemented, orders are conveniently forgotten or lost in translation as they do not get passed on to the next doctors in the next shift.

And so this morning, I encountered several pressure sores which have not (or never) been looked into, a swollen glans penis that no one noticed, no renal profile for a patient who was put on Vancomycin for the last 7 days, intravenous cannula that hasn’t been replaced for the last 5-7 days, blood results not traced for the last few days, social issues of patients not settled or resolved, etc.

It’s enough to blow a few cerebral vessels.

But then, in the darkest most unpleasant of situations, there will always be something to laugh about. It happened when I asked a medical student what those 2 peculiar rounded objects located at the nipple levels on the Xray of a 70-year-old patient were, his answer cracked me up.

“They are piercings!”, answered the students with a straight face.

LOL!!!

Imagine, a 70-year-old guy with nipple piercings! ROTFLOL!

I laughed so hard there were tears in my eyes.

In reality, the round objects are the metallic buttons on the ECG probes, but thanks for cheering up an otherwise dreadful morning.

‘Hematinics’ is a 4-letter-word

In my opinion, the word ‘hematinics’ should be consigned to the same category of other foul-four-letter-words; you know, like the ‘F’ word that rhymes with ‘Luck’ and the ‘S’ word that rhymes with ‘Hit’ and the ‘C’ word…. never mind, I think you get the picture.

Prescribing hematinics to patients admitted in the ward is probably one of the most abused medical practice in the hospital that I practice in. There are various ways in which this prescription is written but these 2 are the most common:

1. Hematinics 1/1 OD (meaning, 1 tablet of ‘hematinics’ a day)

2. FeSO4/Folate/B co/Vit C 1/1 OD (meaning a combo of medications containing iron sulphate tablet, folic acid, vitamin B complex and Vitamin C given once a day)

The word ‘hematinics’ is defined as ‘a medicine, as a compound of iron, that tends to increase the amount of hematin or hemoglobin in the blood’ (from Dictionary.com). In layman’s terms, it simply means an iron containing tablet that is given with the intention of raising the amount of red blood cells in the blood.

Herein lies the root of my unhappiness. In my hospital, this combination of medications is prescribed to almost everyone in the ward regardless of whether there is actually any evidence of deficiency of either red blood cells or iron store! In the not uncommon scenario where patients actually had deficiency of red blood cells (we call this ‘anemia’), little regard is given to what actually caused the anemia or even what kind of anemia the patient has.

Not all ‘anemia’ is caused by iron deficiency. Similarly, not all anemia is caused by deficiency in vitamin B or folic acid. The former gives a microcytic hypochromic picture (meaning, small and pale looking red blood cells) while the latter gives a macrocytic hypochromic picture (meaning, large and pale looking red blood cells) and they are mutually exclusive -  stuffing iron, B complex and folate down the throat of a patient without investigating the anemia the patient can only be interpreted as:

1. the prescriber* hasn’t a clue what hematinics are for.

2. the prescriber hasn’t a clue what disease the patient actually has and for lack of anything else to give, would prescribe the seemingly harmless panacea called ‘hematinics’.

3. the prescriber has a poor grasp of basic hematology.

*the prescriber here can range from house officers to medical officers, to specialists and even consultants!

But hematinics are not altogether harmless. For instance, iron tablets can cause hard blackish stool and constipation (by the way, the better iron formulation is ferrous fumarate and not ferrous sulphate!). Since these hematinics takes a long time for its effects to be evident and not instantaneous, I feel that it is prudent for proper investigations to be undertaken and once the cause of the anemia has been ascertained, the appropriate therapy can then be instituted.

The other fallout from writing such prescription is that the dosages are never written. The prescriber assumes the dispenser of medication (usually the nurses) knows how much of each tablet to dish out! This is a dangerous practice as an inexperienced dispenser may well overdose or under-dose a patient because the actual dosages were not succinctly written.

So, I am appealing to my fellow colleagues here…if you one of these habitual hematinics prescriber, let’s practice good and sensible medicine and avoid the imposing of often unnecessary extra pill burden on our patients as well as avoiding potential adverse effects from these medications.

There, I’ve said my peace. Another load off my chest. (the lab guys are next….)

Fungi on Angsi

Last month, I climbed Mount Angsi with a group of young people from church and with my wife and our 2 kids (which made it kinda historical as it was the first time we climbed together – climbing Broga Hill years back doesn’t count because a hill is a hill and not a mountain!).

We used a new route (it was new to me as I have never ascended the mountain using the Bukit Putus route before) and it proved to be much shorter and as enjoyable as the Ulu Bendul route. I was particularly impressed with the cleanliness of this route compared to the latter which is more often than not, littered with rubbish all the way to the peak!

