New Year's Eve

What a way to end the year. It's 515am now and I'm oncall till 1pm today. Just had to send a patient to the medical ICU. Sick sick sick, like PCO2 86 and pulse ox 65% sick.
But ever get that feeling though, whenever you transfer a patient, that people are looking at you and judging you? That knowing look they give me, that makes you think they're thinking you messed up on the floor and hence the patient crashed and had to go to the ICU?
Maybe it's just me; maybe I've been awake far too long and are reading too much into nothing.

Till Death Do Us Part?

Had dinner with Vic, a friend who's a heme nurse. She's going thru a hard time now, having found out recently that her boyfriend of 3 years who's now in Florida was 3-timing her. And she only found out by pure dumb luck. He was just screwing around. She's had to get the STD screen, just in case (which was negative, thankfully).

We got around talking about numbers. Interestingly, 60% US married men and 40% women have had affairs (which I assume includes one-night stands). Yea, blame America, right?

Wrong.

This came not long after I caught up with some good friends from medical school or college, in and out of Canada. Friends I respected. People whom I thought of high integrity. Even people I'd known for years. You hear stories. From them, about how they got into sinfully steamy situations with others when their spouses weren't around. Or who were telling me about their fantasies about other women. This one guy keeps telling me his fantasies whenever I meet him online. I'm finding it hard to respect him as a man with all this. All these people, despite being married, some only for 2 years. Screwing around.

So much for the sanctity of marriage.

So much for till death do us part.

Maybe I'm being too judgmental; after all it's easy to point and make judgment when you're on the other side of the fence.

But is there no such thing as being faithful anymore? Is man truly that incapable of keeping his phallus in his pants?

I'd like to think that we can exert more control over our mind, body, heart and soul, than that. And I'd like to think that love, ultimately, can be true.

(But then again, what would a single guy know?)

There & back again...

This is a simulated picture (almost identical) of my last code. Can't use the original due to confidentiality issues. But gets you thinking. This poor guy was dead. In V-fib. No chance he would come back. But with 300 joules (2nd shock, did not respond to the first 200 J) of energy, he came back. Was conscious within 30 seconds.
He probably didn't know how close he came to being buried 6 feet under.

Wish we could have done more for the people back home. 20,000 dead, and counting. Doubt I would be able to save that many lives in my entire career. A quarter of this city's population, just wiped out. Just like that.

As a physician and a Malaysian, this saddens me. We try so hard, to save lives. One hard life by another. And then comes something completely out of our hands. And life is vanquished. Just like that.

I pray that the suffering and grieving are able to find peace.

Christmas Day...

Finally.
It's Christmas.
It's cold here, about -20C. But thoughts of family, friends near and far, warm the heart.
Merry Christmas, everyone.

Christmas Eve...

Did some reflecting tonight. Here's why.

I spent X'mas eve amongst my countrymen. My friend and cardiology consultant from Singapore, had a gathering of Malaysians and Singaporeans. It was great to be able to hear all those accents and phrases (Wah lau, etc). I had a great time, just being me. Feeling close to home. All the same, being doctors (most of us anyway) we traded stories. And I heard some firsthand stories of some young S'porean doctors during the SARS outbreak 2 years ago.

• How a doctor who was infected deteriorated so quickly, that he was sending SMS's to his wife every couple of hours. 1st message: I'm not feeling too well, I'm just gonna stay home. 2nd message: I'm feeling pretty bad, I'm going to the hospital. 3rd message: They say they're going to have to intubate me (He died soon after).
• About how they were strongly advised to write out last wills and testament.
• How they were so afraid of bringing back infections that they stayed away from family and loved one.
• How a young doctor (one of my friends tonight knew him personally) died despite loving care at home by his mother, also a physician. She got infected and died soon after.
• How it felt like a battlefield for them, how they had to use masks, gowns, etc.

My hats off to these guys. While I don't envy that experience, and although they flash no badges or carry guns or make a big thing out of it, they're heroes.

My fireplace (minus the presents). The stockings are up... and I think someone put some stocking stuffers into them (I won't peek until Christmas). My solace from the crazy place I call work... a nice beer or hot choc in front of the fireplace.

I kinda prefer something like this. Of course, the big house is a plus too, but I like just simple lights. There's a lighted moving reindeer somewhere in there too, on the lower left corner, though it doesn't show well in here.

