Wednesday, August 17, 2016

A New Decade

I'm afraid.
In a few days it'll be my birthday. 
A. Whole. New. Decade.* see footnote
For the sake of sanity, let's not go into details about which decade, but lets just say I'm not a teenager anymore.
It's kinda surreal. After all there was a time in my life I thought being 24 was "old".
And now, I find myself referring to twenty year olds as "those kids".
And you slowly have to acknowledge the signs that you're no longer a spring chicken. Things like how you develop random joint aches. Or how your hair thins and your children always draws their daddy with short spiky hair in their drawings- all 5 spikes. Or how you've gone from finding grays on your scalp, to finding gray nose hairs, to finding gray pubes. How you find plaid jackets and bow ties fashionable. Or how you think 50-something postmenopausal women to be more attractive than a 21 year old. And how your idea of driving too fast is 76 mph.
Yes, folks, it's that time.
And I'm not sure if I'm just going to wake up that morning to find my scalp totally clean ala Jean-Luc Picard (minus the charm).
A long time ago, I had some pipedream goals for this decade of life. Things like being married and having my own children. Owning a Porsche 911. Having more than 20 publications. Having more than one million dollars in my retirement/investment portfolio.
Hah- most of them will remain pipedreams for now. But here's to the next decade* of life....

* though to be mathematically accurate, the next decade actually starts the following year. Just as how the new Millenium began not in 2000, but 2001, or how we begin counting at 1, not zero. But what's the fun in that?

Sunday, August 14, 2016

Of DRGs and BS

I was frustrated recently by the system and how in some situations it fails the patient.
I was asked to see a hospital consult recently. 78 year old man found to have an incidental thyroid nodule.
It was a 3 cm hypoechoic solid nodule with some microcalcifications on sonogram. The team had already ordered an FNA to be done- results came back suspicious for follicular neoplasm.
Traditionally, with this result, the next step is surgery, as you've exhausted the capabilities of the dainty 25G needle of the FNA- cytology alone cannot differentiate between a follicular carcinoma versus an adenoma. Often, our surgeons would do a lobectomy and frozen section; and if there is no cancer they would leave the intact lobe behind.
Now, with the option of using molecular markers, there is potential for second-tier tests to restratify the nodule into a benign versus suspicious nodule- if it comes back the former, then the patient is spared from surgery as it has good negative predictive value. In a case like this- elderly man with comorbidities who is a higher risk surgical candidate, this would be a good test to try to avoid surgery.
And so when I saw the patient and read the pathology results. I was curious as to why they did not run the additional test. I called the pathologist up to enquire. Frankly I was quite put off by his answer.
This was a Medicare patient, admitted for chest pains. His DRG would not cover the 2nd tier test which means they will end up forking out the cost of the test itself. So it was felt to be unjustifiable.
WTF?
The DRG. Diagnosis Related Grouping. Essentially, it you are admitted for condition XYZ, Medicare pays the hospital a set amount. Anything else on top of this, regardless of length of stay, the reimbursement is the same. A system to incentivize hospitals to not to do too much of keep the patient too long. But in situations like this, backfires on the patient.
My initial thought was- if that was the case WTH did they even biopsy this in the first place? It could have been done as an outpatient. I was a bit miffed that it seemed that the bottom line superseded proper patient care.
And so, I'm left with choices I don't like:
a) Consult a general surgeon for thyroid surgery- something I try to avoid for elderly patients with thyroid nodules as there is a good chance the nodule is no longer clinically relevant. The risk of surgery arguably may be higher than the risk of leaving a small speck of differentiated thyroid cancer in the neck
b) Attempt a 2nd biopsy as an outpatient with the molecular markers- something I do routinely in clinic- but it seems illogical to put him through a 2nd procedure, and it's certainly not the recommended step in a case like this, as the concern is the 2nd FNA might not procure cells from the same location accurately enough to reassure even if the 2nd set of results came back OK
c) Leave things be. Which I'm most tempted to take- given his cardiopulmonary comorbidities. Indeed, when I see clinic consults for nodules, I ask myself if this patient is likely physically fit enough for surgery- if he/she is not in good health I often try to dissuade FNA. After all, if the test isn't going to change my management, why run the test?
And so, I'll be seeing him for follow up in a few weeks. But yet another clear example of why a needlessly complicated system, coupled with money-minded administrators, end up failing the patient.
Sigh.

