Back at Work (Kinda)

After a nice long vacation, I'm back. Well, technically I'm still on vacation till next week, but I stopped by work today anyways to start clearing up some stuff. And came across a note on a patient.

Sometimes you're damned if you do, and damned if you don't. In this case of a young man, we started a medication a few months ago; I had offered several treatment options with him and but in the we picked the meds since this was simplest for him. The side effects, though rare, were discussed. Sometimes though, even if a side effect occurs extremely rarely, when it does occur, it's like a punch to the stomach. And you feel like crap about it eventhough you had mentioned to the patient it can occur. It's one of those things that 99.9% of patients do well with it, but when you see that 0.1% it's enough to make you swear off that route completely. I'm reminded of that case of tension pneumothorax I saw as an intern; years later even until I was a senior resident I still had this intense fear of putting a line in a patient.

I rationalize and tell myself it wasn't my fault, but rather an idiosyncratic pharmacologic reaction, but deep inside, a part of me refuses to believe that since I was the prescriber.

I wonder, will we ever have a medication or a procedure, that truly is 100% complication-free? In this case, we've stopped the medication and he should recover completely with time, but it still leaves a bad taste in the mouth.

Farewells (or See You Later)

I'm not too good with goodbyes. You can ask my highschool buddies that; they'll testify about how I bawled when we all graduated and left for college. I get teary-eyed leaving my family when I check in at KLIA.

But some goodbyes are really more difficult that others. True, my own family is awaiting my arrival in the US anxiously. But sometimes even a family there can't replace some special things in your life.

And it's going to be particularly difficult saying goodbye to her.

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Mmmm. Any Malaysian expatriate will tell you that we all miss the food. And I'm willing to bet my left testicle that you do this too: we ALL inevitably bring foodstuff back to the US/UK/wherever when we leave Malaysia. This one's a definite. The packs and packs of Brahims, Maggi, sometimes even belacan (and you hope you can sneak things in!) just to bring a bit of Malaysian cuisine back to make things easier.
As I joke with my friends there; you miss food and family, and in that order of priority (kidding, mom, dad. Not reducing you to a plate of char koey teow!). But really, with the internet, webcams, Skype, it's pretty easy to stay in touch and see how people are doing (though it never really substitutes the real people) but you can't replace the food. Seeing and reading about food on the net just makes it more painful (so to you people who post pictures of food on Facebook for the rest of us, this is torture!!)
Now, I've seen siew yoke for sale in the States somewhere in California. But even this, never the kind we see here with half an inch of glistening, heavenly fat (note to wife: I picked out the fat from the meat. Ahem).
We'll be back probably in a couple of years. In the meantime, Malaysia, you take care. I'll miss you- see you later!

48 Hours to Go

So, it's begun. The mental countdown to departure; I leave in 48 hours. It's unbelievable how things just breezed by, though this year, the difference is that it's a mixed set of emotions. I'm usually dreading leaving Malaysia, but with a home in the US and my pregnant wife and dogs there, a big part of me is actually looking forward to going home.

Have spent the last few days in KL and I got to meet up with quite a few people. Old friends, people I grew up with, the same boys who have seen me through the worse of times. The people with whom I can truly be myself. It has been a while since I was out with them for late night mamak, or just chatting until 2 am. That's probably one thing I miss there; the people with whom I grew up are here, the kind of friends who know your deepest darkest secrets and still love you for you. I confided to Alvin a morbid, irrational fear of mine of living in the US; would I have many people there close enough to me to be able to give my eulogy at my funeral whenever that may be? People whose lives you know you truly have touched, and vice versa, and not that superficial, polite and proper interactions you often have in a politically-correct country. I'm not sure.

I was reminded too of how, when I'm in the States and I feel like I'm missing much here, life really does go on- people get married, have babies, priorities change. I realized that when I was all gungho about meeting up and hanging out, but now unlike the good old times, there were limiting factors like kids' bedtimes and pickup times for kindergarten, etc. It was also interesting to note how 15 years ago, the topic was about girls and cars, and how the topics gradually changed over the years to the topics we discussed this time, namely breastfeeding, pregnancy, how to raise children! Yes, despite how much we like to hold on to the memories, life does go on and we are getting older. But I'm glad the friendships (despite the other family and job commitments) have not diminished at all.It was neat too to be able to meet up with medschool friends. Looking back, we realized to our horror that our 'good old days' of medical school (whilst in PJ before we went our separate ways in the phase 2 of our program) was 12-14 years ago. We reminisced about the college, our antics, crappy lecturers and hot juniors. We also updated each other of happenings, classmates with whom we lost contact. It was enlightening to hear of ex-classmates doing well, working as various subspecialists. I have to say, I did catch myself pondering; a fear of mine had always been the inability to thrive in the Malaysian system after having trained overseas, but to see my friends doing pretty well here did get me wondering about how it would have been if I had decided to return and work here. Yup, this time of the trips to Malaysia, my mind and heart are usually in a mess of emotions. But this has been a good trip. I got to spend quality time with my family and during Chinese New Year too; I got to see good friends from school, medschool and even an ex-flame. Yes, I think I'm ready to go home. And home, really, is the US now. I can't wait to see my wife and 'kids' (the dogs) again!

