CDMJC

Tomorrow will be terminal call for Gen Med. Last day of service, before I rotate into the medical ICU.
Will also be presenting at conference tomorrow morning.
Use of pulmonary rehabilitation in patients with frequent COPD exacerbations.
I hope I don't get roasted tomorrow. I'm hoping nice pictures of Malaysia would distract the audience enough to not ask me questions I can't answer!

Wish me luck.

Internal Medicine, Class of 2005

One of the many pictures I've been snapping. In preparation for graduation dinner next month, I'm putting together a slide show. Graduation... how time flies. Didn't seem like too long ago (or did it?) when we were starry-eyed fresh interns. So idealistic and naive. And constantly afraid of messing up and killing a patient. Felt like I didn't know enough to treat people.
Now, although I still sometimes feel like I don't know enough, I suppose work would prove us wrong. We treat diseases, some of them acute, without thinking twice... and then when you look at things you suddenly realize that maybe you did learn a thing or two because you knew exactly what to give, where to insert that needle, or if necessary, how to shock like back into the chest. Maybe I'm not such a klutz after all. Or maybe I am

Friends too. People you've gotten so close to. It's hard not to, when you're working side-by-side with them up to 30 hours at a time. When you share the tears, when patients die. Or loved ones. Or just when work gets to you.

We started with 42 in my class. In the last 3 years, we've lost 5. 2 of them my close friends at a time. But this place got to them.

Come July 2005, we'll be separating. Some will stay on here, for fellowships. Some for a staff position (big BIG money!). Some will leave. Big places (Johns Hopkins, etc.). Small places. Cardiology. Gastroenterology. Hematology. Nephrology. Rheumatology. Endocrinology. The first phase of postgrad (residency, specialization) will be done. Next comes the final phase (fellowship, or subspecialty) in our long, long journey, one which I started 9 years ago. One which I consolidated when I took that oath 4 years ago.

The last few years have taught me a lot since my naive medical student days. Some pleasant, and not-so-pleasant things too. Like how love can endure even through death. How the human spirit can be so wondrously resilient. But yet, the darker side of Man. How some people really don't want to get better. How some people will just out and outlie to make you give them narcotics. How a human being can intentionally hurt another.

I've also learnt that life is precious. Time is short. And we all die, someday.

Had dinner with Helen just now. Talked about a few things. Among them relationships. And I guess it struck me then, listening, just how stupid I'd been with how I handled certain issues in my life. Just how absolutely stupid. And blind.

So stupid that it makes me angry now.

Maybe so too because I never learn.

There was a time when I thought I knew what had to be done. But perhaps I have been wrong all this while.

Easter

Was a lazy sort of day for me. Had breakfast with a good friend, dear old Dao, who will be heading to Florida for cardiology this July. Will miss him.... sincere friends are hard to find over here. Anyway, spent the rest of the day at home. Mainly working on my taxes. But after several hours and number that don't make sense, I gave up. Will head to H&R block this week I suppose.

Heard from my interns (had Saturday and Sunday off) that Mr. A was discharged yesterday. Was a wee bit upset that I didn't get to say goodbye to him. The ultimate goodbye, huh? I don't expect him to be around till May. I pray that he will find peace through this chaos. I'll probably send him a card or something. It's frowned upon, some people say that's getting a bit too personal. But scr*w them... I think some doctors think so highly of themselves that they expect us to 'stay professional' and not get too close to patients.

Spent a big chunk of my day working on this big Friday conference presentation too. Had almost completed that, until dear Coolcat said I needed some graphs to make it better (Heh heh, you're probably feeling a wee bit guilty now, aren't you?).

Also... working my my class graduation dinner video. Yes, someone punted the job of making the music video to me. Not that I'm complaining... I like doing these kinds of things. Expect the stoopid Pinnacle Studio 8 kept crashing my pc, and my roomate's pc. So, I either have to figure out what's wrong with that God forsaken program, or stoop down to Windows Movie Maker. Any ideas from all you IT saavy people out there?

I could put the video online too, except I don't know how I could upload this and which server would host this.

