The Rules

It's funny how things happen when you least expect it. It's also interesting how sometimes things can go so well when you throw caution to the wind and break all the rules and norms of dating.

Yea, I'm seeing someone now. And it's pretty unbelievable how much fun we're having. How much laughter. For our first date, we couldn't stop talking after dinner; the waiters began giving us that look, hinting that they had closed 30 minutes ago.

The Rules of Dating I've been told include:

• Thou shalt not bring your date to a restaurant that uses plastic silverware (wasn't intentional; we were told that was a nice 'casual' Italian restaurant)
• Do not talk about politics, money, sex, burping and farting on a first date
• Going to look at dead bodies isn't exactly a date (we went to Bodyworlds)
• Don't send flowers after the first date
• Don't try to be too funny

And you know what? We broke the rules, and had a great time. And then I realized that sometimes, it's not about following the social norms and expectations, but rather, being with someone who is as silly as you are, and who is able to appreciate what others may have considered to be your Archilles heel.

And, if you have to know, she's a cardiac nurse. A really amazing gal; sweet, thoughtful and funny. She also happens to read my blog, and has a gun to my head right now. Though that has nothing at all to do with the compliments.

So Dark the Con of Man

Yea, I saw The Da Vinci Code last weekend. I liked it very much. But no, this is not what my post is about. My supervisor was doing some teaching today and mentioned to the students how some patients, for whatever psychopathology, intentionally harm themselves. The topic was factitious hypoglycemia.

The students seemed skeptical. Like she was making that up, because, why would a person intentionally harm themselves? But no. I think all practising physicians have seen the darker side of the human psyche.

There was this 34 year old woman I saw as an intern, who was admitted for yet another episode of respiratory distress, from an apparent upper airway collapse. ENT couldn't find any problems with the airway, yet she'd appear like she would go into respiratory complications spontaneously. Couldn't eat; she'd gag and aspirate on anything that went into her mouth. The swallowing study was equivocal, and the radiologist reading the study suggested that the aspiration was intentional. She had a percutanous gastrostomy tube placed for feeding. And a tracheostomy, because while people were suspicious, she did appear to have unexplained upper airway collapse. And she insisted on having an epi-pen near her all the time, despite the allergist having proved that she wasn't allergic to anything.

The nurses who looked after her noted that her breathing problems would always occur when physicians were rounding or nearby. Never while asleep. And, there would be periods when she would stroll out of her room, to be gone an hour at a time.

And then one day, a physician who happened to go across the street for lunch at a nearby restaurant sees her there, shoving forkfuls of food into her mouth, plate after plate. Despite being unable to swallow. And then, he tailed her back to the hospital room, where she settled down for another day of the "can't swallow, can't breathe" charade.

Sometimes these are financially or pharmaceutically motivated. Like that patient who betrayed my trust and conned me into giving him a short course of narcotics for severe pain. When I refused to provide another prescription, he threatened to hurt himself. To which I calmly replied, "Just sit tight. Because you've threatened to kill yourself, I'll have to call the police now. Wait right there." He promptly recanted and said he was 'joking'. I fired him from my practice after that.

These might be easier to fathom. The ones with no apparent gain aside from medical attention, those are the ones that remain a mystery.

Munchausen syndrome.

Like that woman who had recurrent forearm abscesses growing polymicrobial bugs including gut flora. Strangely enough, these occur only in areas of her body that were within reach. Everyone who heard her story raised an eyebrow (she was cutting herself and wiping stool into the wounds).

I catch myself wondering, what on earth has to go wrong in one's childhood, for a person to be so messed up like that?

I suspect we'll never know the answers, why Man does what he does. One can only be thankful for a normal childhood and a loving family. But it's scary, how far a sick mind can take you.

Tour de Cure

Dear Friends and Family,
I recently accepted the challenge of cycling in the American Diabetes Association's Tour de Cure fund-raising event. I am taking part in this event because I believe in and support the Association's mission: to prevent and cure diabetes and to improve the lives of all people affected by diabetes.
You, too, can help by supporting my fund-raising efforts with a generous contribution. Your tax-deductible gift will make a difference to more than 20 million Americans who are affected by diabetes and another 40 million who are at risk for developing diabetes. It is faster and easier than ever to support this great cause - you can make your donation online by simply clicking this link.

My boss let me off the hook.

"It's for a good cause. And we deal with diabetes in our line of work anyway..." I said.

So, I've committed to biking 32 miles (51.5 km) on June 3. So, since I'll be risking life, limb AND the family jewels (we all know what damage them bike seats can do to delicate body parts, don't we?) the least you, dear readers, can do is to contribute to my team's fundraising. And no, we don't see a single cent. In fact, I had to PAY to participate and bust my balls (pun intended). So, any contributions (monetary, or private massages after I suffer from heatstroke) welcome.