Since my encounter with my fungi-loving-photographer friend, Dorothy, in Lorne, Australia; I kept my eyes peeled for fungi along this route. Thanks to showers in the days before the climb, there were plenty to photograph! I’d like to share some of the pictures here:

Aren’t they beautiful?!

The longevity gene

The longevity gene is pretty much evident in my family. My grandma became a centurion a few months ago and my dad turned 81 not too long ago. All his younger siblings are pretty much alive and kicking.

Barring the it of drooling saliva, my grandma is still going strong, being quite able to outrun a dog only a couple of years ago! Nowadays she isn’t so active anymore but she is still healthy with absolutely no medical problems.

My dad is like his mum. Despite smoking for more than 50 years (he quit a couple of years ago) and a prostate cancer scare many years ago, he remains very healthy – again with nary a medical problem! Both my dad and his mum attributed their good health to years of indulging in Guinness Stout!

Compared to them, I am at a severe disadvantage. I do not drink Guinness Stout – the strongest I could imbibe is a mild Malta drink! My generation is beleaguered with stress unknown to the previous generation – a polluted world, fast-food, information overload, work stress, family stress, political stress, affirmative action stress, global warming, and bills, bills, bills!!!

I turned 45 today. Compared to my centurion grandma and my octogenarian dad, they would probably say I have not even lived!

Oh but I have lived! And as I looked back in my life, there is much that I am thankful for. Sure, if given a chance, there are some things that I would probably do differently but by and large I wouldn’t change a thing. I’ve had a lot of education, travelled some, read a lot, met and made some real good friends, have loved and loved in return, got lost some times and found my way back, climbed a few mountains, lived in foreign places, got myself some good ol’ Christian faith, laughed, wept, cried, cheered, booed, smiled, frowned, gone skinny dipping and sun-tanned in the buff and did a whole lot of been-there-done-that-stuff!

It has been a good 45 years. Thank you, Lord!

I don’t know when’s my due date. I might live to be a centurion, although I kinda hope I don’t! It’s not a lot fun I reckon.

So, for the rest of my days, I will pray:

“Teach me to number my days that I may gain a heart of wisdom” Psalm 90:12

Jimbo and the radiologist

I was looking at the few blog post drafts that I never got around to finishing and came upon this one. I think I have kept this one in the can for the longest time but I think enough time has lapsed for me to tell this tale which happened during my 2nd year as a Master student.

At the time I was a medical officer in the nephrology unit. I was ordered by my boss to see the radiologist to get an urgent ultrasonograpy of the abdomen done for a patient with high fever and not responding to medications. We wanted to know if there was a collection of pus in the abdomen.

I looked at the roster to see who was the radiologist on call. I remember my colleague looking at the same roster beside me and then he went quiet for a while before turning to me and said:

“Good luck, you are gonna need it!”

Very ominous indeed; although I had no idea what he was talking about at the time.

It took me a while to locate the radiologist on call. I finally found her in the CT room reviewing some films. I approached her, greeted her and proceeded to explain the purpose of my visit – we needed an urgent ultrasound to rule out an intra-abdominal abscess.

She paid scant attention to what I was saying and at the end of my explanation, to my astonishment, she said:

“I DO NOT BELIEVE YOU! I WANT YOU TO SHOW ME THE PATIENT’S TEMPERATURE CHART!”

I was flabbergasted! I was stunned beyond words. And when I finally found my mouth, it was with a lot of self-control that I told her, through gritted teeth:

“Okay, please wait, I will go now to fetch the temperature chart”.

I was seething with anger as I brisk-walked all the way back from the radiology department to the nephrology ward (it’s a long walk if you know the layout of the University Malaya Medical Centre).

She was still there when I arrived shortly holding the patient’s temperature chart in my hands. I even brought the patient’s entire case notes, just in case she decided on a whim to ask for the laboratory tests results! The temperature chart showed high spiking temperature over a few days.

She held the chart and ruminated over it for a while before turning to me and said in a flippant sort of way:

“Yes, the patient needs an ultrasound but actually all my slots are fully booked! Why don’t you come back later in the evening and ask the radiologist on call for the evening!”

Again I was stunned – at her words, at the callous way she treated a fellow colleague (albeit a junior one) and the utter lack of concern for a very sick patient who needed intervention. I mean, if you knew all your slots were fully booked, why make me fetch the temperature chart?!!!

I am not sure if it’s because she woke up on the wrong side of the bed that morning, or she had an argument with a colleague or she had a bad time earlier for whatever reason but judging from the remark I received from my colleague while looking at the roster earlier, I reckon the nastiness was very much part and parcel of her moral fibre.

