Instinct?

Animals, humans included, have such amazing inborn instintcts. Things that these organisms do, without anyone actually teaching them.

Like, how eagles learn to fly. Or how the geese migrate south in winter.

Or, how a toddler learns to pick her nose, and gingerly pops her booger into her mouth like it was a raison.

Yup, that's our pride and joy. And we caught her doing that the other day. Mom shouted in shock, I laughed.

Where DO they learn these things?

I found this hilarious posting on howtobeadad.com. Apparently they contain Vitamin C

Gongxi!

Happy Chinese New Year!

It's the year of the Dragon- woo hoo. Or rather, sighhh. Because it means my age is now a multiple of 12 (whether it's 24, 36, 48 or 60 I'll let you decide, but I'll tell you that story sometime this week).

Anyway, if you're a Malaysian expatriate like me living outside of Asia, you know it can get pretty damn boring, and it gets pretty homesick too. After all, for many of us we grew up having CNY as the BIGGEST event of the year, one that's filled with all kinds of smells, sights, tastes and traditions. But if you're living in the northern hemisphere, it's cold and white and pretty much nothing else that reminds you of the festival.

And so, we're determined to have Alli experience some of this. We dressed her up in a cheongsam her uncle and aunt bought her, and put on her gold necklace Ah Kong and Ah Ma gave her, and took her to a Chinese festival in one of the local colleges. She got to see her first lion dance (good effort though it was weird to see 4 Caucasian women perform it)(wait, then again I'd bet many Malaysian men would PAY to see that).

And though she was too young to understand it, I told her of some of the traditions and things we'd do. Like:

• Having a family dinner on the eve of CNY, then going out to the relatives' for our first angpow hits of the year
• Going to the temple for prayers early in the morning, then coming home and getting dressed in our new New Year clothes
• As kids, after the open-house crowds had died down (ie I had seen the girls I had crushes on), I'd head out on my BMX with my neighbourhood buddies looking for trouble. We'd have a bag of fireworks, and would look for things to blow up. One of our favourites- freshly made cow-dung. Yes, we have a fierce-looking Sikh guy who'd walk his herd of cows from one area to the other, and inevitably they'd leave a trail of dung. And so, we'd dare each other into sticking a single firecracker into it, and lit the fuse. We never ran fast enough to come home totally clean. There was always some green/black splatter on us, or our bikes. It's a wonder none of us died of E.coli poisoning!
• After all that work, we'd be famished and head to each others' houses for snacks, drinks and the all-important gambling sessions. Yes, even parents allowed this, once a year. We'd be playing Blackjack or Cho-tai-tee, with 10-20 cents a wager. It made me feel like a cardshark. But alas, every year I lost. Even to my little brother. The lucky red Superman underwear never worked.
• I miss the fireworks! My favourite was the dinky little Moon Travellers; mom and dad would get use a carton and my brothers and I would preciously divvy them up. They were small little things, with only a minimal pop, nothing like the Thunderclaps people eventually used. I loved the smell of the burnt gunpowder at Chinese New Year time.
• And of course, the food. Mom and dad always had an open house, and they always catered Malay food (yes, race wasn't as big a deal then, unlike what the idiot politicians are making it to be these days). And always, we'd have rendang which was my favourite even now (despite it one year pretty damn near killing me; remind me, there's another story to be told someday), dumped on a serving of fried beehoon.

Yes, wonderful memories. My buddies and I were just reminiscing that on Whatsapp the other day. The 11 of us, spread over numerous continents and most with kids now. But those were wonderful times. Someday, I hope to show Kris and Alli what CNY is like. And someday, I'm going to show my little girl how to blow up a fresh cow dung!

Manuscripts

My resident approached me the other day asking for advice on how to write up a case report. It was somewhat timely as my sister had seeked a similar advice recently. I can't claim to be an expert in publishing materials as at my alma mater, the real experts had over 300 first-author papers each, though I've had my hand in this several times. This is what I told him:

• Use a cover letter. Even if the author instructions lists this as optional. Take the trouble to find out who the Editor-in-Chief for the journal is, and address it to him/her appropriately. Make it succinct, but explain in one or two lines what your manuscript adds to medical knowledge, or why the case/study is special. Otherwise, a manuscript simply entitled "Chordoid glioma of the third ventricle" gives the reviewers little insight and makes it easy to disregard. Thank the Editor for considering your paper.
• Identify potential journals. Not all journals take all types of manuscripts; not all journals take case reports, or medical images, or unsolicited review papers. Do your homework
• Know the format. Once you identify your target journals, use the appropriate format. Double-spacing is a given, but know how they like their references cited, or tables and diagrams labelled. If they lists a word-limit, do not exceed it.
• Use the proper lingo. Obviously, don't mess up the English. That being said, there is a certain type of lingo that is expected in a scientific publication. Informal language should not be used. No DON'Ts, CAN'Ts, WON'Ts, HE'S. My style is to follow reinforcing statements with INDEED, THUS, FURTHERMORE, rather than SO, OF COURSE.
• Don't over-abbreviate. While abbreviations can be used, always start with the full syndrome names and follow this with abbreviations. But do not overdo it. Ie. A 50-yo man with DM 2 presented with SOBOE and ACS...
• Do it now! It's true, the passion and motivation for any case or study will fizzle. So, if you are enthusiastic about writing up something and submitting it, do it now! Because if you don't the weeks become months, and then years. Though I'm pretty satisfied with what I've done, I do have manuscripts that ended up in my dusty to-do folder that will never see the light of day. Including that (sigh) 20-page (double-spaced mar)/80-reference review of thyroid nodules that is now 5 years old and is stale and no longer up-to-date. And I'm too lazy to update this. So, do it while you are keen. Otherwise life gets busy and you make excuses.
• Use reference formatting software. Do not manually type out your references! That is a lot of work, and you need to modify it to the journal you submit it to. And, if you manually type things out, but decide to add a new reference between Number 3 and 4, you're left with manually relabelling references 4-20! There are numerous programs out there that do the formatting for you. I used Endnote back in my day. It was neat, as from Medline or Pubmed you could directly save the citation (even the .pdf) and keep it in a folder, and then just label it when you work on your Word document.
• Don't give up. About two-thirds of my manuscripts were rejected initially. Sometimes it's just a matter of shopping for the right target journal, whose reviewers feel your paper is well-suited to their readership. So, if one journal rejects your paper, look for another. Start with more ambitious ones, the ones with a higher impact factor, and then work down. A mentor once told me, "All manuscripts can be published, if you look long enough for the right journal". (Almost true, though I had one manuscript that in retrospect sucked bad enough that I probably shouldn't have bothered even trying! Ah, that was when I was still a publication virgin).

It's a lot of work. My most hard-earned papers spanned 2 years of my personal work (and 5 years of data). But to get that email, "Congratulations Dr. Vagus, your manuscript entitled X has been accepted for publication...", and then to see your paper in print, is a very rewarding feeling. So, if you are inclined to do research and write papers, it's well worth the effort.

Contraband!

No, not the movie.
Even better.

Look what I found in the pantry over the weekend. I had the case of the munchies, and went in on my usual exploratory searches. And on one of the shelves, I hit jackpot.

Though I hadn't realized it until a month after they left, mom and dad must have 'imported' this from Malaysia when they visited. I haven't had these in well over 10 years. Not one of those things that would come to mind when I visited Malaysia and went out on a food-hunt. But definitely one of those things I missed.

Ah, the memories of my childhood that each bite brought back. It's a good thing Kristin wasn't a fan; I didn't have to share a crumb of this with her.

Thanks, mom and dad!

Ugh

Ugh. I feel like throwing up. And so, I have my barfbag beside me right now, in case something comes up the wrong way.

Though we've been together 5 years now, the wife and I can think so differently sometimes. I blame it on my Malaysian heritage.

I made rendang, briyani (from the packs) and roti canai for dinner just now. I made A LOT of it. And much of it we probably could keep for another day, but I didn't think the roti would thaw well. And here's where we digress.

Kristin: Just throw it away, or give it to the dogs. You can always make more.

Me: You want me to throw away my precious Roti Canai*? Never! Here, I'll find some room for it in my stomach.

In the end, guess whose suggestion was the better one? Ugh. I'm gonna need some Tums.

*May replace with (expired) curry paste/ayam masak merah/sambal belacan/etc. Yes, we've had this conversation many times before. Somehow I never learn.

And yet, ask any Malaysian expatriate. Spices and foodstuff from Malaysia are more precious than gold.

After 9 years.

That's almost a decade. But after 9 years of being in this country, I finally received my green card the other day. It's been a long convoluted road, from a J then H visa and now this.

Though it's a huge relief, and will make travelling with my family much easier, and not having to worry about 'secondary' screens (which is still much better these days compared to the post 9/11 days), getting this was almost a bittersweet moment.

Probably more psychological, since I've called this place home for the last 9 years. Including medical school, I've lived in North America since 1998.

But, becoming a Permanent Resident, also makes it pretty clear (if it wasn't already): This, here, is now home. Here.