Saturday, July 30, 2016

Milo

So, the question is: Should I or shouldn't I? I know it's 2016, but as someone once said, precious food contraband from home should never be wasted. They never expire. Or maybe I said it.
Anyways, if this ends up being my last post, you'll know what happened.

Saturday, July 23, 2016

CGMS

About 20% of my diabetes patients have type 1. And as any patient or physician will know, this can be more challenging than type 2 in many ways- for one a person is completely dependent on exogenous insulin to survive. For some, this insulin-glucose-meal-exercise relationship can be very precarious and brittle.
And to make things worse, over time, many lose their protective senses and have hypoglycemia unawareness. Not being able to rely on symptoms to warn you of low glucose- palpitations, tremors, sweating. The first sign of low sugars might very well be loss of consciousness and a seizure.
Many of my patients try their best- they test their glucose all day. They carry glucose tablets, glucagon at home and at work, medic-alert ID. But sometimes, that might not be enough.
Last month, I lost perhaps my 5th patient in the 8 years I've been here to hypoglycemia. Mr F. was a 52 year old man with very brittle diabetes. He was prone to episodes of diabetic ketoacidosis or hypoglycemia, and was a frequent visitor to the emergency department. It was clear that he would benefit from having closer monitoring with a continuous glucose monitoring system (CGMS). However, these things are very pricey, and while it might be partially covered by some insurance, there is still a huge cost to patients. And his insurance unfortunately did not cover this.
One morning his wife came home and found him unconscious in the living room, drooling and having some twitches. She called 911 and have him a glucagon shot. When EMS arrived, his glucose was 23 mg/dL. He was brought to the hospital, but despite treatment, did not regain consciously. The neurologist felt that he suffered irreversible anoxic/metabolic brain injury. He passed away a week later, in hospice care. I felt his family's pain, after having been his doctor for 7 years, and seeing him struggle.

And so, thinking about him, and many other patients like him, yesterday marked a big step for continuous glucose monitoring devices.
The FDA advisory panel recommended allowing Dexcom to change its label- from a device meant to be used to supplement glucometer data, to a a nonadjunctive use.
The concern has always been if measuring glucose continuously from interstitial fluid, is accurate enough to be relied on for insulin dosing, versus blood glucose. And the truth is, when the earlier generations of CGMS came out they were unreliable, and a hassle to use. I remember seeing a few during training and thinking, "Who would pay to use this?".
This has evolved to very sleek, reliable (somewhat) and frankly, life-saving devices. And they are not too uncomfortable- I wore one for a few weeks to get a sense of how it feels.
The major hurdle for many is cost; and though it might be covered by insurance, there is still a significant out of pocket cost. In addition, Medicare does not cover these at all, so for my older patients, this is not a viable option. One reason has been it was felt to be "experimental".
If the FDA grants it full approval, it would mean they acknowledge that though it's not a perfect device, it's good enough to not have to prick your finger 4-6 times a day to get glucose data (you still need to do so twice a day for calibration). And hopefully, this will lead to eventual change- better coverage by insurors and more accessibility for patients.
Sadly, this will not come at least for a year I'd imagine- it takes time for insurance companies to change their policies. And it will come too late for Mr. F. But I hope this will make a difference for many others.

Wednesday, July 13, 2016

Dumb...

Bell

Get it? Dumb Bell.
Ok, this is a geek post.
As you probably already know, I like space. No, I'm not claustrophobic- but I like all that is related to astronomy.
I'm a Trekkie. I'm a Star Wars fan. All manner of Sci-fi.
One of my favorite books is Stephen Hawking's A Brief History of Time (now, how's THAT for a bedtime story?).
Anyway, I've had my telescope for several years. It's a 4" Celestron Maksutov Cassegrain scope with computerized goto altazimuth mount. I love it. It's given me hours of viewing pleasure. But the mount has always been limiting me to solar system photography- while it tracks the stars, it does not rotate along Earth's axis.
So this year, with the blessings of the wife, I upgraded to an 8" scope with an equatorial mount. And took a deeper (much more expensive) step into astrophotography.
Meet Big Brother....


I still have much much more to learn about deep space objects. But I was particularly proud of this one. 
This was a picture of the Dumb Bell Nebula, or M27. A planetary nebula 1360 light-years away in the constellation Vulpecula. So the light took over 1000 years to hit the camera's sensors.
It was a 20-minute stacked picture at ISO 800.
Sleeping 4 hours that night and feeding the mosquitoes in the backyard was worth it.
More to come in the future.

