Listening

Sometimes, what a patient needs is not medications.
Case in mind, I saw a 62 year old patient for follow-up of his diabetes and hyperlipidemia. I’ll call him Jake. Someone I had been following soon after I began fellowship, someone familiar enough to me that I call him by his first name, and whose face I could picture if you told me his name.
He came in for his 1.30 pm appointment a few hours early. And because the lab was unusually slow that morning, I decided to see him in the morning.
His medical problems were well-controlled with what he was taking currently. Hemoglobin A1c 5.9%, LDL well below the 70 mg/dL goal we all strive for. As far as meetings go, that should not have taken more than 15 minutes. But it was clear Jake had more issues in his mind.
Because my calendar was wide open for another few hours, I just let him say what he needed to say.
His wife of 39 years was having an affair. With a mutual acquaintance. He spoke of how he hurt, first finding out, and then secretly recording their phone conversations. Of the pain he felt when they were being affectionate, or when they talked about sex. Especially when she denied everything to his face, until confronted with evidence. And how he felt trapped, because at their age, a divorce would bankrupt them.
And so, for 50 minutes, I just listened, nodded and shooked my head. Held his hand at times. While the tears freely ran down his cheeks, face contorted with pain.
When he stood up to leave, he did something he had never done before. He gave me a bear hug. And walked out, shoulders a bit less stooped, head a bit higher.
I’d like to think that listening helped Jake much more than the metformin and simvastatin and lisinopril and aspirin that I have him on.
It’s a reminder to me that doctors, despite our license to examine, poke, prod, treat, cut open, stitch, prescribe medications, are still fellow human beings. Nothing more, nothing less.

Blizzard!

No, I'm not talking about Dairy Queen ice-cream.

The whole midwest is in the middle of a blizzard now. Can't say I remember when it ever got this bad. Started as we were driving home after the interview.

Now, snow, I can handle. But the thing that scares the shit outta me is freezing rain. Yes, it can rain during winter. My mom still has trouble with this concept. Basically, rain falls. But once it reaches the ground, or trees or whatever else it lands on, it freezes over. So, you have pretty little icicles on everything. Trees, cables (causes major damage because things eventually collapse from the excess weight). And roads. If you thought driving on snow-covered roads were tough, try driving on ice. Traction is minimal. It's just nerve-wrecking. Coming back, we saw at least 20 cars and trucks in the ditches, having slid off. Veronica had icicles forming DURING the drive. We took our time and got back in 4 hours instead of the usual 3, at 45 mph. I need to find out where Bond got his Aston Martin with the spiked tires.

Right now, we're all holed up, hibernating at home. Times like this I wish I had a snowblower. Then again, I remember my hand surgeon friend Vincent's tales of the patients he saw in the ER with their fingers all ripped off from snowblower accidents.

Drool Factor

What a crazy last couple of days. Kris and I went to this city for a job interview. And since there was a Mercedes dealership there, I made plans to test drive the SLK.

After my interview, the medical center there had a property realtor show us around the housing in the city; we spent 3 hours looking at houses to get an idea of how much property costs there. And then we started talking about cars, turns out he was a car buff too, despite being in his 60s. When I asked him how I could get to the dealership, he came up with this proposal. His wife's car was at the garage for a tune-up, and it happens to be right beside the Mercedes showroom. She was too busy to pick it up anyway, and he was trying to find a way to bring the car home. So, he suggested I drive the car first to the Mercedes showroom and do my thing, and then I can just drive back to the hotel and park it at our hotel's carpark, which was near his neighbourhood. Sounds crazy enough, as it is, right? I mean, I was a total stranger to this chap.

The craziest thing, was that his wife's car was a farking Porsche 911 Carrera. Bear in mind that until today I had never met this joker before. Thus is the typical midwestern friendliness and trust. I thought he was out of his mind.

And so Kris and I drove up to the Mercedes dealership in the black 911 Turbo, parked right in front of the main entrance, casually walked in and said,

"I'd like to test drive your SLK please." Man, was that a high moment in my life or what?

Given our grand entrance (and the guy I'd exchanged emails with knew I was a physician), no questions were asked, except "Which colour would you like to test drive?"

I felt like I was Brad Pitt. Tom Cruise. Donald Trump (minus the bad hair).