So, to you my dear high-and-mighty radiologist colleague, I hope and pray you would have realized the error of your ways and that what you were contributed to rot that is creeping into what was once a noble profession. I am dismayed and embarrassed by your unprofessional attitude and I hope you could seriously consider changing your ways.

There! That’s one old rant off my chest.

Tradition

Some things never change – like the fascination with candles and fire during the days leading up to the mid-autumn festival. Seeing my son lining his lighted candles on the porch’s floor reminded me of the time I was his age – I literally lighted up my house gate with hundreds of burning candles!
The next day, my livid dad gave me a shelling and ordered me to scrape off every bit of melted wax on the gate!
Tomorrow I will probably have to scrape off the wax from the floor but for now, it’s all good. Some traditions are to be kept alive.

Disowned

Much has been written about the oversupply of new doctors, like this well written article by a concerned medical student: Too many doctors, too few hospitals.

I said in jest to a group of medical students yesterday while taking them for bedside teaching: “If I close my eyes and walk, I’d likely walk into 10 house officers and if I throw a rock, I’d hit 5 of them!”

Actually, at the rate we are going, there won’t be any bedside space left for teaching – right now the hospital where I am working in serves as a teaching hospital to medical students from 1 private university, nursing students from at least 3-4 private and government-owned nursing colleges and physiotherapy students from similar number of institutions. When I walked into the ward in the mornings, I get a feeling that I am walking into a Jusco sale.

The reason I jested with my students was because I was trying to impress upon them the need to “shine and rise above the rest”, because despite the sudden rise of number of house officers, the number of training centres have more or less remained stagnant, likewise with the number of specialists/consultants to train them and similarly with the number of postgraduate places available; and this does not bode well for the nation.

We will (or already have) produce a generation of incompetent doctors who will be a danger to society.

When I came back from Melbourne 2 months ago, I discovered that I had 4 house officers assigned to the 2 cubicles that I usually perform my rounds. These 2 cubicles have 16 beds, giving an impressive ratio of one doctor to 4 patients! Since the beds were not often fully occupied, the ratio was much higher in most instances. There is a medical officer overseeing these 4 house officers and then there is me…so the doctor:patient ratio was indeed very impressive.

At least on paper it was.

I don’t want to go into details but suffice to say, I’d rather have 1 house officer who thinks and analyzes than many who merely act as scribes, penning down every word spoken by the medical officer or by me or what I would term as “palliative doctors” – prescribing Panadol for fever or Benadryl for cough, without much thought on why a patient has fever or cough to begin with!

And to add to the woe, these house officers are rotated between cubicles or wards every TWO weeks making it very difficult for me to train them. By the time I see something positive in them, they would have vanished to the next ward or cubicle!

Frankly I’d rather that house officers stay in a single ward or cubicles for a prolonged period of time instead of being moved around. Like they say, “a rolling stone gathers no moss”; likewise a junior doctor being constantly moved gains no knowledge or skills.

And then last week, the department started the shift system for house officers – basically now, medical house officers work in 2 shifts per day. I am not too clear about the way it works but I believe those who work 3 night shifts would be given the 4th day off being starting the day shift. It’s the ‘knee jerk’ reaction from the powers-that-be as a short term solution to the oversupply of young doctors.

Again on paper it looks good. Shorter working hours for young doctors (no one gives a hoot to the long working hours of more senior doctors), the massive amount of money saved because technically since these doctors are no longer “on call”, they are not paid call claims, and it clears the congestion in the wards.

All very good indeed.It’s a win-win situation, they tell us.

I tell you this is NOT a win-win situation. Now, house officers change places faster than you can say “dysdiadochokinesis”!

The BIGGEST LOSER in this whole fiasco, ironically, are the very ones the health care system was set up in the first place: THE PATIENTS.

Now patients had to content with seeing different doctors every day in the wards, each doctor not knowing the management plan for the patient because with all the shifting and moving, no one will take ownership of the patients!

So, if you are sick, come to the hospital at your own risk – you shall be DISOWNED!

Oranges or Grapes?

I just want to vent….

…about the (bad) quality of our educators and education materials used these days.

My son just handed me his English exam paper to sign and he was marked wrong for writing ‘grapes’ in a question that began with “My grandmother goes to the market by bus. She buys……” next to 3 round objects.

Apparently the correct answer was “ORANGES”!

What the….!

How in the world do those 3 dark circular objects resemble oranges is anyone’s guess.

The teacher cannot see beyond the accepted ‘correct’ answer which is “Oranges” and therefore cannot accept any other answers. What’s wrong with saying they are “Grapes”? Aren’t grapes round and darkish as well?