No longer Malaysia. No longer the place I was born. The place I grew up with, the place that holds so many precious memories, and still holds so many family and friends still so dear to me.

Though this was not what I foresaw when I started my career here, this was but to be expected when Kristin and I got married and started our family. And though I do consider it a privilege to receive this card, I am somewhat saddened to think about the factors that led me here. The same factors that have led 5 of the 10 other close friends of mine from highschool to seek permanent residence elsewhere, outside of Malaysia. To cause the massive brain drain from Malaysia, the loss of so many young talents. The same issue that comes up over and over again, in a country that found her independence almost 55 years ago: If you are of a different skin color, then you'll always be an immigrant. You'll never have the same rights.

So ultimately, for my family, for my daughter's future, like many of my friends who think about their children's futures, we seek greener pastures. Though this place is far from perfect, this is now home. 

The Year That Was

I can't believe the year is almost over (yea yea, you people in Malaysia are 13 hours ahead of us, I know). This time of the year, I'm sure I'm not the only one who reflects on what has happened in the preceding 12 months.

Much certainly has happened in 2011. For one, after much suffering and time being apart, my wife finally completed her program in nursing anesthesia. After 3 years of 2-hour commutes and weekdays apart, she pulled it off, graduated and joined a group in town. That was probably our high time; I remain so proud of her. Also, our dear Alli has grown so much this year, from sprouting little baby teeth, to learning to walk and then run (and now to climb down the stairs, much to my chagrin), so saying "More!" when she wants more to eat. It's so fun seeing her silly personally starting to show.

Yes, we have much to be thankful for in 2011. However, if I can take a moment to be selfish and ungrateful, taking a step back, 2011 has been a difficult year for many reasons. It has been a year of losses. And the most tragic, was my best friend losing his battle to esophageal cancer after a 4-year batttle that spanned his wedding, honeymoon and his fellowship training to be a cancer doctor. Though we knew that was coming from day 1, knowing this was stage 4 cancer, losing a dear friend is never easy. Especially at such a young age. Nonetheless, we count ourselves lucky that we were able to travel back to Malaysia to spend some time with him and his wife, shortly before he passed on.

And so, I think I'm ready to move on into 2012. Though we can never foresee what the year holds, I hope this year will have fewer tears for all of us.

Have a safe New Year's countdown, folks!

Tragic

Any accidental death is a tragedy, especially around the holidays.

However this seems heightened when it involves one of your peers, on what started off as a life-saving endeavour.

 (CNN) -- Three people -- a surgeon, a medical technician and a pilot -- were killed Monday when a medical helicopter crashed in Florida, the Mayo Clinic said.

The helicopter crashed at about 5:23 a.m. ET about 12 miles northeast of Palatka, Florida, according to Federal Aviation Administration spokeswoman Kathleen Bergen. 

The clinic said the helicopter was carrying two employees to the University of Florida in Gainesville to harvest organs when the crash occurred. It identified those employees Monday as cardiac surgeon Dr. Luis Bonilla and procurement technician David Hines.

It's sacrifices and risks like these that I never have to take, that reminds me of what these surgeons and their teams have to go through in the name of helping patients. And in the recent years, there seems to be quite a few of these accidents, probably in part due to the increased numbers of transplants that are performed nationwide.

These guys are heroes.

Our thoughts, prayers go out to the families of those killed in this noble mission. Though I have never met either of them, I know the medical community will mourn this tragic loss.

One of my patients came by Friday. I was surprised to see her in the waiting room as her appointment wasn't due for another month, but she wanted to bring me this.
A simple jar of homemade apple butter for Christmas.
Sometimes the simplest of things are the most precious.

She wouldn't let me pay her back. But she said I could pay her in hugs so I did (she's 71 so I wasn't worried of any misunderstanding).
Merry Christmas, dear readers.

Sent from my iPhone

Deafening Silence

My family left today. For my parents, after a month of being here. My brother and sister-inlaw had been here for a week.

With all the commotion and activity and the screaming kids, admittedly it took some getting used to. But then when things settled in, it was heartwarming to see our daughter look up to, and play with her cousins. Or to have my mom and dad teach her the same Hokkien phrases I grew up with. Or have her coo at them. Or simply to share a beer and a nice conversation with my big brother and dad; it's fun in a way, realizing that we're all adults now, and we can have a grown up conversation.

After some migraine-inducing moments with United Airlines (which I won't go into today) they finally caught their flight out to LAX.

And so, for the first time in a month, the house is quiet. There is peace.

