To Tattoo or Not to Tattoo?

Okay, I admit. I've been thinking about hurting myself recently.

But no, not what you're thinking.

A tattoo. I've been toying with that idea for 2 years.

Partially because I'm stupid enough to think they look cool.

Partially because I want to break the preconceived notion that all doctors are nerdy goody-goody-two-shoes types. And partially to remind myself of the strength that lies within, something I sometimes forget in bad times.

And while my dermatology (and other sane friends) tell me to not go for it, this one psychiatrist friend of mine who's had 4 tattoos already is really pushing me to go for it. She even showed me the tattoo of a sun on her left boob.

I figured if I ever get one, it will be on my right arm. So, Let me know what you think.

(And no, I haven't yet committed to having one done.)

Click here to vote!

More Random Thoughts

Had these thoughts in the tub just now. And then, was talking online to HC which made me think somemore.
A wise man once told me.
Sometimes, no matter what you do, or how hard you try, some things just aren't meant to be.

Wise words. Be it career, academics or love. One wonders, if that is the case, why bother? Are we really in control of our lives? Our destiny? Is there such a thing? Are our paths already predetermined, and our roles merely to act it to reality? Pawns in a celestial chessgame, moved by unseen Hands?

What comes to mind, Meg Ryan's character as that heartbroken cardiothoracic surgeon who lost her patient soon after completing surgery.

"Who are we fighting against? Why are we here?"

I know I've had that thought before. Who decides which patient comes out of his vfib, and which patients don't? Who decides which babies live, and how?

Who decides becomes of my life? And when I die?

Can we truly change our lives? Ourselves?

Not sure what I'm thinking about, or where this is going. So consider this thoughts of a muddled mind.

Ironing and Vagus

So after a tiring weekend call, I'm actually glad Monday's coming. I get to go off-call tomorrow morning.
Had a ton of errands and chores to do today. Unfortunately, I had run out of clean dress shirts to wear. Hence, laundry day.
Now, after having been away from home for 12 years, and away from Malaysia for 8, I consider myself fairly independent and somewhat domesticated. I'm a survivor. I mean, I cook decently (ah, what the heck, to hell with modesty, I cook pretty darn well, thank you very much), able to bake a pie or two, I clean pretty well (in a guy's dictionary, 'pretty well' means I don't live in a pigsty, my slippers don't stick to the floor and the toilet is flushed at least once a week).
I do my own laundry. I even know to separate the whites from the coloured (learnt from experience. I still have that bright patchy-pink shirt hanging in my basement).

I wash my own car.

Mop. Do the dishes.
Hell, thanks to my camping days and over 20 camping and hiking trips (including Mt. Ledang, Angsi and Kinabalu) I can even make basic furniture out of small trees and rope, start a fire with just 3 matches. Taking a dump in the bushes and using the leaves to clean up wouldn't unnerve me.
But if there is absolutely one thing, one thing that I hate to do, cannot do, is iron.
Someone once told me, the definition of agony is 'sliding down a razor blade on your balls'. I'm not sure how he learnt that. But I think I'd pick that over ironing.

They can coat the irons with teflon or uranium for all I care, and make it spew steam or whatever it is that they do, but that doesn't make ironing easier. Inevitably, my clothes come out looking more wrinkled after I'm done ironing than before.
Which explains why 90% of my clothes are wrinkle-free. Though the lines do start forming after you've worn them enough. Even though they're supposed to be wrinkle-free (I guess ageing affects everyone. Along those lines, maybe they can coat clothes with botox? Or make the steam irons spew botulinum? It'll be worth the money)
So, when it comes to my future mate, my one criteria will be: MUST LIKE IRONING.

I'll do the rest.

(And no, I haven't the foggiest idea who the babe is. Some Japanese hottie I found online)

Any takers?

Weekend Call

For a weekend call this has been a horrible day.

Never have I had 11 new consults by 11am on a weekend. Not counting the old patients on my list. I was inhouse until after 5pm.

And one of my favourite patients was admitted a few days ago. Congestive heart failure. The sequelae of pulmonary atresia. She's hanging in there, though I wish I could say the same for her morale.

I came home tired, and hungry. So very tired. But I was glad my friends dragged me out for a movie. Inside Man, starring Denzel Washington and Jodie Foxxie Foster. Rowl. Great, great show. I'm too tired to think up superlatives, so 'great' will have to do for now.