Just look at this! Kinda crazy huh? I wonder what they pay for electricity? It's like the north pole or something. If you look closely, there are choir figurines, nutcracker soldiers, the works! There's even a speaker somewhere in there with X'mas songs playing (they turn it down late at night)

This is my tree. We had a gift-giving session before people started going home for the holidays. Heh heh, among the goodies that I got was a Sports Illustrated 2005 Calendar (from Helen, of all people!).

2 Days to Christmas...

Postcall again. Boy, that was a busy call. And one real code too, pulseless v-tac (he came back after 2 shocks and amio). I was talking on the phone when the code pager went off at 7.55am (why was I surprised that the oncall SMuRf hadn't yet picked up the pager from me? Pager signout time was 7am).

Came home tired and just not wanting to do anything or meet with anyone; but I'm glad John and Katie dragged me out for dinner. Nothing cheers you up more than being with good friends.

Went driving around later just to look at the Christmas lights (can't believe how freakin' cold it is here)(check out the weather page. Remember to change the temp to Celsius). There's this house nearby that wins the prize for turning the dead of the night into day. Just look at the picture. There are hundreds of lights and figurines, and even Christmas music playing in the background. Me, I like simplicity... just plain uni-coloured lights.

3 Days to Christmas...

Oncall again today.
Boy, don't think I'm prepared for X'mas. Not mentally, anyway. I don't know, maybe it's just the thought of the year ending.
Darn darn darn. I think I'm getting burnt out, as I seem to be finding a lot of things to whine about these days.
For one, it's frustrating to me to see how the new doctors are being trained. People who do so much research, have publications and stuff like that. But they don't know squat when it comes to evaluating someone clinically. My interns think I'm crazy when I tell them I hear a mid-peaking systolic ejection murmur with a loud S2 and good pulses, and therefore the aortic stenosis is minimal. And they're amazed when the echo proves me right, but their excuse is, "Oh, with echos, we don't need to know all that."
At this crazy place, with more MRI machines that ALL of Malaysia, this may be true, but still... they're DOCTORS, darn it, whatever happened to the physical exam?
Another thing, I'm getting pretty tired of how superficial things are here. Without going into too much detail, I miss those deeper friendships my friends and I share back home.

9 Days to Christmas

What a thrill.

What a Day!!!

I got Tim Allen's autograph in my book today. Tim Allen, the Actor (Home Improvement, The Santa Clause, Joe Somebody, Toy Story, etc.). I'm a big fan, and I love his book, Don't Stand Too Close to a Naked Man. Anyway, he came to my hospital today to visit my patient, Mr. A. Mr. A was expecting him to come, and heard I was a fan, so he offered to pass my book to Tim for him to sign it. And sign it he did. I didn't get to meet him personally as I had patients to see in my clinic, but, man, what a thrill.

I guess that's one of the fringe benefits of this crazy place; people come here for the reputation of the hospital, and hence, we get to meet film stars and celebrity. In fact, the top floor of one of the buildings was designed by the secret service as the presidents (and reputedly, the late Sultan of Selangor) come here for their healthcare.

And to top my day, Mr. B, who had been sitting around on the transplant list for a month, finally got his heart today! Apparently, a young lady was killed in a motor vehicle accident, and they matched her to him! In the midst of one family's tragedy and pain, love and life flourishes.

12 Days to Christmas...

'Chestnuts roasting on an open fire...'

That happens to be one of my favourite songs.
Christmas is drawing near. My shopping is done; I have a neat pile of presents under my tree for people who mean something to me.
Aside from the snow, and presents, and eggnog, Christmas to many is about love, friendship, family, the brotherhood of man. End of the old, start of the new.
I miss the good old days when I would meet up with my buddies for midnight mass at church. I miss having my folks here with me for December last year (I was on a horrid GI month, so it was nice to come home dead tired to a home cooked meal).

While the hospital isn't the best place to celebrate Christmas, I have to smile thinking about some of the patients I have on service. I call them the 3 wise men. The nurses call them the 3 stooges. Men in their 50's on the cardiac transplant service. They have been here for weeks, too unstable to be home. Waiting for new hearts. Yet, looking at them, one couldn't tell. They each had an IV pole, with nesiritide or lidocaine or whatever else keeping them alive. But on that IV pole, they had Christmas holly, lights, tinklets and whatnots hanging. And when we rounded on one of them last week, I did a double take, when I looked at the IV bags and saw a goldfish in it!! He used an empty bag as a temporary fishbowl. My team laughed till the tears came down.