Monday, June 27, 2016

Bedtime Stories

So last night, as I was putting the girls to sleep, they asked for a bedtime story. 
"Something about a Princess!", Ava gushed. After all, it's princess everything, these days.

So I told them the story of the princess who lived on a mountain, who ate too much candy and developed diabetes, and how Prince Metformin came to her rescue, and along with diet and exercise,  lowered her blood sugars from 200 to 100 mg/dL and saved her from the clutches of neuropathy, retinopathy and nephropathy, and they lived happily ever after. 
Something tells me someday they're going to take away my Daddy License. I'm gonna need to work on my bedtime stories 😜.

Sunday, June 19, 2016

Happy Father's Day


Happy Father's Day!


Thank you. For all the sacrifices you have made. Things that I never understood as a child- why you'd spend so much time at work (to ensure your family was provided for), why I got spanked (when I was up to no good), why you pushed me when I wanted to give up. For your love, support and quiet strength, and for being the role model you are.

Being a parent changes one's perspective, doesn't it? I see things a bit differently now. Like how noisy babies on a plane don't bother me anymore (if anything else, I give them a look of empathy). You look at not just the beauty of the world, but the hidden dangers that may hurt your child. You avoid taking unnecessary risks, to keep your kids safe. You get excited over not cars, but over cute kiddie dresses, or nail paint colors, or stick-on earrings. Your TV spends most of its time tuned in to NickJr or Disney. 
You're convinced that your greatest achievement in this world, is having those kids in your life. And part of you fears the inevitable day, then your kids leave home and start their own journeys into the real world, and you can only hope that you gave them a good enough of life's roadmap to make the right choices.
To all the dads, granddads, dads-to-be: Happy Father's Day!

Tuesday, June 07, 2016

8th Anniversary

In the blink of an eye, it's been 8 years.
2 kids, 2 dogs, 5 cars, 2 cities and 3 jobs later.
Though I look nothing like that picture anymore. I've aged significantly while my forehead has, ahem, grown upwards (ie am balding), while my wife has only grown more beautiful, wise and graceful over the years.

Happy Anniversary, honey!

To many more to come!

Monday, May 30, 2016

Of Expirations and Best Before Dates...

Question: Is it safe to consume ikan bilis that expired 4 years ago, or sambal paste from 3 years ago, or rendang mix that expired in 2011?
Affirmative. Affirmative. Affirmative.
As with other few (precious) weekends when I get to play the role of bachelor, when my wife is away visiting family, or at some medical conference, I turn to my vices. And in some ways I wish I could say my life was exciting enough to have secret sex orgies, or drunken escapades, or spending the night in the 'lokap' when I'm a free man, no, what I really do is cook.
As in cook Malaysian food that my kids, wife, neighbors and American friends consider to be more pungent than fermented gym socks.
And because I can't usually cook certain aromatic, spicy dishes, I hoard racks and racks of Malaysian spices. If you're a Malaysian expat living in abroad, you know what I mean. That pack of Bak Kut Teh spices or Rendang paste is more precious than my left arm. 
So when you hoard stuff that you don't usually get to use, the inevitable happens. They expire. But who in their right minds would throw away otherwise perfectly 'good' food and spices from the Motherland??
After all, expiration dates are a government conspiracy. I tell my wife that nothing vacuum packed/frozen ever goes bad.
This weekend, with the missus being away at Boston  with one of the girls, I took the opportunity to make Nasi Lemak.
My wife would rather inhale the air in a small sauna with a dozen flatulent sumo wrestlers than to smell ikan bilis. And with my kid having a peanut allergy, this is a no-no in our household. But with me being semi-alone this week, the timing was perfect.
Except I then noted the print on the packets. April 2012 for the ikan bilis. Ogos 2013 for the sambal paste, and Feb 2011 for the rendang spices.
For a moment, I thought about tossing them and not risking it. For all of 2 seconds.
But then I realized I already have my last will and testament and trust all written up. And life insurance policy in place. And my retirement portfolio has done quite well so far. So the family would be OK without me should shit happen. Literally.
And so, voila:
Nasi Lemak with sambal ikan bilis, ayam rendang, satay sauce. 8 hours later, I'm still alive and kicking. No gastronomic catastrophe yet. I haven't gone blind yet.
Except Ava was getting worried for me, seeing how much I was sweating. The beads of sweat was literally dripping off my head.
In retrospect, perhaps making a spicy dish on a warm 30C day wasn't the best time. But man, it was worth it. And perhaps speaking as someone who hasn't tried it, but there is no way some orgy would be more satisfying that a spicy nasi lemak meal.
Or can it?