And whose idea was it to use such inferior printed material as exam questions?

Personally, if I was asked to answer this question, I would write:

MICROCYTIC HYPOCHROMIC RED BLOOD CELLS!

The next Apple

Every once in a while, some one on Facebook will write this on their wall:

“Planning to get a new phone. iPhone or Android?”

And like vultures to a rotting carcass, there will be a slew of comments from proponents and opponents of users (and some who don’t even own a smart phone!) of either operating system (technically ‘iPhone’ is not an operating system, it runs on iOS).

And almost certainly there will be individuals out there who will write something like this:

“iPhone 5 is coming out! Wait for it!”, or

“iPad 3 is coming soon, wait for it!”

Now, if Apple is a religion and the second coming of a BIGGER JUICIER NICER MORE SUCCULENT APPLE is prophesied and is imminent, for we hear rumors now and again with sure signs of the imminent return of the much desired APPLE, then, yeah, sure, why not….we MUST wait for it then for what is to come is surely better than what we have now.

But Apple is NOT a religion!

Apple makes awesome products (you can see I have crossed over to the White side!) that are functionally excellent and a delight to use. I believe it’s the rich experience of using an Apple product that makes buying and using the NEXT Apple product all that much richer!

So, it all really boils down to the core question: What does one want a smartphone for?

Frankly, if you have not heard of iOS or iTunes or does not know what Honeycomb is, then you have no business even considering a smart phone!

I am currently using an iPhone 4 and an iPad 2 – they suit all my needs perfectly at this point in time: basic communication tools, internet on the go, information literally at my finger tips, AV tools when I need them, music when my soul craves some and awesome games to keep my occupied. When iPhone 5 or iPad 3 eventually are eventually released (and they surely will be), and if I can afford it, I would consider upgrading.

Now consider this – what if I told you not to read the first book of the Harry Potter series or watch the first Harry Potter movie, because “the next book is coming out” or “the next movie will be out next summer!”?!!! You’d think I’ve finally lost all my marbles!

So, how is that different from buying the current iPhone/Pad or Android-enabled device instead of waiting for the next one? The fact of the matter is, there will ALWAYS be a next one (okay, not so with Palm and HP’s Touch Pad!).

My advice is:  go get it if you need it now and it helps you with your daily life. When the next one arrives, go get it too, if you can afford it and the new features enhance your productivity even more!

To those who say “Wait” – stick with you Nokia or SE.

Peace! Cheers!

Ancestry

Not too long ago, my daughter asked me a question that stumped me.

“Who were my ancestors?”

It was at the tip of my tongue to say, “Why, it’s Adam and Eve, of course!” but I didn’t for I saw that she was serious. And in all seriousness, I had no idea myself! My own recollection of any sort of ancestor-ship dates back to my paternal grandma (who btw, is a centurion!) and that my paternal grandfather, I am told, was in the army and police force. As for my maternal side, I had almost no recollection at all for my grandparents passed away long before I was born.

There was a time I tried searching for my ancestors online using the family surname only to find out that the surname didn’t quite exist in China! My lack of proficiency in the Chinese language hampered any further search.

“Why don’t we visit your grandparents (my side) and ask them who our ancestors were?”, I suggested to my kid.

And so, over the long week’s holiday, we visited my parents and when told the purpose of our visit, my dad promptly brought out several old dusty and yellow photo albums. We spent the next 2 hours looking at the old photos within – it was like being transported back in time!

“Oh, it’s because those days the world had no colour. It was only until the 1960s when everything suddenly became coloured!”, I told my son when he asked why the photos were mostly in black-and-white.

I think he kinda semi-bought the story while my daughter, on the other hand, rolled her eyes in disbelief.

Anyway, we discovered that my paternal grandfather was indeed in the army and the police force. He was born in Malaya (his father came from China) and is the 17th generation in the family. My dad proudly showed us the war medals that used to belong to his dad which included the Pacific Star. He passed away long before I was born (I forgot to ask ’cause of death!’).

Details of my maternal grandparents are less clear. My mum could not remember much except that her dad came from China at the age of 13 years old (he ‘swam over’, my mum said). His brother came with him but was accused for being a Communist (which my mum denied) and deported. This is the only photo of my maternal grandparents.

My dad later passed me a small piece of paper on which were written some Chinese characters.

“It details some information regarding your grandfather. Ask your friends who know Chinese to translate for you.”, he said to me.

Unfortunately my almost-zero grasp of Chinese prevented me from understanding what is written there.

I am placing it here hoping that some one could translate it for me. (If you are able, leave a comment!).