Will be oncall again tomorrow (Monday). Monday, then Friday (terminal call) before I begin medical ICU senior month on Saturday. Now THAT's a month I'm almost dreading as much as cardiology. Sick patients. Codes. Basically things I don't get along with. But, April will be my very last month of inpatient oncall for the rest of my working life here. Woo hoo!!

Sigh. Some day I'm pretty sure I'll have hell to pay for ruining so many people's lives.

I had to do it.

I had to make it clear to Mr. A. that there was no hope. That the poorly differentiated adenocarcinoma likely of pancreatic origin had already metastatized to his abdomen. And liver. I had to tell him that we will not offer chemotherapy, because there was no hope. And I told him with his entire family present. I had been working 31 hours and technically was in violation of work hour regulations (maximum of 30 hours nonstop). But I had gotten to know them best and didn't want to punt this thankless task to someone else.

I had to do it. They weren't listening to the medical oncologist. Or the surgeons. Or us. When someone told him, "Less than 1% of these patients make it to 2 years", he thought "If I try hard enough, I can be that 'less than 1%' ". And the family was torturing themselves with the false hopes.

In the meantime, he's spending what is probably his last 4 weeks on Earth in the hospital, hundreds of miles from home, when he should be with family and loved ones. In the last 3 weeks that we've seen him, he's shrivelled up so.

Life isn't fair, he angrily told me today.

Early 40's. Beloved husband, father of 3, youngest child just a week old.

No, life isn't fair. I didn't tell him about the young single mother with a young child who died of complications of ovarian cancer I looked after. Or the young 20 year old girl in the army, who collapsed one day and spent 15 mins in the base clinic waiting room while her doctors were futzing around, while she was in polymorphic v-tac. By the time she was airlifted to our cardiac intensive care, she was essentially in brain death.

Honestly, this unfairness scares me. Somehow, you think death is something only older people have to deal with. It seems natural... you live life, have kids, grow old, and go. Circle of life. But the reality is different. Young people die. Good people. Lives just opening up.

I'm glad I have the next 2 days off. Maybe I'm feeling burnt out. Or maybe I've just been awake too long. I need a break. I really do...

How would you like to die?

How would you like to die, Mr. Bond?

Not everyone has choices like 007 (although personally I think the baddies are idiots. Just shoot him, because you know if you try to kill him in some slow methodical way, he'll escape and hunt you down, with a grin and a vodka martini in one hand, beautiful Russian spy in the other arm).

Anyway. Morbid as it is, this was what our lunch topic was about. Bunch of docs, pondering on the Grim Reaper. Thinking aloud of our cases. Death by sepsis. Myocardial infarction. Metastatic pancreatic cancer (that's a bad way to go). Intracranial bleed. Fatal arrhythmia. Seen it all. If we could choose, what would be the way to go?

As expected, the joker in the group wanted to get a heart attack during sex. He thought it would be a great way to end life. Poor girl though. I mean, can you imagine?

Someone else wanted to go in her sleep. Sudden cardiac death.

Another, skydiving accident. May be a quickie, but boy, I bet those few seconds between realizing your chute's not working and impact would feel like an eternity. And you're probably cursing the guy who packed your parachute too.

Me, none of that. Choice number one, probably stems from my watching too many hero movies... villain takes out his concealed revolver, points it at beautiful princess/President/Pope... and then here I come, leaping into the air... right between them... hammer cocks... BANG... I take the slug in the chest (kinda like Clint Eastwood in In the Line of Fire).

Damsel kneels down, crying "TK, TK, don't leave me...".

Like I said, watched too many movies in my childhood.

Choice number two, would be to burn up on re-entry of the space shuttle. Or on take-off, like the Challenger. While those NASA accidents were tragedies, I think of the astronauts as heros, dying for a cause they believed in; the discovery of space.

Anyway, I doubt my time (hopefully in the much distant future; there is much to do and learn still) would be anything like that.

I'm not sure if 'normal' people outside of medicine think about things like this, about their own mortality, but I know we do for sure. And for me, if I have to go, go with a bang. None of that withering away stuff. Or being mechanically ventilated for months before pulling the plug.