It's late. Brain-block. And I've got the oncall pager till Monday morning. So I'll sign-off here.

P/s: The bad thing about being oncall- you can't drink any booze.

Radiologymalaysia.com

A few weeks ago when I was home, having dimsum breakfast with Alvin, I checked my mailbox and found this email from the editor of radiologymalaysia.com.

I forgot that months ago, I had submitted a story from my blog (well, from my digital diary which preceded my blog actually) for a short story contest about cancer (I did edit my reflections; you might be able to pick up a hint of personal conflict comparing the two). Never mind that being a US resident I didn't qualify for prizes. I just wanted to share that story.

Anyway, that email was a pleasant surprise, for apparently, some people thought my story was pretty good, and scored pretty high marks. And though I didn't win anything, they still put my story on their website (it was easy for me to be nonchalant about the prize; I didn't know then that prizes included iPods and other toys >_<).

Though that event was from early on in my career (I was on oncology; must have been May 2003), I remember the events pretty vividly. I can still picture which room on the 4th floor the patient stayed in. I remember the discussion I had with her parents. And the picture of her son her mother showed me. I remember them well.

By the way, if someone decides to award me with a prize, it's still not too late, you know.... (I'll take a black iPod please)

Today I started my 6-week run in peds endo. Pediatric endocrinology.

Now, bear in mind I'm board-certified in IM. And I graduated in 2001.

So the last time I treated a kid was during my pediatric rotation in August 2000.

My first patient was a 4 month old with failure to thrive.

"Err, doctor, are you sure you know how to hold my baby?"

While examining the infant, I was afraid I was going to break it. Or at the very least, maim. All while pinching his bag-o-nuts trying to feel the family jewels (no, I wasn't trying to be funny. That's what we do).

Trying to recall the developmental milestones was a nightmare as well.

Hmm. So they begin babbling at 6 months. Stranger anxiety 9 months. Talking 12 months. Or was that 16? Smoking 20 months.

This is going to be one long rotation.

Old Flame

So I saw a lady last week for a brain goomba. A 3.8 cm x 3.7cm x 3.8 cm pituitary lesion with suprasellar extension and invasion into the cavernous sinus.

She had a transphenoidal partial resection of a nonfunctioning adenoma yesterday, and was to have been dismissed today to follow-up with me in the afternoon (yes, things do move this fast at this crazy place).

Anyways. The neurosurgeons decided to keep her an additional day because she had some nausea still. So I decided to come visit her in the hospital since she couldn't make my appointment.

Met her daughters and her husband (whom I had met earlier). Since I wasn't in a hurry (no social life to boast of despite today being St. Patrick's Day), I had a nice long chat with her husband. Found out things that you otherwise wouldn't, being someone's doctor. Sure, I know her medical history intimately well; I can still clearly see her brain MRI in my head. And I know her cortisol, prolactin and IGF-1 levels. I even remember what medications she takes. But that's nothing.

I'll call her Mary. She had lost her husband years ago. And her current husband, I'll call him Bob, lost his wife to a heart attack 15 years ago. Bob and Mary remarried last year.

They grew up together, and were highschool sweethearts. Dated through school, but somehow drifted apart when they left for college. And, as life often ends up that way, lost touch for decades. Meanwhile, they fell in love with others; Bob had 5 kids of his own, and Mary 3.

After having to live through the agony of their spouses' deaths, they met again. Bob was the class president, and hence organized reunions every 5 years. At at the last one, someone persuaded Mary to come out of her shell, and attend.

Bob had made rhubard pie (one of these days someone's gotta tell me what the heck a rhubarb is) for the night. A few days later, Mary sent him a thank-you card and complimented him on the pie. And before you know it, they started talking on the phone and went out on a few dates.

Old flames, from half a lifetime ago, rekindled.

After 5 months, with the full blessings of their kids, they remarried. Bob said it was a beautiful lakeside wedding. I believe him. I imagine it's as close to heaven as could be.

It's a beautiful story.

It's been a long week. And a long day. It's Friday night, and I was tired. Who would have thought, that I'd find such a powerful source of inspiration and strength in the neurosurgical unit, from the very people we try to help?

I came home energized.

And feeling honored that Bob had shared this wonderful story with me.