Omigosh omigosh omigosh. I had to force myself to not hyperventilate. I had this stupid grin throughout. With a woody brought on by driving these two supercars.

The only regrets were,

1) It was too cold to drive with the top down on the SLK, though we did play with it a lot. Simply amazing hardtop convertible mechanism,

2) We did not have our camera with us, KNNCCB (after all, we came from the interview).

My verdict, foolhardy perhaps, but I still prefer the SLK. Both were extremely responsive cars, taking off like a rocket with a beautiful v-r-o-o-m. Excellent handling, held on the the wet roads like leech on a fat man, but I thought the noise of the 911 was too much for long-distance driving (although the deep-throated high-RPM rumble was magnificent).

Clearly, one was made to be a racing car, while the other was a luxury sportscar; I preferred the feel of the latter.

Though our trip down here was for business, and the highlight should have been the interview with the very warm and friendly people there (my future colleagues, I suspect. I really liked the practice), my testdrive far surpassed anything else I did down there.

The realtor who lent me his wife's car said we could take it for a spin and have fun if we wanted; because we got lost driving back to the hotel, we ended up driving the Porsche for 45 heavenly, almost-orgasmic minutes.

If I die today, I shall die a happy, happy, happy man. Driving a sportscar with a chick by your side; priceless.

(P/S: no, I will not be making the purchase yet, not until I sign a job contract).

Hypocrite

So the lady and I went out for desserts with her friends last night. At one of the bakeries, for some pies and coffee. I was craving the apple pie, while Kris was eyeing something chocolate-y.
Moments after we sit down, our waitress comes to take our order. And then I hear:
"Hey, aren't you my endocrinologist?"
Turns out she was my 21 year old with type 1 diabetes. The one I just saw again last week. The one I was busting her chops on, for not watching her insulin, her food intake (her hemoglobin A1c was drifting up; she had been snacking more without taking the compensatory insulin shots), and for alcohol binging (especially bad for DM1).
If there ever was a moment I felt like a hypocrite, that was it. I wanted to just disappear. I was tempted to order salad instead. But no, I stuck to my guns, and went for the Country Apple Pie instead. And told her to pretend she never saw me.
I'll have to cut her some slack when she comes in to see me again in 3 months. Hopefully her numbers would look better.

Memories of Chinese New Year, part II

Money. When it comes down to it, Chinese New Year is about money, no? After all, why would strangers take their 5 kids and 4 nephews and nieces to your open house, to have them line up, hands clasped like they were going to pound you to death, to wish you 'Kong si Fat Chai'? And who is Chai, anyway, and why is he fat?

You'd get money in angpowes, or red packet, and keep them close to you. As a greedy kid, I learnt to wear pants with deep pockets (plenty of stash space marr). Angpows that felt thick were a good sign. Angpows that clinked were bad ($1 coins).
After you'd collected a significant amount of moo-lah, you'd adjourn to a friend's house, where the real thing began.
Two-lup. 21 o'clock. All meant the same thing: Blackjack.
Probably the only time of the year adults condone gambling, even for kids. Usually small-time affairs, bets of 25 cents or so. Though I'm sure somewhere out there some kid's placed his dad's car keys in the pot before. It was serious business. You'd eye your fellow cheaters players with hawkeyes, slowly sipping your stiff drinks (7-Up), carefully angling the card ever so slightly from the table to look at your hand. Life or death serious.
Chinese New Year isn't Chinese New Year without the gambling. Usually my dad or older brother would be the 'chongker'. Or dealer. Gutsy; you'd either made a ton of cash (ie. 5-10 dollars) or lost some.
And as a kid, I sucked at gambling. I lost to my parents. I lost to my brothers. I lost to my friends. And I even lost to my kid sister. I tried everything; even the customary red underpants while playing cards (for good luck)(they ALL must have been wearing red underwear, double-layered, no less), or even going commando (not very comfortable).

I discovered only this year at our Chinese New Year party that CNY-Blackjack rules aren't the same as the Bellagio card rules. No such thing as getting triple for two aces. Or double for not having busted with 5 cards ('five dragons'). Heck, you only get 1.5x for a blackjack. Cheh.