My greatest fears? Drowning. Some neurodegenerative disease such as Lou Gehrig's... and for that I will always admire the strength of the character in my favourite book, Tuesdays with Morrie. And pancreatic cancer's got to be near the top of my most-feared list too. My current patient comes to mind... 42 year old man who's probably got weeks to live, in much pain, and a new baby who was born when he was in the hospital on a PCA morphine pump. Had no answers for him when he asked me how God could let this happen. We're gonna attempt a celiac block tomorrow for pain control. Acetaminophen OD probably isn't a good way too. This seems to be the choice of suicide for many young people. But they don't know that fulminant hepatic failure is a slow, torturing way to die. And you turn yellow.

Our speaker at Medical Grand Rounds today spoke of several things. Bright lady, a master clinician from University of California. One of the things she touched on was Death. And she ended with this quote:

Do not go gentle into that good night. Rage, Rage against the dying of the light.

~Dylan Thomas

Food for thought

It was a busy call, again. Sick patients. Didn't sleep enough last night in the callroom.

Anyway, was at rounds this morning, seeing one of our patients, who spent months in and out of a hospital elsewhere, he was sent here for 2nd opinion where our pathologist confirmed the diagnosis of calciphylaxis. My intern gave him (and family) the numbers: median survival 3 months. For another family, their world comes tumbling down.

And yet, while Adam, my intern, was talking, my mind was wandering. Partially from being exhausted and hungry. Was thinking about how rounds were dragging. Thinking about how I shouldn't have skipped breakfast. And what I should have for lunch. Where I should go for the weekend. Looked outside and saw the shining sun; wondering when I could take the bike out again for a ride. Oh, maybe I should buy that new mini iPod shuffle so that I can take it for biking.

And then I caught myself. The normalcy of my thoughts. Here I was, with my team, ruining another family's day with the news, and yet in my little world, cocooned by the perceived protection of my white coat, life was going on as usual.

Guilt. That's what I felt. One, for having 'normal' everyday thoughts in the midst of someone else's nightmare. And two, shamefully, for being grateful that this wasn't my family.

I remember when dad was told of his colon cancer in 1996. I remember thinking angrily when I looked at those around me, Why is everything still going on as it was? Don't you all know what we're going through??

Kinda like the song End of the World. Why does the sun go on shining, why does the sea rush to shore? Don't they know, it's the end of the world... ?

The thing is, we go through this every day. And give little thought to what the patient might be going through. Sure, we listen. And sure, we sit on the bed and hold their hand, and say we'll be there for them. But when we exit the room, life goes on for us.

Wham! Out of the blue. Big dump-o-snow. Started snowing last night, but I found out only this morning when I had to struggle to get to work. So far, 16 inches and it's probably going to go into tomorrow. Almost perfect consistency too. Heavy enough to pack into a snowball. Snow like this, feels fluffy when you walk on it. And a perfect snowball, with a well-aimed shot (usually at my sister's head!) goes 'paff' on impact.

Almost broke my back shovelling my walk.

On another note, it was Match Day yesterday. When graduating medical students find out where they go for residency. The Match, a really traumatic process in which people rank their choices after they've been invited to interview and the hospitals rank them according to how highly regarded they are. And on this day, the results of this match are released. Often, partners are separated. Where one goes depends on the match.

This year, to my delight, we get another Malaysian. That would make the 6th Malaysian running, in the internal medicine residency here. And also, a Singaporean. They should be starting in July.

Well, let's hope they have good winter gear!