The Match

Today was Match Day. A nerve-wrecking day for 26,715 final year medical students and graduates in and out of the USA. The day when they find out where, after a 4 year-long journey in medical school and a year of planning, paperwork, applications and interviews, they move on to begin the next phase of their career.

Residency. Stepping out of the protected world of the student, into the warzone of the practising physician. Postgraduate medical education. Specialization.

After the deed of interviewing is done, they plan and rank their choices. The schools rank them as well. And today, they find out.

I remember my Match day in 2002. 2 days prior, one prays we don't hear from NRMP. This was the dreaded unmatch day, and if you hear from them, it means you didn't get a spot. If the day ends quietly, you know you at least matched somewhere. Where, you don't know.

I was at work at IMU when I checked the website. My fingers were shaking so bad I had trouble putting in my password. I made LP and LY leave my office while I looked. In case I would be disappointed.

Congratulations, you have matched to the XYZ. Yadda yadda yadda.

Undoubtedly, because of the intense competition, not all would get their top choices. And not all would match. I hope this turns out well for my friends and students.

S-T-U-P-I-D

I AM SO STUPID

S-T-U-P-I-D

At the risk of my friends and family reading this (ah, what the heck, I'm a 29 and I'm a doctor. I'll talk about sex when I feel like it, thank you very much!), I'll share this one regret I have. I just have to get this off my chest.

So when I was a medstudent in Canada, a nursing student lived in my dormitory for a couple of months. For some reason she liked to hang out with me, despite us having different cultures and interests (she's caucasian). I think it was because she found my innocence and niceness refreshing. I wasn't trying to get her drunk and get into her pants like many of the people there.

She liked to come to my room and talk. Just talk. About interests. About family. And often I just listened. Made her dinner a couple of times.

While she wasn't a bombshell, she was pretty. With a full, ahem, rack. And aside from a wild nightlife many students have, she was a nice, sweet girl.

So one day, while I was trying to study and she was talking about her sexual preferences, she asked me if I'd like to see her breasts. Literally.

To this day, I regret my answer.

"No, thanks."

ARGGHHH!!!! Okay, before all you guys out there start taking out your baseball bats and pummel my head, I admit, that was dumb.

And no, I wasn't being righteous or anything. Just that being in a culture I wasn't familiar with, I wasn't sure what her intentions were. And I thought she was just testing me, and had I been honest ("Why yes, I'd love to see them"), she'd think I was a dirty bastard (which I am). And before all you ladies tell me I did the right thing being a gentleman; that was a mistake, I was being stupid, so don't tell me I was being a gentleman. ARRGGHH!!!

She was taken aback some. And a bit embarassed. But we remained friends till the day I left. She gave me a hug and kiss the day I left. I occasionally get an email from her now. But she never asked me again.

Trish, you'll always have a place in my heart...

Leap of Faith

Come, come to the ledge, she said.

No, I'm afraid. Afraid of heights.

Come, come to the ledge, she said.

It'll be worth the sight.

Jump, jump over the ledge, she said.

No, I'm afraid. Afraid I'll fall.

Jump, jump over the ledge, she said.

Let's at least give it our all.

And we jump.

And we jump.

And we fly.

So my housemate was postcall today. Cardiology. He told of how he couldn't sleep despite not having a busy night.
I remember that well. Bad memories. But so very very vivid. I'm not even kidding when I say I still have nightmares about codes on bad days.
Cardiology senior resident. In this institution that means you're the code team leader.
It's indescribable what one feels, unless you've been through it before. That feeling of dread, that feeling of impending doom. As I had said once, almost like having a grenade with its pin pulled off, stuck to your pants.
You know the code pager's gonna go off. When, what, where are the questions. And unlike a regular pager, you can't take your time to answer it. You respond, stat. You run, like you've never run before. Once when I was responding to a code, I hollered that we were coming through, and to make room for us. A lady instead turned around to see what the commotion was about, and I ran square into her. The force was so great that we both went flying. Thankfully she was chunky, and had plenty of padding. But yes, when we run, we run. One reason why I wear my running shoes when I'm oncall.
You can't even take a dump, for fear of the pager going off.
You lie in bed trying to sleep, but the palpitations and thoughts one gets can be incredible. I had crazy palpitations; I could see the pen in my breast pocket move in rhythm to my apical beat.
The simple ones are pseudocodes. Syncopal episodes. The easy ones are respiratory codes. The arrhythmias are a different story; will it be vfib, or vtac, or pulseless electrical activity, or asystole? And then there was one patient with a pulmonary tumour who coded from massive hemoptysis.
And just you try to remember those ACLS algorithms after you've been rudely awakened by that shrill pager from hell at 3:54am; it's like your brain-fuse has just blown and you're still in a fog.
But yea, I remember those memories vividly. I admire people who love adrenaline, who thrive under those conditions. But I'd sooner cut off my right foot before I do that for a living. Nope, I enjoy what I do now. Endocrinology and internal medicine are my niche.
Looking back, I bet many of use would fulfill DSM-IV criteria for Post-traumatic Stress Disorder.

