My home

This is where I live. For now at least. Have the Christmas lights set up outside. Was at Walmart this morning, and I had to refrain myself from buying those cheesy lawn Christmas lights. There were 5-foot lighted snowmen, candycanes, etc. Some houses in the neighbourhood have already put up beautiful decorations. This is where the Malaysian kiasu-ism kicks in. Need to be bigger. Better. Brighter.

Or, I could stalk the neighbourhood with a good pair of wire-cutters and snip away everyone else's lights!

Have always been a sucker for X'mas. This is a magical time of the year. Snow. Cool clean air. Tinkle bells, mistletoe and santa. Eggnog. Family and friends. Love. End of the old, and start of the new. Warm fireplace.

Strangely enough, I hated Christmas in my early childhood. All because of a girl.

My first crush was Elaine. That was way back in 5th grade (11 years old), when the hormones started raging. She was dad's good friend's daughter, and I never noticed her until that one Christmas when she performed in a X'mas show. Ahh, you never forget your first love. (But do people ever remember their first 'like'? Or hate, for that matter?)

The little boy was in love. Never said more to her than "Uh, hi Elaine, mumble mumble." All while trying to look cool and walking past her and appearing uninterested.

At that time in life, girls and girlfriends weren't in the picture yet. We were into gangs, with our own codenames, passwords and hideouts. Digging mudholes, exploring. Bikes were our chariots.

Girls were another species and never allowed in. Worst than the great plague, we'd rather eat a worm than kiss a girl. Oh, how have things changed!

Anyway, Elaine was my secret love. I imagined her in trouble somewhere, and I'd swing down in a rope from my helicopter and save her, or something to that effect.

However, my world came tumbling down when I found out a few months later than she was to migrate to New Zealand with her family. And they left sometime near Christmas. And so, for many years after, Christmas songs would always make me feel blue. Especially "Hark, the herald angels sing". That was the song she danced to the Christmas before.

After some years, I guess I finally got over my heartbreak. Last I heard, Elaine's somewhere in New Zealand still and working as a pharmacist, and recently married. Elaine, wherever you are, I'll never forget you, girl!

End of call

Just got back. 1.45pm.
Call was busy. Slept 2 hours. But thankfully, only one code was called, at 8.30am this morning. I was in the middle of rounds, listening to my interns present their patients. Sleepy. Until I got the call. That woke me up.
Ran up 3 flights of stairs to the ortho floor (why wasn't I surprised that the code came from ortho?). As it turned out, it was a pseudo-code. Someone had fainted.
Anyway. It's over for now. The cycle will repeat in 3 days' time.

Doooh. Have been up for the last 19 hours. Another 12 hours to go. Busy thus far...

First call

I'm 4 hours into call. First call as cards senior. Kim had a bad night last night. Many admits, with a patient in slow v-tac. But at least the code pager didn't go off.
Things are ok now. But this is pretty nerve-wrecking, carrying the code pager on my waist. Had a lot of trouble sleeping last night. Went to bed at 9pm (earlier than usual). Kept waking up, 11pm, 2am, 4am and 5am.
I should try to get some rest now, before my interns start getting admissions. Oh, please please pleeeease let there be no codes on my watch.

First Snowfall

It's official. First snowfall of the year. I love the first snowfall. You go to bed one night, and wake up to a winter wonderland of whiteness. The air's fresh, everything's quiet, and all you hear is the sound of footsteps on the fluffy snow.

Cardiology

It's change of service tomorrow. To us, it's kinda like the changing of the guards. We move to a new rotation. A new team of residents come in to take over our patients.

This usually happens at the first Saturday of the month (in this hospital, the first day of the week is Saturday). This usually starts with the new teams calling the old teams up on Friday to get info about the patients we're about to take care of. Also, to find out when our consultants want us to meet. And also if pre-rounds are needed on the weekends.

Pre-rounds. Always a big issue. If our team officially meets at, say, 8am for rounds, we need to have seen patients, examined them, ordered labs and meds and have written our progress notes, before 8am. Depending on the number of patients you're carrying, you can sometimes come in over an hour BEFORE rounds begin. And on change of service when the patients are all new to you and you may need 30 mins per patient, pre-rounding is traditionally not done. That's why there is usually a lot of complaining when we find out we're required to pre-round on day 1 (Usually also a sign of an uncompromising consultant. Bad).