Another sick one

Had another one today. New admission, young-ish male in his 40's, admitted for what appeared to be pneumonia. Cough, left-sided chest pain, some consolidation on chest X-ray. Already on anticoagulation for something else, so pulmonary embolism was much lower on the differential. Admitted to my junior on the floor.
I got involved when she came up to me to ask what I thought of this arterial blood gas pH of 7.1! Asked her how he looked, and she said he looked short of breath but otherwise fine. Thought the numbers didn't make sense, so I thought I should see how he looked.
Checked him out, and immediately knew he was in trouble. Tachypneic at 40 breaths a minute, tachycardia 140's, pulse ox 80's and very diaphoretic. Spoke briefly to him, then scooted out of the room to call the ICU to make tranfer arrangements. Because he looked like he was going to crum any time, asked him about his code status: Full Code.
Rushed him to the medical ICU. In fact, room's right beside my other MICU patient from yesterday, and signed out care to the MICU team (we're Gen Med). Within minutes, they intubated him.
Now, at 122am, he's hypotensive, on 2 pressors. Probably in septic shock despite the antibiotics. My colleagues gave me an update; basically, he's coded once every hour. Keeps going into PEA (pulseless electrical activity). His last ABG showed his pH to be 6.8 with pCO2 greater than 100.
I just spoke to him this afternoon. He looked sick, but was able to talk. But now, he's not going to live to see tomorrow. And he has no family around.
Life can be so fragile.

This brings back some haunting memories. Things I still see in my nightmares after a bad day:

• That young male patient with advanced myeloma, who developed a tension pneumothorax after he had a central subclavian line place. I saw his pressures drop to zero. Despite the surgical resident's heroic efforts to put in a chest tube.
• That dialysis patient who coded when I was an intern and 2nd in line on the code team. I did the chest compressions, and I remember exactly how it was, me straddling his chest and pushing, feeling the ribs crack. Crack, crack. I still feel it.
• That middle-aged gentleman with a mitral St. Jude's valve who developed a huge right arm hematoma while on coumadin. We had to stop the anticoagulation; we had no choice, knowing the risk of clot formation. I was at clinic when the oncall resident paged me: Your patient is coding. By the time I rushed over, he was gone.
• That elderly patient I had in the cardiac intensive care, who kept going into pulseless ventricular tachycardia. We coded him many times that night. Shock shock shock, 300 joules. Until his wife said, enough, let him go. I still hear the cardiac alarms in my dreams.

Arrghh!! It's a plague! Got this email today from another friend:

Hello Ppl! Just thought I'd let you guys know that I will be getting married this year. Chinese wedding will be on the 24th of Sept. Church wedding will be some time in July. All events in Seremban. May leave from either KL or Sban. Not sure about the timing yet. All are invited to be 'chi mui'.:) Will keep you guys updated. Pls tell me you all can make it.

Ciao!Sal

See what I mean?

They say prayer heals.

Though I don't consider myself a very religious person, I do think I'm pretty spiritual.

Just got word a patient of mine isn't doing too well. 75 year old male with renal failure on intermittent hemodialysis, admitted for abdominal pain. Found to have a loculated peritoneal effusion with spontaneous polymicrobial bacterial peritonitis. The general surgeons felt he was too sick to undergo surgery. So, we had interventional radiology place 2 drains into the peritoneal space to drain the infected fluid. Broad-spectrum antibiotics.

He progressively declined. Today, his pressures dropped to 68/35 despite fluid resuscitation. Had to send him to the MICU. Last I heard, he's developing a small bowel obstruction.

I spoke to his wife before I transferred him. Told her his prognosis is grim. And should he code, we would never bring him back to a quality of life he'd appreciate. I suggested she think about changing his status to DNR (Do Not Resuscitate).

So, tonight, I'd like to say a prayer for him, and his family.

What the hey...???

What the??? Look at it. Just look at it. That's my thermometer. Yup, you read it right. It's -10.5!! So much for spring coming. And I just took that this morning before I left for work. Thought I could get away with lighter clothes, so I wore my usual suit and tie (yes, that's standard work attire here. A freaking suit). Took a step out, and promptly came back in for my coat and to check the temp.
In fact, right now (745pm) it's snowing.
Just heard from mom. A buddy of mine and childhood friend, Kevin, is engaged. D*mn. And I've always had this comfort zone with some of my friends still being unmarried. Looks like this is fast changing.
Let's see. My highschool gang (11 of us, mostly of the prefectorial board): 5 are married, 4 are attached and 2 are single. And ahem, the other single guy we've always wondered if he was.. err.. playing for the other side. So that leaves me.
Kinda funny how things go. When I left for med school in Canada 7 years ago, Mom (being so traditional, afraid I'd end up with a kwai-poh) said, "Go find a nice Malaysian Chinese girl..."
And then a few years later: "Find a nice Chinese girl..."
Most recently: "Find someone..."
My housemate TS confessed just a couple of days ago that my mom asked him to help find me a girl. Heh heh heh. She must *really* be getting worried.
Perhaps I should put up an ad, huh?

