Of (medical) Zebras and Unicorns

Today I saw my 5th case of inn-sue-lynn-no-mah (intentionally misspelt*, but you know what I'm talking about) in the last 1 year. Something that comes up frequently on medical school exams just because it's rare and exotic enough. And probably something some of us here have begun to take for granted, because we see these rare conditions so frequently, because of the referral bias. The rule of "when you hear hoofbeats, think horses not zebras or unicorns" may not apply here.

It's pretty amazing, thinking about it. Incidence of 4 per 1,000,000 patient years. Many endocrinologists and most doctors never see a case in their careers, and this is my 5th in a year, plus a case of hypoglyc@emi@ from islet hyp_erplasi@ and another case of insulin @ntibodies. Not that I'm expecting these cases to be a part of my practice in the future, but it's nice to have seen some rare medical conditions. I do feel blessed and fortunate, to be able to work here, with some leading experts in these fields. After all, our patients travel the country, even across oceans, to see them.

He's gonna have surgery Friday. I pray things will go well, although the surgeon is undoubtedly one of the most skilled in the world, and if I was to have my pancreas screwed with, it would be by his hands. I remember that adage in my medical school surgical rotation:

Rule number 1- Don't f*ck with the pancreas

He'll be in good hands, so I suspect the patient will sail through this.

*Apologize for the intentional typos. These conditions are rare enough that I don't want a patient or a future patient Googling my blog.

The Procedure

We're having our (belated) Thanksgiving dinner party tonight, to be hosted by HH, our cardiologist friend from Singapore. This year, they let me prepare the turkey. A 10 kg turkey. Big mistake. Never. Ever. Let a crazy endocrinologist prepare the bird. Especially one armed with an 18-gauge needle, syringe and some crazy homemade marinade. It's sitting in the brine right now; stay tuned for the end results. You'll probably read about it in the newspapers.

"22 Foreign Doctors and Family Admitted with Acute Gastroenteritis"

Addendum: I know this sounds like I'm boasting, but I swear the bird was the juiciest, tastiest turkey evar! All (almost) 10 kgs devoured by the ravenous indigenous tribe of the Singapolaysians. No mercy was shown.
Recipe:

Brine (to soak bird in):

2 liters water

1 cup brown sugar

1 cup salt

2 tablespoons each of black peppercorn, allspice berries, crystallized ginger (mashed to a pulp)

Soak bird for 12 hours. If you have sadist tendencies, feel free to inject some of that brine into the breast with an 18G needle. Brine 30 mL IM prn.

When ready to roast, make deep 2 cm incisions/stabs around the breast and thigh and shove in garlic and/or raisins. Baste generously with butter. Place breast side DOWN (keeps breast from drying out). Place 4x6 inch pieces of foil on back, thigh to prevent burning. Add pieces of sliced pineapples on top. Roast for 4-5 hours, until 180 °F (with meat thermometer, or used rectal thermometer) in thigh. Baste with butter every 45 mins.

Serve. And be prepared to feel like a God when your humble vassals feed upon your heavenly fowl. Be forewarned: head swelling is expected.

To Be Attached

Having a Significant Other changes things. Especially when you've enjoyed your freedom for long time. You have to learn to live, to function, with another person.
Like it or not, you have to get used to each others' qwerks and nuances.
For example, she leaves the toilet seat down. I don't dry my hands after washing. She leaves the toothpaste upcapped. I recycle my clothes/utensils. She showers in the mornings. I shower at night. I function with 5 hours of sleep. She doesn't. She loves her salad. I'm a carnivore. She talks in her sleep. I fart. She drives like a maniac. I fart. She bakes. I fart.
It's a wonder she puts up with me.

Then again, having a partner does have its benefits as well.
I have someone to remind me to zip up my fly after I go wee-wee. Or check my nose for boogers. Or to let me know my socks/shoes/corduroy pants/shirt are mismatched (I've been told by the many women in my life that I'm fashion-blind). When I'm ill, there's someone to care for me and to ignore my pathetic whining while telling me 'That's nice, dear.' and reading Cosmo.
And it's nice that someone thinks you're nice and lovable. A bonus that she likes to bake, and bakes well (though I've had to work out extra to burn off those calories).
We make trips to places I'd otherwise never visit. Go out for movies and dinners and not having people look at me like I'm gay because I'm watching a chickflick with my roomate (nothing against gays. Just that I'm not. Straight as an arrow).
On that note, strangely enough, while interviewing for a job years ago, some people did think I was gay. But you see, it's not politically correct to ask someone what his race, religion and sexual orientation is in the United States (unlike Malaysia, where you need to include your religion and race in your official documents AND examination papers), but I finally caught on when that program director in that Ohio hospital took the interview in a weird direction:

Interviewer: I see there is another Malaysian doctor interviewing today. Do you know him? (was on the interview trail with LP)
Me: Yes, he's a good friend of mine.
Interviewer: I see. Are you travelling together?
Me: Yes we are (to cut costs).
Interviewer: Ah, I see. *one eyebrow goes up* Will you be, ahem, doing a couples match?
Me: *Alarm bells go off* KNNCCB, I'm not gay lar you lanjiau! (okay, I didn't say that)

But I digress. Back to the girlfriend. Yes, it's great to have someone who brings so much joy to your meaningless life. Even if it means I need to eat my veggies, and can't fart/scratch body parts whenever I want. Can't have wild promiscuous sex with every other hot chick who's crazy about me (waited 30 years, none so far, but I know they're out there). But you know what? It's a small sacrifice and it's all worth it.