They hung X'mas deco around the ward. And even put up a 6-foot X'mas tree in the family room. They flirt with the nurses (their wives rolling their eyes). Joke with the doctors ("Hey Dr. K, can I have your autograph? Right here on the discharge slip/morphine prescription"). Try to outdo each other with the IV pole decorations.

I told them they should each hang mistletoe on their poles and stand under them so that the nurses would kiss them.

The human spirit. Looking at them, you wouldn't think they're sick. But collectively, their EF (ejection fraction) is less than 50%. Mr. S keeps going into slow v-tac every other night. They have one foot firmly in the grave. But their smiles and resilience hide it all.

So before I get upset about working in a busy service in December, about not being at home for Christmas, I look to the 3 wise men.

Ode to My Pager

Oh Code Blue, you hateful Code Blue
I dread the days when I hear from you.

Up the stairs, and down the halls I race,
To find the patient, who's trying to leave for a better place.

I shout to the nurses, "I'm here, I'm the code team leader!"
(But actually, there isn't anyone in the room stupider).
Check his airway, breathing and circulation
Then shock, shock, shock for ventricular fibrillation.

Epinephrine 1mg q 3 minutes
And other crazy chemicals in the code kits
Should I try lidocaine, or should i do amiodarone?
Quick, quick, decide, before the patient's gone.

Do we have pulses, or is he in PEA?
Oh, crap, what's making him this way?
Stat blood gases, and check his electrolytes.
Is this an MI, PE or some other plight?

Thoughts of you, give me sleepless nights,
Coz I don't know, when my pager might bite.
I might be showering when the patient decides to die,
Or will you code, when I go to pang-sai?

So here I am, awake on my callroom bed,
Need to poop, but I think i'll hold it in instead.

Nephrologist, anyone??

This will be a short, shameless ad.

We have a Malaysian patient here with amyloid kidney (yea, he flew here). He's gonna need good follow-up back home, and one of the nephrologists here treating him know I'm Malaysian and asked me to see if I could recommend someone.

So, if anyone knows of a nephrologist in the KL area, preferably based in a teaching hospital, who doesn't have a personality disorder, please let me know. You can email me directly. Thanks.

14 Days to Christmas...

Phew. Pooped, big time. Postcall today, although Friday night wasn't all that bad. We didn't get hit with too many patients, although we ones we got were sicker. Young girl, 27 y.o. female with CAD, left main (ostial) disease who had a surgical pericardial patch 2 years ago, now presenting with unstable angina. And this other guy who came in with a NSTEMI; he got me worried because he had occasional breakthrough pain despite nitro and morphine. And his TIMI risk score was 6!!! So, I bit the bullet and started him on integrilin (IIb/IIIa inhibitor). We'll send him to for angio on Monday.

Slept an hour.

Anyway.

Saturday night was more fun. My housemate and I hosted a 'Pre-Christmas Christmas Party' (see picture. That's Cindy, me, Katie, John and Kim). Did it early coz those on non-call months would most certainly travel home for X'mas. Good turnout, 20 people. Made popiah (was tired of all these fake American egg rolls, thought I should show them what it's supposed to be!), sushi. And then there was chicken wings, coffee flan, desserts. And booze. Heineken, Leine's, Bacardi, Mike's hard, chardonnay, cabernet and whisky. It's interesting to see how EtOH disinhibits people; near the end people were almost wanting to karaoke. But we settled on poker and X-box instead.

The girls wanted to play Fuzion Frenzy. The boys, Halo 2, naturally.

The presents are under the tree. Waiting for a fresh dump of snow.

16 Days to Christmas...

It's another one of those days.

I feel dumb. I just have trouble working with this colleague. She's one of the seniors on cardiology as well. And she happens to have the day after me for call. Anyway, technically, call begins at 7am. So at 7am, the seniors are supposed to pick up their call pagers, including the hated code pager. But this girl has been coming in at 830am for call, leaving me with the pagers until then. In fact, I had to run a code at 815am postcall last week, when I had already been awake for over 24 hours, and this was during her shift. Anyway, I just bluntly told her today, call begins at 7am, so I would appreciate it if you could pick up the pager at 7am. Last I heard, she's pissed at me now for making her come in early. This really gets me; she leaves at 3pm every day, leaving the other seniors to supervise her interns. And she always comes in late. She has no right to be pissed now. And the dumb thing is, I'm upset that she's pissed. I came home thinking, should I have kept quiet and pick up her slack instead? Intuitively I know I stood up for what was right. But I suppose it's human nature to avoid conflict.