I remember when I was a fresh intern, slower, looking after sick ICU patients. I was coming in at 530am to see patients. Those were dark times. Now, I can round on a patient in 5 minutes or less, and still provide good care.

I begin cardiology tomorrow. Again. But this time, as the SMuRf (Senior Medical Resident). I will not carry any patients of my own. No need for daily notes; my minions will do that. My responsibility will mainly be of a supervisory one, and I write only supervisory admission notes. Call will still be q4d. For me, that means overnight on Sunday, Wednesday, Saturday etc etc. You get the picture.

With that, however, comes my greatest apprehension. I get anxious thinking about it now. The CODE PAGER. A 2nd pager besides our usual one. A simple, 3" by 4" device with a shrill alarm that wakes even the dead up. A code is simply, a cardiopulmonary arrest. Patient dying, or dead. Although sometimes people have been known to call codes for fainting spells. Most people have trouble going to the toilet for a Number 2 when they're carrying the code pager. Hey, you never know when a patient decides to crump when you're taking a dump.

When a code is called, the code pagers go off first. Followed by an overhead announcement seconds later.

The problem here is, being the cardiology SMuRf, you're the code team leader. You call the shots. Decide which medication you need to give to the patient. Immediately. Stat. Shock or no shock. CPR or not. ICU or CCU. Bleh. I'm gonna give myself irritable bowel thinking about it.

Thanks to shows like ER or Baywatch, many patients get the idea that if they code, you almost always bring them back. It's quite the opposite. Less than a third come back. Depending on the medical center, and how old or sick patients are, probability that the patient will live to walk out of the hospital ranges from less than 5% to 30%. And having seen enough codes, you realize, if it's my time to go, let me go quietly. A code is very traumatic, for the patient, family and staff. People shouting. Alarms. A crowd of medical staff in the room. The sound of the defibrillator. Sometimes, the smell of burnt flesh. Blood. Tubes. Needles.

Happy Thanksgiving

Happy Thanksgiving!
Post-call today, but thankfully I got some sleep last night in the callroom (ever notice how you NEVER sleep well despite having no pages? It's like trying to sleep with a grenade stuffed into your pants, not knowing when it will blow). Got out early today.
I'd like to reflect on life. On things I take for granted most of the time, especially on days I bitch and whine.
I'm thankful for my wonderful family (of course, I'd never say that to their faces, especially my dear thick-skinned sista). Dear, dear friends, who despite being half a world away, are still close at heart. Friends here, who have helped me keep my sanity (and gain pounds, what with our 'Eat more get fat slogan'). By the grace of God, my career and the chain of events that led me to here, now. Of course, my health. My sight, my senses. My experiences in life thus far. I'm thankful for the chance to make a difference in my patients' lives. For the people I've met, the privilege of being able to hold a dying person's hand.
And of course, I'm thankful for Veronica.

I'd like to share this prayer, by Abigail Van Buren (Dear Abby):

O Heavenly Father:
We thank Thee for food and remember the hungry.
We thank Thee for health and remember the sick.
We thank Thee for friends and remember the friendless.
We thank Thee for freedom and remember the enslaved.
May these remembrances stir us to service.
That Thy gifts to us may be used for others.
Amen.

Christmas Tree, O Christmas Tree

Call me impatient. It's not even Thanksgiving yet, but I already decided to put the tree up. I thought, what the heck, I was free anyway. And they were already playing X'mas carols on the radio. Snow was forecasted for the weekend.
So, loaded my X'mas song collection and pulled out my 6' fake tree and started working on things. When my housemate (guy from Penang, also in medicine) came home and saw me, he shaked his head and mumbled something. I think it had something to do with needing to call the psychiatrist.
I remember being surprised years ago when I discovered people here preferred fake trees in the name of conservation.
Anyway, my tree is up. With all my Christmas trinkets. The lights for the yard, well, I'll work on that some other day. And I'll keep my mistletoe in the cupboard until it's at least December.
What do I want for Christmas? Hmm. A Palm Tungsten? A Honda S2000, whom I'll call Jessica? A date with Kristin Kreuk?