"Short single Chinese doctor seeks female. I can cook and clean, prescribe narcotics, disimpact bowel. Sometimes handy around the house, good for warming the sofa. Looks adorable in a chili-red apron (included). Please contact me at 1-800-DESPERADO."

Mt. St. Helens in the background. Beautiful volcanic park in WA. Made famous by the massive 1980 eruption. Still active; in fact, there was a minor eruption just last Tuesday (even dad said he read about it in the papers in Malaysia). There is a live volcano-cam here if you wanna see if you're lucky enough to see another eruption.


In this picture, you can see the massive crater left behind when she blew her top. Cleared out a massive area. Still looks pretty barren now.


A close-up of the crater.
At 8:32 Sunday morning, May 18, 1980, Mount St. Helens erupted. Shaken by an earthquake measuring 5.1 on the Richter scale, the north face of this tall symmetrical mountain collapsed in a massive rock debris avalanche. In a few moments this slab of rock and ice slammed into Spirit Lake, crossed a ridge 1,300 feet high, and roared 14 miles down the Toutle River.The avalanche rapidly released pressurized gases within the volcano. A tremendous lateral explosion ripped through the avalanche and developed into a turbulent, stone-filled wind that swept over ridges and toppled trees. Nearly 150 square miles of forest was blown over or left dead and standing.



The green lake was previously a creek, until the blast caused a massive landslide that turned the creek (river) into a lake. On the hill beside the lake (inset) you can make out the trees that were snapped away in the direction of the blast, like toothpicks. And this, several miles out from the actual eruption!

The Pacific Northwest

Wow.
Thought spring was here. Woke up at 6am, looked at the morning sky and I immediately knew. Snow. Was due to take a flight from Minneapolis to Portland and was originally planning to drive up to Minneapolis. But I had second thoughts after seeing the snow. Not because I wasn't confident of driving, but because Veronica looks so clean and shiny now. Was tempted to take the airport shuttle... but I realized how I was thinking, and started laughing. Heh heh heh... not wanting to drive my car for fear of dirtying it. I think I need to get a real girlfriend to replace Veronica.
Anyway, flew into Portland today. 3 hour trip from Minneapolis. This place is beautiful.... warm, so green. Picked up a rental car and drove 2 hours to the Mt. St. Helens National Volcanic Monument. Spent some hours there hiking and taking it all in... it was just beautiful. Was humbled by the power of Mother Nature, how she could have just lifted the top of that hige mountain in that 1980 eruption. Took some pictures, and I'll post them up once I get home. After all that, checked into my hotel and was pretty delighted by what they gave me. Nice big suite with a separate room, jacuzzi and even a TV in the bathroom (total 3 TVs).
For dinner, because I have been too deprived... I pigged out, shamefully. Sushi. Alone, I devoured one whole spider roll, 2 Unagi, 2 Ubi, 2 Tamago and 2 roe rolls. Now, 2 hours later I can still taste the sushi. Bleh.
Presenting tomorrow... wish me luck. Not that I'm taking this too seriously. The winning paper gets to attend the national conference in May in New Orleans, but my other paper has already been accepted for presentation there, so I'm going anyway. So that's one reason why I'm taking things easy.

Pretty blurr now.

Really dislike this postcall fog that I get. Came back at 1pm, tried to sleep, but woke up at 3pm. Kinda feels like a mix between being drunk (minus the high) and being jetlagged. Tired, so tired, but yet can't sleep.

There was this study published by the Harvard guys in the New England Journal of Medicine. Increased rates of motor vehicle accidents in housestaff after a long shift. Kinda no-brainer, but it's interesting because that's generated concern here. Our program has graciously offered to pay a cab to drive any of us back if we're too tired to drive postcall. I suppose this has legal implications if anyone gets into an MVA postcall. But, boy-o-boy... I wonder how the patients feel if they find out that the doctor stabbing that 10cm long needle into their back has been awake for 30 hours? We've all been in that situation. I had to do a lumbar puncture at the very end of my 30 hour shift.