On another note, I struggled with this difficult patient too today, and this just spoilt my day. 64 year old male who had an invasive left upper lobe adenocarcinoma of the lung, with what appears on CT to be adrenal and thoracic nodal mets. The tumor basically invaded the aorta deep enough to cause a large thrombus to form. So, he embolized some of this to his coronaries and presented to us with a non-ST elevation MI (NSTEMI). Also threw some to his brain and stroked, presenting with cortical blindness and mental status changes. We also found infarcts in the kidneys bilaterally and spleen.

The family was adamant about doing the full cord press. Full code, wanted us to do parenteral nutrition or even PEG tube feeding. Wanted surgery, chemo and radiation.

I had to sit them down today to review what the neurologist, oncologist and cardiologists (us) were saying. Doing more would prolong only his suffering. It's time to let him go. Time to heal and comfort, not to cure.

In the end, they tearfully decided to change his code status to DNR (Do Not Resuscitate). And we'll start looking for a hospice facility for him.

What a day. How does one come home and pretend he or she didn't just have the most heart-wrenching conversation about letting go? Dying. How does one go on with life, with so much death around?

This makes every thing else seem so... umimportant.

Some of my colleagues and I. And no, that's not a real heart I'm holding.

Way to go.

This patient came in last weekend in a-fib with RVR. Started her on heparin and took her for a transesophageal echocardiogram followed by cardioversion.

She converted successfully after just one shock of 20 Joules. So we started transitioning her heparin to coumadin.

My staff wanted to load her higher so that she would be ready for discharge by this weekend (she had a wedding to go to).

"Let's load her, 10mg, 10mg then 5mg."

Not a good idea, I said. Naturally, the consultant staff overules my opinion. After all, they pay him over $200,000 a year (US dollars). And I'm just a measly SMuRf.

Day one, INR 1.1

Day two, INR 3.3

Uh oh. Maybe we should back down on her load.

Day two night; she complains of abdominal pain. Stat CBC shows a hemoglobin of 6.6, INR 5.9. CT abdomen: large rectus sheath hematoma

We had to give her 2 mg of vitamin K and fresh frozen plasma, and obviously, blood.

So much for getting her home by the weekend.

Way to go.

Lesson: Stick to 5mg po daily loads. Even consultants can make bad calls.

Found out one of the patients I admitted on my last call 2 nights ago coded on the way to CT. The lady with PEs. As it turns out, she had a massive thrombus seen on the echo, running from the IVC into the right atrium. It was flapping wildly. That was almost certainly the source of her bilateral emboli. They were wanting to image the thrombus before deciding on intervention. But she suffered a v-fib arrest in radiology. 30 mins of CPR. Defibrillator. I bet the room smelt of burnt flesh by the time they were done, if they had tried for so long. They couldn't bring her back. I bet she clotted off a large portion of her IVC. My hunch is she had an occult malignancy.

Just had to leave all this behind when I came home. So, curled up in front of the fireplace, fired up the X'mas tree lights. Started wrapping my presents. Was almost tempted to wrap up my present to myself, a leather Kenneth Cole briefcase, but I thought that would be too corny.

17 days to Christmas...

You know you're in a crazy world when:

• You sleep 2 uninterrupted hours oncall and you think that's lucky
• Your idea of fun is to watch a drug-eluding stent being deployed in the cardiac cath lab
• You're so tired that you can't remember your mother's name, and here you are with an 8-inch long needle and you're stabbing it into someone's chest
• You're responsible for the lives of over 50 patients on the cardiac floor, and you're the code team leader, and yet your parents don't trust you when you advise them about what they should do for their high-blood pressure
• You still find it fun (after 3 years!) to watch the helicopters land on the hospital roof
• At a click of a few buttons, you are able to order an MRI which costs as much as a used car
• High-pitched beeping sounds make you jump. And higher pitched beeping sounds (not unlike the code pager) make you crap in your pants
• You find hospital scrubs sexy
• You spend 80 hours a week in the hospital, and still come home to watch ER on tv
• You drink 6 large mugs of Starbucks coffee a day to function
• You stick your finger into bodily orifices, drain smelly purulent abscesses, and can still wonder what food they're serving in the cafeteria
• You spend 11 years training to be an endocrinologist
• All the people you hung out with in the last 3 months have either an M.D, PhD, or R.N behind their names
• The only illicit substances you've ever used are alcohol and chocolates, and you have the power to prescribe morphine, fentanyl and any other narcotics known to man
• You get turned on talking about the differential diagnosis of hyponatremia
• You sleep 5 hours a night at home, and you think that's plenty