What do I REALLY want for Christmas?

• To meet with my highschool buddies at midnight mass and give them all a warm embrace and tell them what they mean to me, and how they got me through those trying times after my break-up
• To be able to apologize to my ex-girlfriends for being an immature jerk
• To have a joyously loud dinner with my family, and see my new nephew
• To be able to take my late grandpa out again for his monthly haircut and listen to his stories about his old friends who had passed on. Or to be able to tell him, "Ah Kong, I made it."
• To, for once and for all, find love
• To feel confidently, that all the sacrifices, are worth it

Mission Accomplished

Finally. Had the day off today. Completed the entire game of Halo 2. Man. Kinda anticlimactic, if you ask me. The end sequence wasn't a lot to shout about. But it's clear, Halo 3 will be in the making soon.

The lies my mom told me

1. Don't worry, life gets better after medical school
2. Don't worry, the girls will come lining up once you become a doctor (nope, not happening yet. Not unless you're talking about patients lining up for a Pap smear. Uncomfortable. But necessary enough, I suppose. See digression)
3. Women like a man who can cook (can whip up a tasty chicken pie or sushi in no time, but ain't working yet)
4. You can still grow taller
5. You can use pandan essence in place of leaves for the nasi lemak (see recent picture)
6. Making popiah is easy
7. You can machine-wash this shirt (I now look like the guys from Queer Eye for the Straight Guy when I wear my long-sleeved t-shirt. It shrunk a few sizes)
8. Your feet will still grow, so you should always buy a few sizes larger (Explains why I look like I'm wearing ole' Ron McDonald's shoes. Mom: I have a medical degree. One's feet DO NOT grow in size throughout life, unless you have a hormonal imbalance)

Digression:

Pap smears (or Papanicolau), an uncomfortable screening technique for early cervical changes associated with cervical cancer. This happens to be a very slow-growing malignancy. So why do so many women in Asia, including Anita Mui, succumb to this? Lack of awareness. The words 'Cancer Screening' apparently do not exist in Malaysia.

Here, we recommend all women above the age of 18, or after first sexual contact, to begin annual Pap smears. This may be decreased to every 3 years with 3 consecutive negative tests.

Mammography every year or every other year, starting between 40 and 50 years of age.

Colonoscopy every 10 years after 50 years of age. Earlier, if there is a family history of colon cancer.

But ask yourself, or those around you: How many people who fall in the groups above have actually done so? Is it a big surprise then when that report was published in the paper regarding the high cancer-related deaths in Malaysia? Even my good friends, married or unmarried, do not think they need to get Paps. Instead, the labs in Malaysia profit from doing expensive blood tests for 'cancer markers'. This, unfortunately, is not based on evidence or data.

Post-call

Dooh. What a night.
Probably my own stupid fault. The Gods of Call were listening.
My night was slow. One consult for most of the day. Had an extended dinner at the cafeteria. Hmm. It was wild rice, fried chicked, chicked quesadilla, salad and fries. Starbucks coffee.
Hey, I was hungry. And the food was free (free food oncall).
Even watched TV (Law & Order: SVU) from 7.30pm-10pm.
Made the mistake of commenting on how bored I was. I swear, there is a microphone somewhere in the internal medicine lounge. Because shortly after that, after I had retired to bed, I get this panicked call from the orthopod (orthopedic surgeon. But I like this name better; makes them sound like insects).
"Can you come help us with this patient? 67 year old lady, post-op day 3 laminectomy T10-L2. Unresponsive and tachycardic."
That effectively ruined my chance of sleeping. From the stat bloodwork, EKG and then head CT, followed by CT angio of the chest, etc etc.
As it turned out, she was unresponsive because her family kept clicking her PCA button for fear of discomfort. And gave her several boluses of fentanyl.
And the tachycardia was probably from a UTI.
Went to bed again at 3.30am. Another call at 4am. SOB (shortness of breath). Chest Xray. Congestive heart failure. Lasix lasix lasix. Pee pee pee. Feel better. Cured.
Decided to drive to Minneapolis for Dim Sum lunch (although it was pretty hairy driving 1.5 hours after having been awake 30 hours). Met up with friends from KL and Singapore. And ate my sorrows/frustrations away. Heh heh. 4o dollars later, I feel better.