Being Bloated

While it's great to be back, one thing I definitely don't miss, is the perpetually bloated feeling. You know, the feeling like you're stuff to the point of needing to throw up, and yet something inexplicably makes your dominant arm reach out for yet another piece of New Year cookie.

No, I'm certain it's got nothing to do with the fact that I've been having 4-5 double-helping meals a day. Or the numerous snacks in-between. Or the lack of self-control.

It's probably just something to do with the Malaysian heat, or the humidity, or possibly the heavily polluted air.

Sure.

But yea, I feel stuffed. I feel like a pig (but, oh is this pig in bliss...). I can't see that semblance of a six-pack anymore. My hard-earned biceps and triceps have lost their tone. In a way, it's probably good for my health that I'm only back for a couple of weeks; at least in the US I can try to stay in shape (my wife would disagree, but round IS a shape). Here I think I lose all control. Thankfully.

And yet, maybe I've been away too long, it's still surprising to me how Asians have such lower BMIs. I don't think we eat particularly healthy, but yet, compared to the average Midwesterner, the skinny girls here almost look anorexic. I suppose it's got a lot to do with what we eat; I don't think Asians have really fallen for the fastfood epidemic as much as the West (though our average life-expectancy is still far below that of the USA).

But for now, ah, let's not get too technical. I have another 8 days to eat. Let's eat.

Happy Chinese New Year: Traditions

Gong Xi Fa Cai, everyone!

It feels great to be back, especially this time of the year. The last time I was in Malaysia for Chinese New Year proper (I arrived back once, on the 15th day) was 2002. You realize how you miss the simple traditions, the things your family does for the new year. Even things you used to loathe, but did anyway, because it would mean you'd get a nice angpow (I suppose this is the Chinese version of "You'd better be good if you want your present from Santa"). Traditions like:

Having out family dinner on New Year's eve. It's been a while since we last sat down for dinner. This time with my brothers' 3 kids. Having mom's usual specialties like ginger chicken soup. Or that sweet roasted pork in black sauce (hun, I promise I took my Lipitor!).

Going out to visit the aunts and uncles in Seremban after dinner. Usually the first stash of angpows for the year. We'd then get home, and break out the fireworks. In the past, mom and dad spent hundreds of RM on us the 3 boys. And boys, being monsters, don't always do what you're supposed to. Several years we've had 'Moon Traveller' wars with the neighbours. Rather than pointing the bottle rockets up, we'd aim them at each others' houses. Until that one year we set some grass on fire at the neighbours! Never saw dad run that fast before (he and uncle Kenny were running buckets of water over!). This year, with only 1 nephew not afraid of fireworks, and that these have been banned, it was a smaller stash of some bottle rockets, fountains and sparklers (if anyone from Polis Diraja Malaysia is reading this, this part is entirely fictional!). I have to say though, the acrid smell of burnt gunpowder still gets me excited!

Mom would get us to do the midnight prayers to welcome the God of Prosperity. As kids, we'd be objecting, having been forced to stay awake so late.

The following morning, on the first day of Chinese New Year, we'd get up early and head to the temple for prayers. To this day, the smell of burning prayer sticks has a special place is in psyche; it makes me think of home, and the festivals. I realized this the last time we were in San Francisco and caught a whiff of this in Chinatown, and I immediately thought of this. After the prayers, we'd head home and get things ready for the open house; hordes of people (many I swear coming for just the Angpow, the red packets of money- I recall people bringing their troops of kids just to collect the money, and leave in 5 mins for the next house to hit). I'd get to do my own visiting and seeing my friends only from the 2nd day of CNY onwards. Oh, the things we did: as kids we'd go around on our bikes and a stash of firecrackers. We'd pop them into things we'd see while cycling from one place to another. One year we came up to some freshly made cow dung, you know, the one that is still soft and green. Well, suffice to say, after that firecracker went off, we had to cut our visiting short, and all went home for a shower. When we were older, and able to drive around, we always had mini casinos going in the houses we went to (ah, gambling- another Chinese New Year tradition).