True to our nature, when the 30 or so of us got together for CNY this year, we broke out our lion (again, I danced the part of the lion ass), homemade 'yee sang', and more importantly, the gambling table. And for as long as I can remember, I actually made $10 (USD!).

It's our way of feeling closer to home on this auspicious event. This is when I'm usually most homesick, since for many of use this is THE event of the year.

Found this video off YP's blog. Man, if this doesn't make you homesick this time of year, I don't know what will. You've been warned...

Whoever Chai may be, Gong Si Fat Chai, everyone! (Gambling session, my place, midnight)

Valentine

I had grand plans for tonight. I got her roses. And chocolates. And planned to take her to a fancy Italian restaurant. And then I heard over the radio, men spend an average of US$150 today on their dates. And because the wait for a table at the restaurant was 2 hours, we had Vietnamese food instead (they wouldn't take reservations tonight).

I feel like a stingy bastard.

Anyways. Beats those highschool Valentine's day dates, when I'd save up for weeks to buy one miserable stalk of rose that looked more wilted and limp than a noodle.

Hope everyone had a good evening. Whether it was with a significant other, good friends, loved ones, or a good book. Someone I know calls this day Singles' Awareness Day- SAD. However, I for one never thought it to be a bad thing to be single and alone on Valentine's day. And I actually had one very memorable Valentine's day blind date just last year!

I have to say though (I'm sure everyone thinks this of their girlfriends, but I'll say it anyway), I feel blessed to be with Kris. She's an amazing gal; not only is she one of the kindest and most considerate people I know, but she is ever so supportive in my career, personal, social and family life. Sad to say, I know of some friends whose significant others may treat them well, but do not nurture or respect their friendships with other people. And so, you never see them again once they begin dating because their spouses/girlfriends don't want to hang out, or want them to go shopping etc etc. Almost to the extent of being selfish. And as their friends on the other end, it's disappointing.

I'm thankful that Kris makes it a point to know my friends' names, to spend time with them and more important, makes sure I don't neglect my buddies. Or my family.

Happy Valentine's day, everyone!

Memories of Chinese New Year, part I

So Chinese New Year is just round the corner. Next weekend, to be exact. To the uninitiated, it's like THE biggest holiday for many in Asia. Bigger than Christmas, or New Year. Bigger than the Superbowl. Even bigger than the one with Janet Jackson's wardrobe malfunction.
A 15 day celebration, with generous helpings of food, money in red packets, lion dances, gambling, and of course fireworks. Till today, the smell of gunpowder brings back those fond memories of my childhood.
No parent will wittingly let her child play with low-level explosives that may potentially hurt or maim. However, Chinese New Year seems to be an exception, because of some ancient legend of some monster that would come annually to feed on hapless villagers, who despite his size, was terrified of noise from fireworks. So, many parents spend up to hundreds of dollars on these instruments of goodwill and luck (aptly named 'Thunderclap', 'Tank' or 'Bazooka').
Coming from a household with 3 boys and 1 tomboy (thankfully now grown into a beautiful young lady), one doesn't need a lot of imagination to guess what kind of mischief we got into with some ammo.
One of our favourites was the humble firecracker. Looking like a miniature stick of dynamite, these small red suckers had an inch-long fuse that would ignite and burn like a pissed-off snake. Psshhhhh-boom. You'd hardly 2 seconds before the explosion. It was small enough that you could poke a small 0.5 cm hole in the lawn, stuff one in, and watch the ground explode. And it was easy to blame the dozen or so holes in our garden on our 2 dogs.
"Yea mom, Snowy was out digging again, honest!"
Except you'd see fragments of red paper, evidence of our act.

Sooner or later, you'd find some poor animal to stick this too (yup, us boys were monsters. My patients have trouble believing this now). Me, I'd find some pest to blow up (personal favourite- fireants), though my brothers have blown up a frog or two.
There were cows in our neighbourhood way back then. Another favourite target of ours was fresh cow dung. Really. You'd find one, the size of a medium Chicago-style pizza (except it was a dark bile-green colour), about 2 inches thick, gently inserted a stick into the middle, get the newbie kid in your group to light it and run. Except with the short fuse, everyone would invariably get some splatter. It stank like the devil, but the crater left in the dung was a real beauty.