Sunday, May 29, 2016

On The Mend

Thanks for the well wishes. The trooper she is, she seems to be on the mend steadily. She had her "permanent" cast placed the other day, And being smaller, and below-elbow, it's proving to be more comfortable. And she was actually excited to be given several choices for color- she picked tie-dye.
The pain is completely gone. Gone enough that we have to keep reminding her to not do anything too physical. After all, my greatest nightmare is to need an ORIF.
And yes, that's a hula hoop she's holding- but that's about all we're letting her do. No slides, climbing, trampolines.
She was initially unsure of how her schoolmates would react. I have to remind myself that they grow so fast- and now she's already to the point where she cares about what others think.
But when she learnt that she could customize the cast, this gave her something to look forward too. 
And so, daddy hot-glued some crystals on it. And because she's always wanted to be a superhero, I put a Batman patch on her sling.

Now she's all set to take on the world. Just don't be breaking any more bones!

Sunday, May 22, 2016

Poor Alli

It's one thing being the doctor.
It's a totally different thing being a father.
I learnt this the hard way a few days ago. Allison had learnt how to use the monkey bars at school, and so wanted to show us she could do it.
Inevitably, when you wage a battle with gravity, gravity always wins. And so she fell, and suffered a distal radial fracture.
While it was not life threatening, it breaks the heart, seeing her cry, and knowing even before the X-rays that the radius was fractured. After all, there was an obvious body deformity.
The X-rays and fluoro told us all we needed to know.

I've seen perhaps 20-30 fracture reductions during medical school and residency. Not a whole lot, since my career path was destined for a nonsurgical route. While I've always felt for the patient in pain, I've never experienced anything like this.
Seeing your own daughter, in so much pain, in so much fear, looking at the foreign white lights of the ER. Seeing the strangers in white coats (not something she is used to, since neither mom nor dad wear white coats to work), poking and prodding.
And then, despite the sedation and pain medication, seeing the orthopedic surgeon reducing the displaced fracture. Despite the sedation, she was somewhat whimpering. And it was sickening, nauseating even, to see your child's distal forearm manhandled, and twisted in abnormal ways to reduce and reposition the fractured fragments. I'm glad I sent my wife and other child out- even I could not keep my eyes dry.
Thankfully, that did not last too long. And so, after a 4 hour ER visit, she went home. With a cast that she will wear for the next 2 months, right into summer vacation, right into her birthday.
She's not happy that she has to miss swim class, or skip gymnastics, or riding her bike, or jumping on the trampoline. But she's being a trouper so far. And perhaps even finding things to look forward to, like how she wants to decorate her cast, or her sling.
Hopefully, this will all be over soon.
But it has me thinking wondering if playsets with monkey bars are secretly sold by companies owned by the American Orthopaedic Association?

Tuesday, May 17, 2016

5 Years


I can't believe it has been 5 years since you left us.
How time flies, my friend. In those 5 years, the world continues to revolve but yet, our precious moments and memories of you become frozen forever.
Down here, much has changed. I've become more cynical, jaded, tired and aged. We now have two girls- you met the older one in your last weeks, remember? She's now in kindergarten, while the other is in preschool.
I miss our conversations; truth is with work and life as a parent, it's hard to form bonds like those we had, when we were relatively young and carefree, and it's hard to find a confidante to fill your shoes. I miss those sessions we would have over a meal, or Halo, complaining about work or life (usually it's me, with your patiently listening). Now, I like to imagine that when all is not well, somewhere up there you're still listening...
I sometimes think about the unfairness of life; of why someone like you would be taken away so soon, so young. Truth be told, I've asked myself many times in the past- why a man like you? Why not someone like me? After all, you'd leave a bigger mark in this world than I ever would. Or maybe that was the point- to teach the rest of us who have much to learn, how to life live and make the most of things.
I remember the time when you told us that you decided to not carry on with chemotherapy. Being the oncologist you were, you knew the odds  even before treatment began. And you knew when you had had enough, and you wanted to just make the most of your time. We both knew the implications of your decision, which was why we made that last minute trip back to Malaysia.
And I'm sure you knew, as I did, when we had dinner at that food court that evening in Penang, that that would be the last time we would ever see each other, at least in this world. Yet, in your usual quite demeanor, you seemed a bit embarrassed when Kris and I gave you our goodbye hugs. You were at peace and perhaps more ready to move on- but we certainly weren't.
You carried yourself with more strength and grace than I ever will know. You never once asked, "Why Me?". And did I ever share with you how I actually met the wife of one of your patients here; someone who was bitter and angry and had trouble accepting his diagnosis, until he found out that his oncologist had stage 4 esophageal cancer, and yet carried on in peace? His wife told me that you gave him newfound peace, that when he finally lost his battle, he was no longer angry.