Babe, this one's for you. Happy Thanksgiving. Come back here soon. And watch out for those speed traps!

Dressing too sexy?

I cringed when reading of Datuk Abu Bakar Hassan's implication that the female reporter who had her thighs videotaped by the security camera of City Hall asked for it by dressing too sexily. Though totally neanderthal and sexist, this coming from a Malaysian chauvinist isn't unheard of. After all, state leaders have issued statements in the past that people should not hire good-looking women as they are a distraction and a source of sin.

So I wrote in to share my humble view, that they're just idiots with no self control.

"These men need to learn proper self control. Or be blindfolded"

Don't you like that? Huh? Huh? (P/S: Remind me to watch my back the next time I visit Malaysia)

Well, today I was blown away further by this answer in today's papers. Probably more so that this came from a Chinese lady based in Australia doing her PhD in biochemistry. I suppose it's an eye opener for me.

"Ultimately, I believe it sometimes takes two to tango – if the woman does not tempt, the man does not get tempted.
I commiserate with most rape victims, but not those who dress provocatively. In a way, they asked for it."

Phew! While I don't claim to be an expert in this, I have read papers and studies and attended courses by people in this field; often it's more a show of power and dominance than a crime of lust. While I disagree, especially with her statement about rape victims asking for it in the way they dress I wonder what my readers have to say. Yea, sure, if you see a scantily-clad woman your imagination (and karma, naturally) does some acrobatics, but I'd like to believe Man is not as primal as that, and is able to exert some self control.

So, please leave a comment or two. And, if everyone seems to think it's ok to snap pictures of women's thighs just because they're showing too much skin, I'm going to run out and get myself a 200 mm zoom lens. And a 2Gb memory card.

Stories of my Ah Kong

Today marks the 8th year since grandpa left us. Left us while I was in medical school in Canada, and could not come home. So I thought I'd repost this in memory of him. I miss him.

Thought of my late grandpa today. And this funny story comes to mind:
Malay wasn't his strong language. Like many of the ah peks and uncles, he spoke rudimentary Malay, just enough to get by.
Sometimes when my folks went out for banquets, grandpa would babysit us. And answer whatever phonecalls dad would get.
The thing that drove dad crazy was when grandpa would say,

"Takda rumah, sudah keluar minum samsu!"

A direct (okay, somewhat direct) translation of the Hokkien lim-chiew (banquet).

Except when taken literally, means out to drink homemade (illegal) rice wine. The stuff that makes people blind.

Gawd, that would drive dad nuts, especially if it was his business colleagues who called. They must have thought he had a brewery in the basement. I remember that fondly.

I don't care that it's officially still autumm. When you get dumped a foot of snow in a day, winter's here. (view from of my backyard)

To Err, is Human?

Everyone's entitled to make mistakes right? After all, we're just human. You know, forgetting to do something, or doing the wrong thing. With meetings, patient appointments, paperwork, labwork, manuscripts, phonecall and pages, it's inevitable. And I'm not even talking about the lack of sleep yet.

But when you're someone's physician, and you make a mistake regarding a patient, even if it's a minor issue, it makes you feel like the most incompetent, stupid and dangerous doctor around. Even if you were a superstar physician and saved lives just a day before. It make you feel like shit. Literally. You feel like crawling back into bed, or hiding in the bathroom, or just simply disappearing. You feel angry that such a thing could have happened. That you could have overlooked that. And you have trouble forgiving yourself. It spoils your entire day.

S-T-U-P-I-D

I know doctors are still humans though we like to play God, and that implies we make mistakes, but unfortunately (or fortunately?) the medical, legal systems and our own expectations of ourselves don't quite allow that yet. We expect perfection. And when patients depend on me, I expect to give nothing less.

Yes, I had such a day today. On days like this, you begin to question everything you do. When I was an intern many many years ago, I even had what I called the Black Book. A list of last names, dates and mistakes I made while looking after patients. Forgetting to check the INR before a procedure, writing the wrong dose, misreading results of tests. I did it to help me learn, to never make mistakes again. But as my friend said, I was just tormenting myself. So I finally stopped keeping record.

It takes just one mistake to undo the good you feel from the week's work.

A medstudent, trying hard to decide his career path (yes, you have to decide on your specialty 2 years into medical school) asked me:

Why endocrinology? Don't you miss the adrenaline? The rush?