Except suddenly it doesn't feel like a home anymore. Like there's something missing. And the silence seems deafening.

I'm sure we'll get back to our own routine, but it'll take a few days. And just a few hours into it, we're missing them already.

Have a safe flight back!

Chaos

Our home is a madhouse right now.

Utter chaos.

We have family visiting- my parents, brother, sister-in-law, and their two kids. And then there's Kristin, Alli and I. Plus the two dogs. All cooped up indoors because of the cold weather outside.

And so, our house looks like a tornado ripped right through it. One that smells of sambal belacan and ikan bilis.

And yet, I caught myself thinking this over the weekend when we had our (early) Christmas celebration: It's funny how, amidst all the chaos the family reunion brings, one can be filled with peace, warmth and love.

It's been awhile since we were together for Christmas, and though not everyone's here, it's still nice to have family around. And it's so heartwarming to see our daughter play with her cousins, and her grandparents.

Yes, it's easy to forget what this season is really about. It's easy to get sucked into the superficial façade of presents and ornaments and sales. When truly, it's about family. 

 

Season's Greetings, and Best Wishes, from mine to yours. Safe travels.

My Christmas Wish List

1. Miraculous scalp hair growth
2. World peace
3. To have my patients be cured of their diabetes
4. A Ferrari 458 Italia Spider (in red, of course)
5. To have no late-night DKA or thyroid storm consults for the next year
6. As much as I'm a fan of Vettel, to see poor Schumacher win at least one podium finish in the 2012 season
7. To get my six-pack back again
8. To be rid of corrupt politicians (something tells me this will be the most impossible)

Failing of all which, I'd just then humbly ask Santa for a $10 gift card to Caribou Coffee.

Happy Shopping, everyone. Just 12 days to Christmas, Lalalala-lala-la-la.

Difficult People

It's sometimes hard to deal with difficult people. And though sometimes the rational side of your brain tells you it's not you but them, admittedly I'm guilty of taking things personally.

Today was one of those days, and truth be told, I'm still reeling from that verbally abusive patient I saw on what started out to be a nice Monday morning.

Even before I went him, I heard him yelling at my nurse. And then when you have someone accuse you of being a bad physician, in part because you refused to prescribe antidepressants (when you were consulted to assist in his diabetes management), and accuses you of being rude to the pharmacist (I'm not even sure where this came from), and blames the high cost of healthcare on doctors like you who make him get his other nondiabetic prescriptions from his GP (hence giving him two co-pays), and so generously throws out F-bombs at you as he accuses you of intentionally making his diabetes worse so that you have an excuse to put him on insulin, it's hard to even give a response to any of that.

I tried to explain my stand on things and tried to make my case, but in situations like this, there was no way he was going to listen.

We both agreed I should never be his doctor again and offered to have a colleague see him from now on.

But deep down, I catch myself wondering, how could our doctor-patient relationship has gone so wrong? For the rest of the day, I caught myself in doubt, of both as skills as a physician, and as a person.

For, as unreasonable as the accusations may be, if someone yells at you loud enough, you can't help but take it personally.

It's on days like these, that you almost wished professionalism and ethics would let you confide in the other patients you see. The patient who have been coming back for years, and with whom you get along, and who seem to trust you. You almost wish you could ask your patients, "How am I doing? Am I treating you well as your physician? Am I taking good care of you?"

But no. We aren't allowed to do that, are we?

And so, you grin and bear it. Life goes on.

My patient said to me today that she felt lucky that she has such a smart, handsome doctor looking after her.

Never mind that she's

- 86 years old

- Has bad cataracts

- AND, has strabismus

This patient's a keeper!

A Love Letter

This was a letter I wrote on the behalf of a patient to her medical insurance company. Now, maybe I'm naive enough to think that HMOs and insurance companies, while they do make a monetary profit, is genuinely there to help patients. But sometimes, as when this patient called me up crying because she was told her medication wasn't as necessity, I do wonder. The 'medical reviewer' who looked at her file said there were 'other' options. That she didn't need these pills and so they weren't going to pay for them.

This was my response.

Re: Denial of Calcitriol for PATIENT X

I am writing to appeal your denial of coverage for this patient’s Calcitriol. I disagree with the reason for denial, that this is excluded by this member’s plan.