Only in a sick and convoluted world such as medicine do you hear statements like:
"Wow, I lucked out last night. I manage to sleep 2 hours in a row!"
"I get to wake up late today; have to start work only at 6.30am."

Nail Polish Emergency

Err. How does one remove nail polish? Hospital-grade alcohol didn't work too well. Prizes offered to effective solutions (short of cutting off my tootsies).
This needs to be OFF by the time I hit the gym on Monday.

Crazy nurses

Was at a party at one of the nurses' house. It was a barefoot party, for what it's worth. Lets just say that nurses (I guess residents too :) ) can be pretty crazy when they're all boozed up.
I'm now oncall again. Sitting around my callroom in the hospital. Wondering why on earth did I let someone give me a pedicure.
Well, at least I have pretty purple toenails now.

Silver lining?

I'm feeling good now.
Maybe woke up on the wrong side of the bed. And have been grumpy for the less couple of days. But I guess things are going well today.
Saw patients at clinic today. In one of them about to undergo surgery, heard a loud late-peaking systolic murmur. My attending thought it was just age-related. But I pushed for an echo. "Severe aortic stenosis, valve area 0.7cm2." Cancelled the surgery; he's probably gonna need a valve replacement first. Or he could have gotten into real trouble in the OR.
Another patient. History of asymptomatic CAD, picked up incidentally and underwent a 5 vessel bypass 9 years ago. No stress test since. Didn't like his story. And he was due to have a carotid endarterectomy. Decided to stress him with a dobutamine stress echo. Came back as positive for ischemia, low ischemic threshold of 74 beats/min. High filling pressures. The cardiologist estimated his risk of a cardiac event on the operating table to be 80%. Postponed his surgery as well, until he gets an angiogram. He would have had a heart attack on the table.
And then, a med student from Germany whom I worked with last year emailed me. She was turned down for a position here. She's devastated. USMLE of 99. And she's good too. So I emailed my program director to put in a good word for her. And he was surprised. As it turned out, they did want to interview her, but she got a letter of rejection by accident. So, they rectified things, and she's coming in January for interviews. And she's happy.
Perhaps the day isn't too bad for me, after all.
I feel good.

I want to believe...
I want to believe that goodness brings rewards.
I want to believe in a world where people who are kind and thoughtful, go farther than people who lie.
I want to believe that our acts and words last longer than reputation and wealth when we die.
I want to believe that actions can touch us for a lifetime.
And that goodness, kindness prevail over arrogance and impatience.
And that love matters.

~Author unknown

Kitchen experiment

Nasi Lemak. Hah hah hah. At least, it's MY version of it. Was craving for some good ole nasi lemak, so did some online searching, and had a go at making this. Problem was, I used pandan essence in place of real pandan leaves... and was somewhat taken aback by the colour of the rice. As you can see.
At least it tasted kinda ok. I was impressed with the sambal, even without lemon grass and belacan, it tasted quite good. The pandan essence, well, that did nothing to the rice.
Let's hope I don't go running to the toilet tonight for gastroenteritis...

This pisses me off.
I have this colleague, who is a real loudmouth, an impressionistic person who lacks in real substance and personality. However, she is good at carrying herself, and sells herself well by saying the right things to make her look good. Even things which were not necessarily true. In fact, I've caught her telling outright lies about others before. And she's able to secure a fellowship in GI, one of the most competitive medical subspecialties. And she's always surrounded by people, albeit shallow friendships most of them. Frequent parties, things like that.
Now, take D. A good friend of mine from Vietnam, who is the nicest and most big-hearted person around, and who also happens to be an excellent physician. However, he is not very fluent in English, and thus, doesn't always say things clearly. And people judge him for that; and he is having trouble convincing others that he is a capable person. It's his birthday today. But he's celebrating this alone at home. Even his 'friends' whom he took out for their birthdays, didn't bother to look him up. If i wasn't oncall and had to be in-house, I'd take him out.
Is this place really that shallow? Are people really incapable of judging someone based on more than how they look or speak? This sickens me. But you see it so much in medicine. People who like to show off, whether or not they have real substance, or the backstabbers, are the people likely to go further. What a shame that things have come to this.
Also, maybe I have high expectations from my friends. But when I go the distance for friends, I'd like to know that I can depend on them to do the same for me too. Here, I can't say I feel that of many people. Unfortunately.
I'd like to tell them. "For every time you had to reach for someone in your moments of despair, ask yourself, how many times have you reached out to help someone in need?"