Buddy- my best friend and confidante, my partner in crime during those 6 years at WFMC, my room-mate, my Best Man, my brother, my Halo teammate.

5 years ago, the world lost a wonderful man, brother, son, husband, oncologist. And yet, you remain near to those whose lives you've touched, never to be forgotten.

I miss you, buddy. Till we meet again someday... here's a toast to you. I'm sure you and our pal Gene are living it up there. 


Saturday, April 16, 2016

Ok, I admit it.
I've gotten lazy.
It's been 3 weeks since my last post. 
Therein lies the issue. Maybe life has gotten to be too mundane. Or busy with the kids. Or perhaps I'm just blissfully happy and have no need to vent out on my blog anymore Smiley. After all, I think that was one of the drivers for my posts:
Complaining about work.
Complaining about being homesick.
And perhaps most of all, complaining about being single (hoping that a girl would fall in love with me reading my blogs!)

It's interesting, a bit embarrassing, and maybe envy-inducing, reading my old posts, those going back 10 years ago when I was a trainee, working at the Mothership under the supervision of the Medical Gods, and seeing all those super-rare cases. Then coming home to a small rented house, hanging out with our community of Malaysian/Singaporean friends. I had a lot more free time then at night, and perhaps a lot of brain-juice and flowing creativity (hah).

I admit I've neglected this. For some reason, I just have less to say. I can't help but notice though I'm not the only one. Many of the blogs I used to follow (still sometimes check it out) are kinda like mine. Lapsed, infrequent entries. Or perhaps stopped completely. Are blogs fads that have passed, perhaps superseded by the newer social media platforms? After all, I vent and share so much more easily on Facebook, and at least I know the people there a bit better. I haven't yet caught up with Twitter or some of the other stuff out there, and it makes me feel old saying that.

Anyway, I'll still continue to update this with boring, mundane stuff. And the way life is right now, much of it will probably be of my most priceless possessions- my girls (wife included). I'm not even sure if I have any real readers anymore, beside those spambots- feel free to drop me a line if there are real people out there.

Happy weekend.

Wednesday, March 23, 2016

15 years

The wife and I were talking last night, when our university days came up.
And I started off wanting to say that it wasn't that long ago that I was in university.
Until I actually stopped to count, and realized to my horror:
I have been a doctor for 15 years.
FIFTEEN.

15 years ago, I had those letters M and D added to my professional/academic name. Be it a blessing or a curse, it's been with me since.

Holy cow- did the 15 years just whizzed by. After all, between that day (graduation) and now, I've done clinical teaching at IMU in Bukit Jalil, completed my residency in internal medicine at WFMC, followed by 3 years of fellowship in endocrinology, gotten married (twice- but to the same girl thankfully!)(in the USA and Malaysia, lah!), had 2 kids, and have been in practice for 8 years.

It's true what they say about time flying. But it's also interesting to note how I've changed professionally. Sadly enough. After all, ask any keen medical student, and they'll tell you they're going to change the world and help everyone. But somehow along the way, you get jaded, numbed and burnt out from the harsh realities of medicine in the USA: the complexities of health insurance and the skyrocketing cost of care and medications, the greed you sometimes see from industry, the bureaucracy, the lawyers and administrators. And yes, sometimes the patients too- when they argue and fight or are simply indifferent.

But, life goes on. We do what we can. Perhaps less of a spring in our steps, but we have after all taken that oath, and it's one I intend to keep. And the few guiding principles I try to live by:
  • The needs of the patient come first
  • Primum non nocere
I wonder where I'll be in the next 15 years?