Snow in March

So I thought winter was over.

It was warm Saturday. Warm enough that I actually was able to go biking, albeit with a longsleeved athletic suit and gloves. 15 glorious degrees (celsius)!

Well, apparently not. It snowed again today. Not a whole lot, but for an hour or two, huge snowflakes. Wet snow.

As though Mother Nature was mocking us. Or confused. A little bit of warmth to tease us, and then a quick 180° turn.

Kinda like how a woman changes her mind: "Not now, honey, I have a headache." Meanwhile you're left hanging, about to pop. And you beg: "But, but you said you wanted it just 30 seconds ago...." And everyone knows begging is so unsexy.

Or how you think that last piece of constipated poop is just about to be expelled, and then whoops, maybe not. Need to take another deep breath and try again.

Okay, maybe a wee bit too graphic there, but I'm just getting a bit impatient with the slow changing of the seasons.

My bike's out and ready to go. The gears are oiled. The helmet's polished. And the gloves washed. Come on already.

Last season was disappointing in that I didn't ride as much as I wanted to. Only 420 km since August. I'm hoping to hit 500 this year.

Career Flowchart

Someone emailed this to me. Found it hilarious. Fitting flowchart for the many medical students I met in IMU who were in a dilemma regarding career choices.

Just found out too that I get to go to Boston in June for a presentation. Already get to present in Chicago next month, so this was a nice surprise. Didn't think my abstract on Cushing's syndrome from a bronchial carcinoid was all that interesting.

It's been a good day. Good day, indeed.

Book Chapter

I finally got a copy of my book. Well, not really mine, after all, I just wrote a chapter. But still, it's pretty exciting to see your name in print. Especially in the company of some experts of the field. A good book too, if I may say so myself. Heh.

An amazing woman is gone.

Dana Reeves, wife of Christopher Reeves, died of lung cancer at the age of 44.
In his autobiography, "Still Me," Christopher wrote that he suggested early on to his wife, "Maybe we should let me go."

She responded, "I'll be with you for the long haul, no matter what. You're still you and I love you."
Those were "the words that saved my life," Christopher Reeve said.

Now, a year and half after he passed on, she joins him.

In a way, this has been an inspiring and refreshing story of love and devotion between a man and a woman. Despite a catastrophic spinal cord injury. Especially in the apparent shamdrudgery of Hollywood 3-week-marriage love.

She stood by him for the 9 years he courageously lived his life after his injury.

I can only imagine how difficult it was for her to live the last year after he was gone.

One can only hope, that we are all that lucky when we pick our partners in life.

As Morrie put it (Tuesdays with Morrie- Mitch Albom); love each other, or perish.

Wherever they are, at least they're together again.

Invictus

Out of the night that covers me,
Black as the Pit from pole to pole,
I thank whatever Gods may be,
For my unconquerable soul.

In the full clutch of circumstance,
I have not winced nor cried aloud,
Under the bludgeonings of chance,
My head is bloody, but unbowed.

Beyond this place of wrath and tears,
Looms but the horror of the shade,
And yet the menace of the years,
Finds, and shall find me, unafraid.

It matters not how strait the gate,
How charged with punishments the scroll,
I am the master of my fate,
I am the captain of my soul.

~William Henley~

I seem to be getting PMS'es a lot these days. Sometimes, doing volunteer work gives life meaning, enriches the soul like nothing else can. Often find it therapeutic. Unfortunately, today wasn't one of those days. When you see patients for no charge at a free clinic, which provides medications for free, and when these patients turn around and start making demands about how they can't get 200 insulin syringes for free etc., it can really spoil your day. Really. Especially since you're pulling a 14 hour day.