Hail the Master Chief!

Finally!!
Halo 2 is here!
Have waited long enough for the sequel to Halo, the very reason the Xbox was created (well, at least for me).
Was postcall on Nov. 9th, when the game was released. Nick paged me as I was rushing through morning rounds at 730am.
"I'm in Walmart, only 3 copies left. Do you want one?"
Hell, yea! The USD 54 was well worth it.

On Day One, my housemate and I were both postcall. I was on Medicine Consults, him on Pulmonary. I had been up most of the night for me with an unstable patient with PSVT, while he didn't sleep a wink. Came home, and before we even rested, started playing till we both we nauseated and felt like puking.Literally.Combination of fatigue, and the 3D graphics.

But man, is that a sweet sweet game. And, better than the first, now you can yield TWO weapons at the same time. New weapons (Covenant carbine, battle rifle). And best of all, ability to play online.Met up with Quan online, with him being in Texas. Naturally, he got creamed.

ACP

Presented a paper at the American College of Physicians Regional Scientific Meeting today. It was fun to see what was going on. To meet up with friends. Met with LP, one of my close Malaysian friends doing internal medicine in Minneapolis. He's going into nephrology next year.
Except it was hard trying to present after being oncall the night before; and I had to drive too...

ACP Group picture

One of the many fascinating cases presented at the meeting. This was a horrible case of orbital mucormycosis. I don't think the picture turned out well, but let's just say it made many seasoned doctors there lose their appetite. This was an operative picture with basically the right face opened up. The 2nd picture was what's left of the eye.
I gotta stop rubbing my eyes...
ACP

Poor guy.

Just had a long chat with this patient of mine on the ortho service. Guy in his 70's who came in with yet another infected left knee arthoplasty. He has had multiple infections, needed several months' worth of IV antibiotics. Now he's growing MRSA, coag negative staph AND pseudomonas from the knee joint. Surgeons are suggesting an AKA (above-knee amputation). After all the pain and suffering he's gone through, he's finally agreed.

Meanwhile, he's tired. He's been here for weeks. And he's in constant pain. And he's upset that he's gonna lose his leg. And worse of all, his 56th anniversary is tomorrow.His wife has been by his side constantly. Really gives meaning to the words commitment and dedication.

I think I'll bring them a cake or something tomorrow.

Oncall Again

Oncall again tonight. Q4d. Every 4th night. A quarter of one's resident's nights spent in-house.Not too bad today (touch wood). The surgeons and neurologists pissed me off yesterday. The surgeons called me late in the evening. Wanted me to clear a patient with cholelithiasis for surgery. Spent 30 mins looking at the chart but the story didn't fit. The guy I was looking at was just septic, BP86/40 and tachy. Why on EARTH was he going for a cholecystectomy?? I called them, and the surgical intern apologetically admitted, they gave me the wrong patient to see, so would I please go clear the right patient? The process repeats itself, and I find that THIS guy (right guy) was already cleared for surgery last week as this was an elective laparoscopic chole. Called the surgeon back, in my most patient yet sarcastic tone, guided him to the patient's chart on the computer to the part where it says "... he has been cleared for surgery, another *PAME not required...".And the neurologist. Gawd. "Please *PAME this patient, 68M with CVA, may undergo CEA." You do the PAME, and find that 25% of the patients you clear end up not going for surgery at all. What a waste of your time, resources and the patient's money.*PAME: Preoperative/Preanesthesia Medical Evaluation, CVA: Cerebrovascular Accident or 'stroke', CEA: Carotid Endarterectomy
I think they're all afraid of pissing off the SMR (Senior Medical Resident)(then again, medical juniors call us seniors SMuRfs) again tonight with bad consults... maybe that's why my pager hasn't gone off much today."Think happy thoughts..."At least I have something to look forward to. Planning a 2 week vacation back home. Probably May/June 2005. My very last month of residency. It'll be good to see family again.