Sunday, March 06, 2016

Disney Cruise, Part 2

Ok, this is a bit of an outdated post, but I've been busy (and lazy).
We got back from our 2nd Disney cruise a couple of weeks ago. Again, we sailed on the magnificent Disney Dream ship. It was no surprise that Cruise Critics awarded the Dream the 2016 Cruisers' Choice award. 
We went on this cruise with family last year. And this year, it was a long-overdue reunion with friends from my medical residency days, including one from Malaysia.
The last time we all met up, there was only 1 child amongst us.
Now, well, the picture speaks for itself.
The last time this group got together, it was 2004!

This time, we took the 5 day/4 night cruise to the Bahamas (we did 3 nights the last time). And like the last time, we had a blast. There is always much to do on the ship- plenty of activities for the children: a huge playroom with free child watch, with enough stuff that I had fun there too (I mean,come on, they had a mock up of the Millenium Falcon!!) and the kids spent hours there. Meals were provided in the playroom if the kids wanted to stay, and adults get a "wave" phone that allowed them to text you if your child wanted to be picked up. But the one thing I was surprised by the first time, was the amount of activities to keep the adults occupied. Sports bars, jazz bars, karaoke, games,gym, adults-only pool. And this time, at last knowing the layout of the better, we were able to explore much more compared to the last time.
The first day was spent sailing from Port Canaveral to Nassau, Bahamas.It was a quick overnight sail, with the ship getting into port in the morning. The kids wanted to stay in the playroom so the wife and I were able to explore the island on our own a bit. We got to sample some pretty good rum cake. And the straw market is an easy 5 minute walk from the port- plenty of nice little souvenirs you can get; and they're always open to haggling (I wish I brought my mom!).
We left port that evening, and sailed towards perhaps what is the most amazing part- Disney's private Bahamian island, Castaway Cay. We arrived at about 8AM the following day. It's a smallish island, only about 4 km2- but large enough to give the cruisers plenty of space to have fun and explore. Pick your activities- the two family beaches including one with water slides, the adults only beach, cabanas for rent, water sports, kids' play areas, snorkelling, biking, character meeting. Of all the activities, my wife had to sign us up for the Castaway Cay 5 km run! I suppose it was a good way to burn calories from the amazing food.

Truth be told, the February waters were a bit too cold for me (though the air temp was comfortable). That didn't stop the hordes of swimmers though. After saying farewell to the island, we sailed off- day 4 was spent a sea- and this was the difference between the 3 and 4 night cruise. This was actually a nice welcome- it turned out to be a relaxing day as you didn't have to rush and get everyone ready to disembark for activities. So we just replenished our Vitamin D, laying on the deck on the bow of the ship, and hung out with the other adults in the group.

We got back to port about 6AM the following day. After an early breakfast, we disembarked early at about 8AM to do some exploring in Orlando. All in all, it was another great cruise, and it was especially nice to see some old friends.
Would I sail Disney again? Hell, yes. Maybe not next year as the budget probably won't allow, but in a couple of years, perhaps.
If you're planning to do Disney, some words of advice:
  • If you want to explore the pool, choose an early boarding time
  • You'll need to pack a daybag, as your luggage will be brought to your room only many hours after you board. Obviously, you'll need swim gear if you intend to use the pool while waiting around- but it's a good idea to actually be wearing your swim suits under your clothes when you board. The last cruise, there was a long line for the ladies' restroom so the girls had to wait to get their suits on
  • You'll have a choice of first or 2nd dining for meals- with younger kids, I'd say the first dining is best- you get to have your dinner and catch the shows after that. And the shows were excellent- don't miss them
  • Consider using travel agency for booking. We used Dreams Unlimited- fares were the same as the Disney website, but very helpful agent, and they give freebies, as well as onboard credit ($100 this time, and $250 the last cruise- so it's really a rebate).
  • Plenty of websites with room suggestions- check it out. Very helpful times. We got a deluxe verandah room with balcony- on the port side of deck 8. I thought this was a great location. Port side is where they dock on Castaway Cay; but if you want a view of the beach from your room, then pick starboard.
  • I think this changes depending on wind conditions- but the two times we sailed with them the fireworks on Pirate Night was towards starboard, so not visible from our room.
  • Alcohol is pricey. Yet, they allow you to hand carry alcohol onboard if you wish- check out the website for limits.
  • If you have young kids, bring their pirate/princess costumes- great photo ops for Christmas cards.
  • Likewise, if you intend to give the girls a treat and send them to the Bibbidy-Bobbity Boutique, dress them up in their princess dress and then take them there- you'll save a huge bundle having them do the hair package only, but yet they'll already be in their dress. They'll feel like real princesses for a few days!