Think of it as money well-spent. You get to have me bike in spandex tights. So think of it as the dollar bills you slip onto a stripper's (me) bikini. And as a special for my blog readers, if my blog raises more than US$200 you get a topless picture of me. So, come on...

I'm relieved.
My 17 year old patient had thyroiditis, and not Grave's. I don't have to ablate her thyroid with radiation. Not that it would be technically difficult, or life-threatening. But perhaps because she is so young, I had reservations about nuking her thyroid with radioactive 131-I. And commit her to lifelong levothyroxine (although if that was the case, then the radioablation would be the most straightforward). And so I sent her on her merry way, to see me again in a month. With her thyroid intact.
Attended a talk by the previous U.S Secretary of State Colin Powell. He was here in our medical center to give a talk about leadership. Very entertaining, very charismatic and funny speaker. Yet inspiring; I enjoyed his advice on how one becomes an effective leader.
A different type of speaker compared to the Dalai Lama a few weeks ago, but both equally enjoyable, and inspiring.

Some words of advice

My kid sister and her friends leave for the 2nd phase of their medical education soon. For this group, Canada. One step closer to becoming a doctor. Once you get there, once you get those letters behind your name, and take that oath in the presence of faculty, family and God, life will never be the same. For, you will never again be called Mr. or Miss. From that moment on, you are a doctor. Society comes to expect certain things from you.

If there things I wished I'd known when I started out, it would be these. So, just words of advice, survival tips for medical student clerkship or interns, from someone who began this journey years ago:

• Sleep is essential. Sleep when you can.
• Eat when you can. And never say no to free food when your attending offers to buy.
• Don't study from the start to the end of a chapter. Read around your patients. As you shall teach them, you learn from them too.
• Study smart. Hours don't matter.
• Never recap the needles. Accidents happen.
• You can't save all the patients. You have to lose somedays. Such is the circle of life.
• Life isn't fair.
• It IS humanly possible to work nonstop for 38 hours. Just when you think your body and mind will give up on you, you might just surprise yourself.
• You will make mistakes, either by action or inaction. Sometimes the consequence will be fatal. Learn to forgive yourself, and learn from it.
• Remember, the patient is the one with the disease.
• Never be too proud or afraid to say 'I don't know'.
• Learn to brush your teeth and get ready for work in 10 minutes.
• The nurses own you and your sleep. Never piss them off.

When you come to the edge of all that you know, you must believe one of two things. There will be earth upon which to stand, or you will be given wings to fly.

Kembang

Okay, I'm a Dragon, and a Leo. Hence the stars dictate that I'm an egomaniac, and need to boast. And since this is my blog, I can say whatever I want.
So, here's my kembang moment for today.

Though to be accurate it should be 'Parathyroid' project.

Ladies: the price has officially gone up to Rm 0.69 per kilogram. Free cellphone case with purchase.

Oops

I wish I could say I'm one of those doctors who don't get fazed by anything. Cool, collected thoughts, systematic approach to solutions under duress. Including patients who make you nervous.

"Yawn. 2 patients coding at the same time? No problemo, dude. Let's do this..."

But no, I'm not. Hence my avoidance of surgery, cardiology and critical care medicine.

Case in mind, this patient whose thyroid I biopsied today. Now, bear in mind I've done over 20 thyroid ultrasounds and have biopsied over 15 nodules. So although I'm in my first year, I know how to handle the probe and needle.

So this was a 30 year old lady with a thyroid nodule. She also happens to be someone I've worked with in the past. And, she also happens to be a very very VERY attractive, very friendly person. So, I coolly examined her neck, idle smalltalk, trying to put her (well, probably myself more) at ease.

Lay her down on the examination table. Disinfect her neck. Apply ultrasound gel. Nurse holds the needles, ready to give to me. Then place the probe on the neck.

Thinks to self:

(What the?? Why does the neck look so bloody strange? Familiar, yet strange...)

Then my attending pops the bubble:

"Dr. Vagus, perhaps you'd like to turn the probe around..."

Dooh. >_<

Doesn't inspire confidence, does it? My attending had to tell the patient, "Don't worry, he's not usually like this."

They all had a good laugh (patient included).

My attending and nurse gave me a hard time the rest of the day because they know I'm pretty handy with the probe and biopsies. Usually.

So there's a bike race coming up next month, 32 and 50 mile trips. Organized by one of the medical associations, a fundraiser of sorts. My nurses were bugging me to sign up (they wanted to raise more money).

So, I tell myself if I wanted to race proper, I should get a road bike (racer) instead of using my trusty mountain bike (lower wind resistance).

$ ka-ching $

Then, I tell myself if I was going to get a road bike to race, I should get a proper cycling jersey.