Slept 2 hours last night. Feel like a total zombie now; this is what we call the postcall syndrome. Kinda half jetlag, half drunk. Recently, the attention has shifted to resident work hours in the USA, after that article was published in the NEJM showing an inverse relationship between medical errors and the number of sleep the interns get (duh!). I remember thinking at 10am today after having been on duty for 27 hours; how can one expect to NOT make mistakes. I had trouble remembering my phone number, and I had to use a calculator to count someone's anion gap (a simple X - (Y+Z), something a kid could do in seconds). Anyway... it's obvious that we don't function as well with no or little sleep.

Varied patients last night:

• Non ST elevation MI's
• Patient's AICD firing due to intermittent runs of SVT (automated implantable cardioverter/defibrillator, something that costs more than my car. Clear mortality benefit in patients with ischemic cardiomyopathy and low EF)(MADITT trial)
• CHF with pulmonary edema
• Bilateral pulmonary embolism
• Symptomatic junctional bradycardia
• A-fib with RVR (rapid ventricular response)

I learned a few lessons too:

• Even if the intern is good and tells you the patient has a new left bundle branch block, look at the EKG yourself. I almost activated the cardiac cath team for a post-op patient with a non STEMI acute infarct. Until I realized the QRS was 102 milliseconds
• Orthopods can be dumb, or lazy. My medical colleagues did a PAME on one of their high-risk patients and suggested pre-op beta-blockade. They disregarded our recommendations. Patient infarcts post-op.

Darn it. Darn darn darn.

Today was supposed to be my day off, but had to go in anyway.

"New consultant tomorrow, and your interns don't know the patients as well. The senior should be around, just in case."

Yea right.

So that's the reason I had to drag my sorry *ss out of bed at the ungodly hour of 6am on a Sunday. And we rounded till 2.10pm. That's 6 hours of nonstop standing/walking and talking to/about patients.

And on top of that, my clever intern had to bolus a patient with an ejection fraction of 25% with 3.5l of 0.9% saline. That promptly put her into pulmonary edema (obviously, this isn't my patient's).

I had to transfer her to the ICU.

No rest for the wicked; I'm oncall again tomorrow.

Darn it. Darn darn darn.

Oncall again

Oncall again. Tired beyond belief. It has been a busy night... all the teams are getting crazy admissions. We've already had a number of unstable patients. And already one code today. Thankfully that guy came out ok. My hunch proved right; hypoglycemic seizure.Have another 14 hours before I complete my 30-hour run. And my migraine is acting up...

These are my dreaded pagers. The one on the left is the code pager. I remember the pride I felt when I first picked my pager up.

"Wow, I'm a real doctor now."

An hour into my first call, after it had beeped over 20 times, I was ready to flush it down the toilet. So much for pride.

If I could give advice to would-be medical students, it would be to read Samuel Shem's 'The House of God'. It's almost required reading amongst interns and residents, mainly because it captured the plight, trials and tribulations this group of new doctors had to endure. It was based loosely on the hospital of the Harvard Medical School. While in some parts exaggerated, a lot of the emotions and insecurities were real. People who have idealistic, unreal impressions of the glories of being a doctor need to realize what may be in store. And a lot of the cynicism in the book (and in real life amongst docs). After having been a doctors for 3 years, I realize the laws quoted in the book were often true.

LAWS OF THE HOUSE OF GOD
I. GOMERS* DON'T DIE.
II. GOMERS GO TO GROUND.
III. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
IV. THE PATIENT IS THE ONE WITH THE DISEASE.
V. PLACEMENT COMES FIRST.
VI. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14 NEEDLE AND A GOOD STRONG ARM.
VII. AGE + BUN = LASIX DOSE.
VIII.THEY CAN ALWAYS HURT YOU MORE.
IX. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
X. IF YOU DON'T TAKE A TEMPERATURE, YOU CAN'T FIND A FEVER.
XI. SHOW ME A MEDICAL STUDENT WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
XII. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
XIII.THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.

*Refers to an elderly patient by the author in the book. Not really a politically correct term; unfortunately, used frequently in real life.

From House of God by Samuel Shem