Sunday, February 14, 2016

Happy Valentine's Day!

I saw this on FB today. Sorry, the endocrine geek in me could not resist.

Happy Valentine's Day!

Saturday, February 13, 2016

John Cena

One of my patients broke his leg the other day. A 27 year old man with type 1 diabetes who also has cognitive disabilities. Had a hypoglycemic episode and fell down a flight of stairs and unfortunately fractured his right tibia. I saw him a few days after his surgery, and he was in some pain, and crying because he wanted to go home to his bed.
He happens to be a a huge fan of WWE. This was obvious in the years I have seen him in clinic- he would always come in his WWE cap. To him, John Cena was God himself. And so, yesterday, I dropped by his hospital room to drop this off.

                                                     
Sometimes, it's fun to get to know your patients. Despite all the frustrations of this job, perhaps the greatest joy is getting to know your patients and feeling like you're a part of their lives. He was still yearning to go home, and was still in some pain, but the smile he flashed when he saw this was priceless. The nurses later told me they hadn't seem him eat so well since he was admitted (though not necessarily a good thing with his diabetes :) )
Ava even drew him a picture/get well soon message. Note the bleeding from the right leg.

Sunday, February 07, 2016

Happy New Year!

Happy Chinese New Year!
Another year, another CNY.
Can't believe it's already 2016. And can't believe it's another CNY. Well, it's not hard to forget living in the relatively culturally secluded Midwest, where there isn't much festivities.
Year of the Monkey. None of my kids are monkeys, though they certainly act like one sometimes. However, my late Ah Kong was a monkey. Until his final years when he was showing some dementia, he was always soft-spoken, gentle, and serious; not the kind of personality the horoscope would suggest.
This is always the time of year when I yearn for home (yes, this is home now, but you know what I mean) the most. When you get a flood of memories, the traditions your family has. The things you'd do, even if you didn't understand why. Traditions you know will die with you, as you plant your new roots in a different land, on which you will make new traditions for your kids to pass on- but not the kind of traditions you grew up with. Bittersweet, but alas, to be expected raising kids here.
However, the standing plan currently, if budget and time permit, is for the family to spend Chinese New Year 2017 in Malaysia. It's ambitious, and with Allison in school now, we'll have to take her out. And the ticket prices will be horribly expensive. But it's important to me that my children at least see and experience a Malaysian Chinese New Year with my parents at least once, so that they'll somewhat understand what their daddy did during his version of 'Christmas'. Thankfully, my wife understands this is important to me. And so, 2017, we'll be there.
In the meantime, here's wishing all you readers, family, friends, loved ones, a Happy and Prosperous New Year, and may the Year of the Monkey be filled with silly laughter and happy memories.

Thursday, February 04, 2016

Sick Day

I took my first sick day this week.
I just couldn't take it anymore- my head was pounding, I had a runny nose and congestion, and a sore throat. And so I asked the clinic to cancel my afternoon.
It was my first sick day in 14 months.
Strangely enough, there was no pride that it's been that long since I last called in sick.
Instead, I felt horrible for a few reasons.

For one, I felt an immense sense of guilt because I knew that would be pissing a long line of patients off. Patients who have waited 2-3 months to see me, especially the very-anxious new consults for a variety of issues they or their PCP felt was urgent and hormonal. And so, to cancel would mean rescheduling and waiting another few months. Who would not be miffed?

The second reason that I felt bad though, was just the sheer madness of the situation itself. I'm not proud that I have a 'clean' record of not taking time off for illness. Instead, I'm ashamed of it. I'm perplexed that we function in a world where either patients or doctors see it wrong, to be ill and to take time off for themselves. We see it unforgivable to make a patient reschedule- the very people who are often themselves on sick leaves to come see the doctor. And yet, for some stupid reason, we think so highly of ourselves that we think our immune system is s resistant to influenza, parainfluenza, rhinovirus, coronovirus, strep or whatever else germs are out there. Perhaps the M.D. degree hanging on my office wall had antimicrobial properties. But no; we are human too, and we do get sick. So why do we find it so difficult, why does the system make it so difficult, for us to acknowledge that, that often we go to work if we are ill, if we think it's mild and not too infectious?