Another favourite of mine was the 'Moon Traveller®'. Small bottle rockets, one of those things that would fly up and explode. Stick one of these into a pipe, and you'd have an instant missile launcher, with a range of about 50 meters. My neighbours and us would have inter-street artillery wars. Naturally, because of our balcony, we had a better vantage point and had a better hit rate than they. The neighbourhood wars stopped one year after we set fire to a neighbour's lawn (I swear, it was too dry anyway). That was about the time I had a fascination with astronomy and the multi-phased Saturn V rockets used to transport the astronauts to the moon. So I soon learnt to loosely attach one moon traveller to another and light one fuse a moment later than the other. And vóila, you'd have a multi-phased bottle rocket. Psssh-pop-psssh-pop. Double the range. At about the time when I stopped playing with these things, the humble moon traveller was replaced with the mighty Thunderclap®. It's like comparing the Stinger missile to the Patriot. Instead of a wimpy pssshh-pop, you get a banshee-like scream as the rocket lifted itself into the sky, followed by a flash of light and a loud boom a second later.

You'd find anything to aim these rockets at. Including a drain swollen with rainwater; the rockets still flew underwater and made a loud pop and big splash.

I imagine Bush and Saddam had the same stupid maniacal grins when they lit their rockets and ran for cover. Except theirs cost over 4 millions times more than those fireworks. It's hard to believe parents actually let kids play with this stuff. And we were lucky we never blew any of our fingers off. Can't say I wasn't too surprised when they finally banned these things in Malaysia.

Then again, looking at our Mentos-Coke and Dry Ice exploits, I guess boys never do grow out of their fascination with things that go boom. Someday, I imagine the social workers would come and take my son away from me, for teaching him the finer things in life, like how to make a dung-bombs with firecrackers.

Back to work

How does one go back to work, to a large, well-equipped, modern medical center with over 85 ORs, 2000 doctors, 3 helicopters and an airplane, after having seen the Katrina aftermath?

I thought this as I came to work today, dressed in my suit as I walked in the subway, with soft elevator music piping in from the overhead speakers.

Believe it or not, I felt guilt. Guilt for leaving those patients behind. Guilt that I was warm, fed, dressed, healthy. Guilt that I was listening to my new iPod nano, while they were struggling to buy strips for their glucometer.

And yet, a tinge of anger and frustration, when I saw patients here who complained about having to wait 2 hours for an appointment, or having to fast a few hours for a test. Knowing that Mr. CC waited in the cold since 2 am that morning to see me at clinic.

And the most bitter pill yet? How shielded some people here are, how biased with their preconceived notions.

I had to bite my lip several times today when I heard some senior colleagues here say how the people of New Orleans 'asked for it' because they blew whatever relief cash they were given on jewellery, or how they were 'lazy' and did not try to pick up the pieces themselves after Katrina.

What pieces? When your whole home is condemned, your documents lost, your office of employment nonexistent, and your family spread out over 3 states?

The Mission

The Departure:

There was an air of excitement, akin to a trip to Disneyland, meeting other team-mates at the airport. Familiar faces though names unknown, people one recognizes after working at the hospital for 5 years. Each giving a smile of acknowledgement or a nod, knowing our common goal.
This felt like going on a camping trip, almost clouding the scope, the depth and seriousness of our mission. But this will change soon after we arrive.
At the New Orleans airport, the welcoming team waits for us with signs, Operation Blessing, MC Team. As we gather, people walking past us in that busy airport lobby clap, or give us the thumbs up, recognizing our medical center's name and expressing their gratitude. I imagine the astronauts on Armageddon must have felt something similar as they prepared to leave for their mission. We left the airport chattering excitedly.
However, miles out, things became more solemn. More real.

Despite being a year and half out from Katrina and Rita, it's apparent that this city has not yet recovered. We passed miles and miles of neighbourhoods in utter ruins. Though an unfair comparison, I imagine this is how a warzone resembles. Demolished houses on one street, intact ones another. Homes vacant, windows nailed shut with plywood. Collapsed roofs. Condemned homes.

Spray paints on the walls, a scar from the search effort, seemingly in some alien language, with a large X and other symbols. We passed some homes that were being rebuilt. Many however, lived out of trailers and campers parked in front of their homes. I noticed a familiar yet alien landmark. A Toys-R-Us store, it's windows shattered, walls brown, carpark ruined and totally empty but for trash. Similar curse befell hotels, stores, car dealerships.
We are here for a reason, I realize. Fate put me here for a reason. From a small town in Malaysia to Canada to the USA and now to here.