$ ka-ching $

Then, I tell myself that perhaps my bike helmet was too old, and that I should get a new flashier one for the race.

$ ka-ching $

Then, I tell myself that perhaps I should get a bike lock for the new bike.

$ ka-ching $
Then, I tell myself, now that I'll have TWO bikes, perhaps I should get ANOTHER bike computer for the 2nd one.

$ ka-ching $

And then I find out that I'm oncall the weekend of the bike race, and likely won't be able to join.

$%^&*&%@!!!

Road bike=$ 160

Jersey= $25

Bike helmet= $22

Lock= $7.99

Bike computer= $30

Being able to blow cash without having to ask for permission= priceless

Medical School

I love teaching.

I did a year of this while waiting to start work in the US years ago, teaching starry-eyed young medical students.

This month, I'm on a special attachment. Besides seeing my own patients at my clinics, I spend half-days at the medical school, teaching 1st year medical students basic endocrine physiology.

Interesting for a few reasons:

First year students are usually so idealistic that it's refreshing. And funny. They're still in the "Oh, I want to be a doctor to save all my patients, and still be home in time to take my wife out for a nice dinner."

You can almost see their feet levitate an inch above the ground when they speak like that. So energetic. So keen. So humanitarian. And so utterly foolish.

You almost hate to destroy that glimmer of enthusiasm in their eyes. You know that's going to happen, when you've been awake and on your feet for 30 hours straight, and are about to do a lumbar puncture with your trembling hands, while you patients curse or poop on you. If one doesn't get jaded from medical school, internship's bound to do it. That's usually when they start hating their moms/dads/grandaunts/girlfriends/Santa Claus for making them go into medicine.

It's also unnerving. They expect you to have all the answers, but they don't realize that you were there 10 years ago (at least for me; I started medschool April 1996). And now, when you're a bigshot fellow, a PGY-4, in a famous hospital, they look at you funny when you don't remember the mechanism for G protein-mediated signal transduction, or something clinically irrelevant like that. I get the feeling they think I'm retarded, or bought my medical degree for 5 bucks from Chow Kit or something like that. Like all that information would ever help a patient in the hospital.

"Quick, begin CPR. You, 1 mg of epinephrine stat. And you, the short guy, recite the f*cking Krebs cycle, NOW! Hurry up, the patient's dying!"

Strangely enough, I don't remember much from my first year. Just bits and pieces. It's almost like I have selective amnesia from a steamroller running over my brain, trying to force out whatever torture I had to endure back then.

Seeing them brings back all manners of memories.

I love teaching.

Why I love working here

It's going to be difficult if/when I decide to go home to practice, seeing the difference in how medicine is practiced. Especially after training and working here for 8 years.

And I'm not even talking about the huge salary difference.

I thought about this yet again when I saw a patient with a pituitary macroadenoma. The pace at which things move here can be dizzying.

Day 1: I see the patient, order lab tests and MRI. Visual field testing.

Day 2: Results show this is nonfunctional. Consult neurosurgery.

Day 4: Neurosurgical consult. Agree to proceed to surgery.

Day 5: Transphenoidal resection of pituitary tumour.

Day 6: Discharged from hospital.

Or, something else I see frequently, primary hyperparathyroidism:

Day 1: See patient for chief complaint of hypercalcemia and high PTH. Order other tests and parathyroid sestamibi.

Day 2: Results suggest an adenoma. Make a surgical referral.

Day 4: Surgeons agree to take patient to surgery.

Day 5: Surgery. Discharged on same day.

Same applies for other fields in medicine. Take an MI (heart attack) for instance. I thought about this when I read about 2 prominent Malaysians who died of 'heart attacks' in the last 2 weeks, and wonder if those could have been saved had those hospitals had the resources:

0 minute: Patient experiences chest pain.

23 minutes: Brought to ER. EKG shows ST segment elevation. Stat labs show elevated cardiac enzymes.

24 minutes: Patient codes from ventricular tachycardia.

24 minutes 15 seconds: Chest pads applied. 200 joules given. Returns to sinus rhythm.

24 minutes 21 seconds: Patient is back from the dead.

31 minutes: Goes to emergency cardiac catheterization.

44 minutes: Coronary stent deployed.

5 days: Patient walks out of the hospital, alive.

I catch myself wondering if I'll be able to switch gears and get used to the system back home. Here, I feel like I'm making a difference, and am truly helping patients. I'm not sure how much I'll be able to do back home. Or, if I'm going to be able to change things for the better.

After all, we physicians do get so spoilt here. Order a chest CT, and within 4 hours I'm seeing the report and the images on the computer.

I know doctors back home do the best they can, and often patients do receive excellent care. But I do wish there was more funding for public healthcare.