Flashback to my last Code Blue as a senior resident in the ICU:

"Code Blue, D-building, room 455"

That promptly wakes you up at the unholy hour of 315am. You'd be surprised at how much adrenaline your adrenals can churn out at short notice. You slip one your shoes and pop a piece of gum in to hide your breath. You race 300 meters to the site of action. Along the way, you half hope to hear a 2nd page: Code Blue, all clear (never happens, false alarm). Halfway, you start huffing. You pass the 2 pharmacists racing to the same place pushing the fabled 'crash cart'.

You see the room from 30 meters away. There is a crowd. Commotion. Need to get people up and free up space for those involved.

"MICU Senior's here!" You shout.

"Cards Senior's here", someone else shouts.

The main players of the code team are there; the team leader, airway and central line technicians. The crowd backs away to reveal the patient, straddled by a heavyset nurse performing chest compressions. You get a 20 second run-down of the patient's history, and do a quick look over. Defib pads go on. Airway goes in. You deftly thread in a central femoral line. Everyone stops momentarily to look at the cardiac monitor. Pulseless electrical activity. In goes the epi. The compressions and bagging resumes.

After 20 minutes of strenuous coding, we are about to give up. I have sweat running down my cheeks despite the thin, cool blue hospital scrubs. My back aches. Depending on the code team

leader, the time varies. This patient, admittedly we were trying longer, because this was totally unexpected. Her husband thought he'd be taking her to the nursing home in 2 days. Though unspoken, we dreaded the thought of a sweet old man coming expecting to discharge his wife, only to find her in the morgue. Just as we are to 'call the code' (stop efforts), her pulses return. We package her up and ship her to the medical ICU. Being the senior there, I accept the patient formally and begin a thorough examination on her. She's breathing on her own. But I find her pupils blown and dilated, unresponsive. Zero brainstem reflexes. Braindead. Given that, likely to stop spontaneous breathing soon

.

I had to break the news to her aged husband. And seek permission to stop the ventilator. But at least we've given family a chance to say goodbye.

No, I don't miss the adrenaline. No, I don't miss the rush. I like to take my time, to get to know the patient, to form a relationship, to even look forward to seeing them again for a 3-month follow-up. I like knowing them well enough to understand why someone would defer thyroid cancer treatment for a month because of his daughter's upcoming wedding. Or why she couldn't stop smiling ear to ear because she had lost 25 pounds. I like to have my time, for myself, for my wife, for my children.

A Good Cause

Yvonne Foong probably needs no introduction to the hordes of Malaysian fans and admirers out there. No, she is not an actress, model, famous scientist or an heiress. But I do consider her to be one of the bravest, pluckiest and most resourceful people I know of.

She has neurofibromatosis type 2. Despite numerous surgeries, she is now deaf and was left with a facial palsy. In an attempt to treat the deafness, she underwent surgery in Los Angeles, California last week. She will be there will November 22. Despite the surgeon having waived his fees, the cost is obviously astronomical. But instead of sitting around askig for donations, this plucky lady and her friends embarked on a fundraiser of impressive proportions, which included designing and selling T-shirts and earrings, organizing a concert, blogathon and writing a book (I'm not sick, just a bit unwell).

Her achievements put many of us to shame; she was browned the Most Outstanding Youth of the Year 2005, is represented by the Euro 1 Motion Picture and Literary Agency in Eastern Europe and the Balkans, Fine Art Synergy, founder of NF Malaysia, freelance contributor to the Sun Newspaper, writer for YellowPost, among others. And to think my proudest achievement was being able to stuff 4 hard-boiled eggs into my mouth at one go (kids: don't try this at home).

(Picture borrowed from Kenny, with permission)

She is currently recovering from surgery in LA. Being the KPC that I am, I am trying to help promote her cause in hopes of raising some funds for her. I came across her most recent update from Kenny's site, and it hit me at a very personal level. Perhaps this stems from the guilt and helplessness many overseas physicians and surgeons I know have; we help hundreds or thousands of patients here, but are almost totally helpless to those back home. I try to volunteer here, but you know you can never reach that far.

And even in Malaysia, although we have an army of dedicated docs, the nonsensical government redtape and lack of budgeting for healthcare leave much to be desired. RM 500,000,000 for a sports complex in London when hospitals need ventilators and MRI scanners? After all, when did you last see a minister use a public hospital's regular ward? The same people who made policy decisions about spending, when they need healthcare, they go to private hospitals, or fly overseas. I should know. I've seen numerous Dato's here, 22 hours away from Malaysia, who strut around like they own the damn hospital. Just cos they wanted to 'go to the best', while they neglect the ones at home.

So, I'm hoping some readers out there could help with donations. The Paypal link from her site makes credit card donations easy. And though she needs over RM200,000, every little bit, every dollar, would be appreciated. I've made a sizeable contribution myself. For those in the USA, for the cost of a meal at Applebees or TGIF, you can really make a difference. Think about it. If a hundred of you here donate US$10 each, it would translate to over RM 3000. So come on, if you're like me and need to work on your karma for all that boozing, womanizing and whatever else, go ahead and help a plucky young lady.

Thank you, all, and God Bless.

(Disclosure: I have no personal ties to Yvonne, though I admire her courage and wish I have even half of her gutsiness)