The Mission:
We began seeing patients from Sunday, January 28th, and did so till our departure on Saturday Feb 3rd. Our exam 'rooms' were nothing more than 8' x 10' rooms with curtain walls in a large tent, with a table and 3 chairs, no bed. I averaged about 20 patients daily, from the first one at 6 am till about 4 pm. Though they had specifically wanted some of us there for subspecialty support, I saw everything from sore throats to gonorrhea to bad backs and of course, diabetes.

After several days, exhaustion creeps in. Probably more psychologically than mentally. Our days begin at 4 am daily, leaving by bus to the medical camp at 5 am. The extent of our duties became apparent when our bus nears the medical campsite. There, the 530 am darkness is illuminated by the lights of hundreds of cars, lined up waiting to enter the triage are. We have the New Orleans police department, the Army National Guard and our own security force watching our perimeter, complete with two army humvees parked out front. Many patients began waiting from 3 am, knowing that there will be masses of patients should they arrive late. Our camp caps at 500 (unofficially we've been taking 750, I've been told), and the numbers are filled by noon, with excess patients having to return the next day.
It was heartbreaking.
There was no other way to describe it. My soul feels both so fulfilled, yet so tired, so bitter, at what these fellow human beings have to go through. Most of them had not seen a physician in a year or more. Most with active medical problems, hypertension, diabetes. Blood pressures over 200s. Hemoglobin A1c 23% (I never even knew you could measure something that high. It was probably a sensitive machine).
This one patient had renal failure from diabetic nephropathy. After having undergone dialysis for a few years, he had a transplant. The allograft worked wonderfully, allowing him to live a more normal life of not having to spend the 4 hours 3 times a week hooked to a dialysis machine. But when the hurricane hit, he lost access to all his medications including his antirejection meds. Knowing full well what the consequence of that would be. And so he lost his kidney. He's back on dialysis now.

Most of my patients stopped all their medications at least 6 months ago. Systolic BP's of 180 were the norm, some up to 220. A1c mean was 11%, amongst the diabetics I saw. Who can blame them, when a vial of Lantus insulin means several meals for the entire family? Which father or mother would let their family starve at their expense?

Many patients came just because they had not seen a doctor in months, and wanted someone to check them out. Some, it was clear, needed to talk to someone, to feel that someone cared. I had many patients, when prodded, just started sobbing uncontrollably. They thought that no one outside of New Orleans cared. They just needed to feel like they're not forgotten.
It was heartbreaking.

I also had one of the most surreal experiences in my life the other day:

This volunteer peeks through the curtain separating my room from the hall and says in a heavily accented speech, "Doctor, please come, emergency."
I admit, my first thought was she was exaggerating. After all, she wasn't a medical professional, but a layperson volunteer (bless her heart).
I step out of my room and see a body on the floor. Right in the middle of the waiting room, which
was a 15 by 10 foot area at the front of the tent. My consultant was checking his airway while someone else was trying to start chest compressions. He is a middle aged, obese male patient. And he is pulseless.
"He was just sitting there, when he suddenly slumped over." Someone said.
I could not feel a femoral pulse despite the compressions, and took over chest compressions.
"Call 911, and get Dave (the critical care fellow on the team. After all, the last time I did a code was 3 years ago)."
I start chest compressions, thankful that I work out frequently in the gym- it's not easy trying to perform a perfusing massage of the heart of a 150 kg patient.
"Check pulses, and get a pulse ox. Get labs." I tell someone. Aside from the synchronous femoral pulses with the chest compression, she feels nothing.
What made it unreal, was that the waiting room was full of patients, sitting on the chairs waiting for their turns. 10 people, the closest was just 1 meter to my right. As I push down onto the patient's chest and feel it give under my weight, I hear another patient, a lady, pray loudly. "O Lord, please have mercy. Please have mercy. Please have mercy...". It was unreal.
My consultant administers mouth-to-mouth (we were unable to find the dang face mask).
The AED (Automated External Defibrillator) arrives. We slap it on, and cease resuscitation momentarily. He remains breathless and pulseless.
"No Shock Advised. Continue CPR if pulses" the monotonous electronic voice says.
We restart. "Epinephrine?" I hear someone ask. "Yes, 1 mg stat" I yell back in sync with someone else. but before that was given, but after what seemed like an eternity (really just 3 or 4 minutes into CPR), we see spontaneous chest movement. He is back. By then, EMS arrives. The patient opens his eyes, and unbelievable, actually responds verbally.
"Is there someone you want us to call?" my colleague Tanya asks him. His answer belies what he had just gone through (he probably didn't realize it yet)- "No, I'll call her from the hospital", he says drowsily.
He'll be alright, we think to ourselves. Needless to say, I was no longer sleepy when I went back to my room.
It was surreal, really. How I was there to see endo patients but ended up helping with a code.