Indeed, I posted something on my blog years ago- results of a survey asking if people preferred their sick doctor to still see them knowing that they might be infectious, or have their doctor reschedule the appointment and wait another few months to see them?

The results- most polled that they still preferred to see the sick doctor.

Tuesday, January 19, 2016

When Breath Becomes Air

After waiting a few weeks for this, I finally received it yesterday.
When Breath Becomes Air, a book by Dr. Paul Kalanithi, a Stanford trained neurosurgeon who was diagnosed with metastatic lung cancer during his residency.
The first part of the novel is about his early years, and his foray into the world of medicine. He shares his experiences during residency, and having gone though this myself, at many levels this hit close to home.
The 2nd part is about his struggles after his diagnosis. As a doctor and surgeon. As a husband, And later on, as a father. This too, hit close to home.
It was an easy read. It was a difficult read. It was a good read.
I couldn't put it down- and so I began reading the book at 6:30PM, and finished it at 10:45PM. By the end, I was a mess. I was quietly crying in bed as my wife and kids slept.
For one, this brought back all kinds of memories, experiences I have always been ashamed of, but could relate to. I remember the torture, the sheer exhaustion, as an intern. I remember the times when I could not take it any more, and had to go into the bathroom during rounds to just sit down and cry for a few more minutes, before I could go on with work again. We all start off human, but the truth is the training kills off part of the soul, part of the human side. Paul shares a story of how his colleague wished a patient had metastatic pancreatic cancer just so his Whipple's would be cancelled, and she could get some much needed rest; of how when she realized what she was thinking, she just broke down in shame. I can certainly relate to that. No matter how we try not to lose our humanity, sometimes you are so beyond exhausted that you think the unthinkable. I remember having had those days; when the nurse calls to tell you that your patient died overnight- the first thought that comes is that of gratitude, so that you have one less patient to round on, and you get perhaps another 15 minutes of precious sleep. I remember having that exact reaction- moments thinking that, that I started to cry uncontrollably in the oncall room because of the sheer shame I felt, even having that thought cross my mind. No, I've never ever told anyone those thoughts, until now. In a way, I'm relieved that I wasn't the only one cruel enough to think that, and I'm glad that was a phase of my training that is well behind me.
The 2nd part was difficult for me to read too, for obvious reasons. We've all lost patients, family, loved ones. And the person that obvious comes to mind was Buddy. After all, he could have written a book like this. Indeed, a now-stalled dream of mine once was to write a book about him- and though I have a few stories in my hard drive, the momentum is lost and the stories will instead be committed to the heart and mind. Anyway, this could have been his story though perhaps being a medical oncologist and not neurosurgeon, perhaps the work-related stories less dramatic. And instead of Stanford, we were at the other premier medical center. And instead of lung cancer, it was high grade adenocarcinoma of the distal esophagus. Paul died at 36; Buddy at 32. And though I would have loved to share his story on print, the reality is the stories will die with us, those of us who had the privilege of knowing him, and spending those last few precious years with him.
I remember how he broke the news about his cancer. I remember the chemotherapy sessions, the many hospital admissions for intolerable emesis and dehydration. I remember the discussions we had about sperm banking before the chemotherapy would kill his chances of fathering offspring. I remember being in awe of his apparent strength, his peace, despite the unfairness of having an uncurable cancer, with a dismal prognosis that as a cancer specialist he was only too aware of. I remember when Buddy asked me if he should marry his sweetheart, knowing very well that he would make her a widow. I remember asking myself, asking God, why him? Why Buddy, who was such a talented, wonderful human being? I remember asking the obvious: Why not me? It's a question I sometimes ponder still. Why him, and not me? He would have made such a positive difference in so many lives. Buddy was such a better human being, a doctor, than I would ever be. God, I miss him; but reading Paul Kalanithi's books brought back a flood of memories of my friend. And in a way, it was comforting reading Paul's words as it seemed to give me some insight into Buddy's psyche.
This would be the last I'd ever see him alive. We both knew; it was pretty obvious the way we said our goodbyes. He passed away a months after we visited him.

It's a good book. It was a real tearjerker for me. And perhaps in part because I am now a husband and father, it was particularly poignant that the book was completed posthumously by his wife because he took a turn for the worse unexpectedly. It made me think about how things would have been if I was in his shoes, at this stage of my life.
Ultimately, it's a book about faith, strength and love. I'd highly recommend it.