Will be leaving for Washington tomorrow morning. That should give me some time to rest. 3 days off for my conference, yaayy! And best of all, thanks to my generous travel allowance I'm getting a suite in a nice lodge there. Hoping to do some travelling if I have the time. Will be presenting my paper on Friday, so I should have some time to check out the place Thursday. Have always wanted to see Mt. St. Helens.

Vancouver, WA, not Vancouver, BC!

Darn it. This trip has been problematic from the start.

Just found out, the stoo-pid travel company issued me a ticket for the wrong city. In fact, the wrong country. One's in Canada, and the other in the USA.

Am due to leave in 3 days for my conference; my abstract was accepted and I'm due to present my paper on marantic endocarditis on Friday. First, problems with ticket prices. Then, with vacation days. Now this. Almost makes me wanna cancel, except that my institution will be paying for a suite for me in that hotel. Jacuzzi and fireplace. Hopefully this will get resolved soon.... darn darn darn.

Have another one coming up in May, New Orleans, to present a different research paper. Hopefully that one will be more uneventful.

By the way, today is heme-onc match day. My housemate TS (mentioned in my article) will be staying on here for hematology/oncology. Heh heh. Another Malaysian gets sucked in.

Well. Looks like spring is a-coming. It was a glorious Sunday... warm, up to 20C in the afternoon. Most of the snow melted, and that's what's left of our snowman. In fact, it was so warm that I was able to go out in shorts, and washed my car properly, after 5 months! Plus, the mess that was left in it after my family left

Looking forward to warmer days. Didn't realize how much I missed the sun. Hoping to take my bike out of the garage soon, and to organize another canoeing trip.

Was hoping to sit down on my lazy chair and enjoy the TV (have been waiting for Formula 1 racing season to begin). Turns out I read the time wrong. %^!*@^!! What a waste. And of all things, Schuey didn't complete the race???

The next race will be in Sepang. 1am Rochester time. Problem is, I'm oncall the following day, which means I'll have to be there by 7am. Dare I watch that? Hmm...

It's a Girl!

My best friend's wife delivered a healthy baby girl last night. Caitlyn, 3.2 kg. And yes, for all those readers who wanted to know, she did opt for the epidural!
On another note... oncall again. Was miserable as I had to watch my family leave for Malaysia. They're probably somewhere over the Pacific now. Note the blue hospital scrubs and the pager (my oncall leash), right before I left for work. They'll get to Singapore before I complete call and come home again.

Family will be leaving tomorrow morning.
Will be oncall again, so I can't even send them to the airport. Oh well. After being spoilt with mom's cooking for a month, it'll be hard to cook myself again.
I guess they've been away for long enough.
I'll see them again soon enough, I suppose, when I return in May 2005.

Back to work...

It's 2.06am now. There must be a reason why I'm snacking on Lay's Potato Chips and slurping down Kemps Lowfat yogurt.
Yup. Got a case of the munchies. It's been a busy night... I woke up at 6am yesterday, and basically have been on my feet till now, with the exception of Morbidity and Mortality Conference at noon, when I got to rest my tushie and scoff down free food.
Does anyone know if it's a full moon tonight? The ER just went nuts... admission after admission. And I had two interns to supervise.
"Agree with the findings and recommendations of Dr. Intern..."
Been starting notes like that the whole night. My first few notes were legible and actually contained some useful information. My last note, really just some chicken-scratches, could probably be played on the piano.
Looked at the ER admission board. Gen Med 1, full. Gen Med 3, full. CIM (Community Internal Medicine) full. Pulmonary, full. GI, full. The list goes on. Looks like all the services tonight are capped. On a night like this, all the internal medicine teams are cussing about how lazy/stupid ER docs can be (if you are an ER doc... no offence!).
I don't know about the other teams, but our team got some crazies today.
2.14am. Maybe I can catch some sleep before morning report and rounds in a few hours...