This patient has post-surgical hypoparathyroidism. As any basic physiology textbook will show, parathyroid hormone is necessary to hydroxylate or activate 25-hydroxy Vitamin D to 1,25-dihydroxy Vitamin D, which is ultimately responsible for gut absorption of calcium. While most patients do not need Calcitriol as a form of vitamin D, in the absence of parathyroid hormone, patients with hypoparathyroidism cannot physiologically do this, even if taking massive amounts of over-the-counter Vit D. Therefore, the ONLY possible option, is Calcitriol. As you should be well-aware, there is no clinically available means of replacing PTH in these patients (the only recombinant PTH available is Teriparitide which is NOT used for hypoparathyroidism).

Not having access to this will lead to hypocalcemia which can be life-threatening. If your company wishes to be responsible any potential hypocalcemic seizures or worse for Patient X, please let us know and we will attach this in our medical records for her. If you wish for a refresher in basic calcium homeostatic mechanisms I would be happy to recommend a medical textbook. 

Yours truly,

Dr. Vagus 

I must say, I thoroughly enjoyed writing this letter. I had had some other frustrating insurance-related issues, and I happened to have some free time at work, so I vented my frustrations in a creative way. Sometimes I love screwing with these people.

We'll see if things get approved now. Damned greedy insurance companies. Sangchaimosifatt!

Happy Thanksgiving

Happy Thanksgiving, folks! As we celebrate this holiday, let's take a moment to reflect on all the things we can be thankful for. Things we take for granted. For me, it's my family, and our health. My parents are here with us for this this year which is a bonus. And yes, if you're wondering, that's a turkey sitting in a pail. Will pop her into the oven for the traditional turkey dinner. If you're into roasting turkeys, you'll find that it's all in the brine. Given the amount of time the bird stays in the oven, there is a tendency for the breastmeat to dry out. So, putting the turkey in a salt solution keeps the meat moist. For my recipe, I use a cup of salt, half a cup of brown sugar, ground peppercorn, aniseed and cloves. You can also use apple cider/juice in place of the cold water. Let it soak for a day before the big roast. Give it a try!

Happy Holidays, everyone!

I just had to share this. No, I did not take this picture, but we saw it on FB somewhere. And with Thanksgiving and Christmas round the corner and some neighbors are already putting up lights, this was the perfect time!

LOL.

Yawn

I'll admit it.

I've had on numerous occasions been tempting to stop blogging.

Not that I don't enjoy it anymore (I do). Just that, looking back at my posts 5-8 years ago, I realize that now, things are just so.... mundane. Boring. Yawn.

Maybe life as a resident in an academic center was more interesting.

Stories about cardiac code-blues.

Or my culinary experiments.

Or attempts to find me a mate and seeing how desperate I was.

Now that I'm 35, married (happily, of course) and a father, and am out in the boring world of practice, my posts just seem so uninteresting.

Yes, admit it, I know you think so too.

The posts about work. My daughter's diaper colors. My dogs. My bowel habits.

Maybe someday life will get more exciting (not that I'm complaining).

Maybe someday a busty redhead Russian spy is going to drive up my driveway in a Ferrari 458 Italia, wanting to seek my help in trying to prevent the domination of the world by the evil organization SPECTRE.

Maybe someday at work there will be a medical crisis, and in swoops the heroic endocrinologist with a syringe of insulin in his holster, and some Levothyroxine pills in his hands, to save hundreds of the critically ill.

Maybe.

Until then, you're stuck with this.

In a Heartbeat

We are lucky.

We have our health and each other. It's one of those things, simple no doubt, but we can so easily take for granted.

The last month has  been somewhat of a challenge because of a healthscare. Without going into details, you realize though how things can change in a heartbeat.

How things may be good one moment, and then the very next, because of a simple phrase from your doctor like "I'm worried it's cancer..." time suddenly stands still.

I recall this clearly too when my buddy first told me of his diagnosis of esophageal cancer. And with this recent development, it put us almost in a state of dejavu. And I couldn't help but re-live many of those emotions we went through 4 years earlier.

It's like you suddenly stop breathing. And life stops moving. It's a shock, and you're left reeling from the news.

And then, when life resumes, when you finally find the courage to start breathing again, you're breathing a different breath of air.

In my buddy's case, it was as if a virtual clock had started ticking. Him, the oncologist, was most familiar with this. You're talking about 5-year survival rates and median life expentancy.

And so, with every heartbeat then onwards, you are reminded that life has an expiration date. Except this time, as parents we have other thoughts going through our heads in addition. How will our children be provided for? Will we see them grow up? How will life continue?

In this recent healthscare we underwent, I'm glad the news was good, unlike our previous chapter. And so, life is getting back to normalcy. Perhaps it is serendipitous that Thanksgiving is next week. But we are again humbled and reminded, to not take life for granted. And that things may change in a heartbeat.