You go as far as asking yourself why you even bothered in the first place. Next time just have them pay US$300 to see you at your clinic.

Days like this I go over my collection of poems. Stuff I've been collecting since medschool. Of all the material I have, I like this one the most. Invictus. By Henley.

Other favourites include If by Kipling, The Road Not Taken by Frost.

Nope, I'm hardly a cultured person. But I do find these to be a source of inspiration. A means of escape from the dreary, unkind world.

Hypochondriasis

They say that docs make the worst patients.
I'm home on a Saturday night, almost doubled over with this gnawing, nagging epigastric pain.
Gastritis? Or worse, peptic ulcer disease? No reason to get pancreatitis (except for the, ahem, occasional resident-style EtOH binges).
A bit of knowledge is a dangerous thing. You tend to self-diagnose. And, if you're a hypochondriac like I am, imagination can sometimes take you places.

The last problem I had was when my right thumb swelled up. Tender, and I had difficulty flexing it. As it so happened, I was working at the thyroid clinic that week. Which made thyroid biopsies extremely painful for me as well as the patient. Had the lab draw up some tests, which were unremarkable. Tried to talk a rheumatologist colleague of mine to give me a cortisone shot for the inflammation. But no, she said it wasn't necessary. Just give the badminton a break for a few weeks. Sheesh.

And then there was the time when I had issues with recurrent severe pharyngitis/tonsillitis. The 2nd time I had to go to the ER I was convinced there was something else wrong with me, what with the pains, severe shaking chills. I had just finished call and dragged myself down to the ER. As it turned out, I was right; the CT showed a peritonsillar abscess. Which meant an I & D. Therein lies my mistake, I neglected to ask the ENT resident who saw me that September how senior he was (he was almost brand-new). He hurt me. After 4 attempted passes with the needle and one with a scalpel, he had to get his senior. It was so bad that after they were done, an older nurse came in and saw me in tears and asked me, "Oh you poor honey. Can I get you anything?"
To which I could only whimper, "Morphine. Please give me morphine" (I kid you not; the pain had me crying like a little girl. I still see that ENT resident occasionally, and we both just share a nod and an embarassed smile).
Morphine sulphate 4mg IV and 6 hours later (I spent the night in the ER observation unit) I was up in my scrubs pulling my IV pole to the computer so that I could follow up on my patients' labs.

Anyway. Back to my tummy pain. Hmm... perhaps endometriosis? Or, perhaps a leaky AAA? Ectopic? Gosh, maybe I should get myself checked out in the ER? Maybe someone ought to do a DRE.
(in all probability, it was just the fried rice noodle with salted fish I ate)

Orion

The stars were brilliant last night. As I was walking into the house, I glanced up and saw a familiar friend. Orion, my favourite and one of the most easily recognizable constellations. I just had to grab my camera.

(2nd picture edited to outline Orion. Key: look out for Orion's belt, easy to find)

Reminds me of a certain night at Port Dickson in 1994.

Holy crap. Has it been that long?

Pheochromocytoma

Here's a tip.

If you see a patient with paroxysmal spells of syncope, palpitations, headaches, and you image him and find a 3 cm enhancing adrenal mass on CT, please bloody have the sense to check his metanephrines and catecholamines before you decide to stick a needle into that goomba*.

I imagine that medical team (from another hospital before the patient transferred here) darn near shit and pissed in their Pagoda undies and panties when the pathology report read 'pheochromocytoma'.

They're farking lucky that patient didn't die on the table during the biopsy (no alpha and beta blockade).

You don't need to be an endocrinologist to know. Maybe just a brain larger than the size of a pea.

Idiots. Can you spell L-A-W-S-U-I-T ? (which reminds me. Piff, you need to give me your business card).

*Goomba (noun): Technical term describing a surprising find of a mass on radiologic imaging. Often used with objectionable phrases or words describing the genitalia. Example: "WTF?? What the KKC is that Goomba on his left upper lung field??" May also be used to hide ignorance about the pathology of a lesion. Example: "This is a 78 year old male with a right cerebral Goomba..."

Found this in my clinic mailbox today. And I thought they'd send me a complimentary ticket, or at the very least, a list of their stewardesses' phone number.

Sheesh.