"O lord, please have mercy....." Simply surreal.

But through this all, the people endured. In every possible way. And the biggest surprise? The people of New Orleans remain ever so warm, so friendly. This was purely a voluntary effort. The patients did not have to pay financially. But, pay us they did, with their graciousness, warmth, touching stories, handshakes, hugs and even kisses. When they thank me with tears in their eyes, how can I tell them that I feel guilty that I seem to be getting more from them than they are from me? I learnt so much from them.
While I felt that I was helping some, there was some bitter frustration and feeling of hopelessness as well. You provide patients with care and medications for a month. They get better. But you know they'll probably stop once they run out, unable to pay. Or, the patients with poorly controlled diabetes on NPH insulin to whom you're trying to teach dose adjustment and they get that glazed-over look. It's clear they're confused, or don't understand. And many of them can't read, so you can't write the instructions down. The "Oh honey, I left my reading glasses at home and can't read that" probably is their way of saying they're illiterate. So you take a leap of faith and come up with a guess of what their insulin doses are, and send them out. Knowing you'll never be able to follow up with them for adjustments. You pray that they'll fly, but deep down worried that it may be shortlived.
Despite all that hopelessness, it was encouraging to see how big institutions pool their resources together. We gave out $27,000 worth of medications one day alone. By day 3, the whole operation had given out over $300,000 of services and equipment. And when we mentioned to our hospital at home that the patient tents were dark, the supervisors here went out and bought dozens of lamps within minutes. And how they urgently shipped down hundreds of glucometers when we ran out, to be given to patients. The hospital provided us with numerous cellphones for us to use when we needed a language interpreter. We were able to call our hospitals interpreters from New Orleans who translated for us over the speakerphone. I truly feel blessed to be working for this institution. There was also a group of chinese doctors, 20 strong, who took leave and paid to fly here to help. On their own time.

When darkness befalls fellow men, it's heartwarming to see how people reach out.

There was a media frenzy as well. Reporters from TV stations, newspapers. Two interviewed me, though I'm not sure if that will ever see the light of day (doctor with braces= not very sexy. There was a reason they didn't pick a pimply-faced kid with braces to play Dr. McDreamy). My colleague who was standing right beside me during her interview appeared on prime time national news. And I thought this would have been my big break into some medical reality show (Dr. Sugarboy, 55905).

Though the week is over, and the job is far from done. Hopefully, we can help patch up some wounds. And more than that, hopefully the country becomes aware that this city is far from healed. This is truly a national tragedy, and more aid is needed.
The people who organized this are simply amazing. It's not that difficult working your ass off, volunteering for a week. But when you do that all the time, it takes real dedication. The day before we left, after the tornadoes hit Florida, some of the Operation Blessings people left us for the disaster area, ready to set up camp there. The trucks with the emergency equipment were being packed as we left, and are probably on the way there now.

This has been a truly amazing week for me, for us. At the predeparture briefing, they had said this would be a life-changing experience. It certainly has been. And on top of it, I've met and worked with some wonderful, selfless colleagues, new friends: doctors, nurses, pharmacists, lab techs and other allied health members. In a way, like camping; we slept in groups, on bunkbeds, ate in mess-tents; except it was a camping trip with a purpose.

It has reminded me of what being a doctor is about. Something we take for granted and forget in an extremely academic and competitive place. It's not about publishing papers, presenting at meetings, writing grants. It's about helping fellow human beings.

More information on this website, with a short video essay.