Yes, it's great to be back, to again be soaking up all these familiar sights, sounds, smells, and taste. I only wish that Kristin didn't have to work and was here; my hope though is that when little baby Shim is old enough that we all get to spend Chinese New Year here. As it is with us calling the US our home now, it's really important for me to let our kids experience these little traditions in life.

Sometimes you just can't leave work behind. I find it extremely ironic to be going over my patient charts here, while on vacation 9900 miles away. I had a bunch of pending labs when I left, but some of those I just couldn't punt to my colleagues.

Like that Mr. H I just saw last week. Sometimes you kinda knew what you were going to find.

He is a 34 year old man, who was found to have nodules in his thyroid during a CT scan following a motor-vehicle accident. He was promptly referred to me, and I was surprised that no one (himself especially) had noticed 2 prominent thyroid nodules, at least 2 cm by palpation. And it didn't feel good too; the nodules didn't have the firm-soft nodules you usually feel. Instead, they were rock hard.

Things didn't look better when I put the ultrasound probe on the neck- there were microcalfications within the hypoechoic nodules. Given the suspicious appearance, I biopsied both, each with 4 passes.

The results came back in my virtual desktop- papillary thyroid cancer for both contralateral nodules. I kinda suspected this when I saw him, and did somewhat prepare him. However given his young age and the slow-growing nature of these, the prognosis should be excellent.

I just didn't want to wait until March when I get back to work to set him up to see a thyroid surgeon.

You Know You're Back in Malaysia When:

• You see that Chinese uncle with loudly sucking at his teeth, with a toothpick in his mouth
• There is absolutely no sense of order as everyone just shoves to get on the Aerotrain at KLIA
• You see cars zipping past you eventhough you're already going at 120 km/h
• Cars are parked illegally, then double-parked, and clogging up the roads
• The foodstalls are still crowded at 12:30 AM, with people and stray dogs
• You see all manners of modified cars sporting decals of equipment they clearly do NOT carry (I'm not sure why having a DOHC sticker on a clunker of a car does anything)
• You get your first case of travellers' diarrhea only 14 hours into your visit
• Your buttcrack feels sticky again just 2 mins after your shower (and no, it's not from the diarrhea)
• After a meal, all you have to do to get the bill is to use the usual pen-writing-in-the-air gesture or circle your index finger. The last time I did that in the USA the waiter brought me another cup of coffee.
• Suddenly it doesn't feel out of place to say Aiyah, Alamak, or KNNCCB (well, maybe it should be for this one)

Not that I'm dissing Malaysia/Malaysians or anything like that, it's just that I'm guilty of many of the above (ask my wife, she'll tell you I do Number 1 very well). Also there's something very comforting to be back in the midst of such familiarity. Ah, it's nice to be back.

Going Home

It's interesting how despite having been away 12 years I still refer to Malaysia as home. Despite the fact that our house is here. My wife, and soon to be daughter. Home will always be home, I guess, and my wife doesn't take it the wrong way when I call Malaysia that.

Yes, weather permitting (it's a freakin' snowstorm out there, KNNCCB!) I should start my long journey home in 16 hours. A long 20+ hour flight (not including the 16+ hour layovers), though sad to say I'm looking forward to the business class seats as much as the visit itself (no, I could never have afforded it; I had enough miles for a one-way business class upgrade).

In my mind, I've already started the usual, listing down the friends I want to see, the foods I want to stuff myself with, the places I want to visit. And this will be the first Chinese New Year I'll be celebrating there in many years.

And as always, once I arrive, the mental countdown clock begins, of the remaining days before I leave again.

Will be travelling without Kristin this time, which makes me seem like a bastard leaving my pregnant wife alone for Valentine's Day! (but we celebrated tonight, if that's any consolation). Kristin is fearful that I'm going to marry 3-4 Malaysian wives and will never be coming back to the States. But no, how could I? I ask her; my cars are here!

Malaysia, see you soon!

And for those of who are interested, I'll be giving the usual talk (Applying for a Residency, Part 4) at IMU on Feb 22nd. For details ask Aznah of Student Affairs.

And the Award Goes to...

So, looks like most of you voted for baby girl, huh? 69% think we're expecting a girl.

Well, we went for the 18th week ultrasound today. Both Kris and I were staring and squinting at the realtime images, trying to see if we see the sex of the baby. I guess there's a reason neither one of us are in OB:

Us: "Oooo, is that the baby's eyes??"

Ultrasonographer: "Uh, no. That's the heart (never mind that it was beating in all its glory)"

For a moment I thought I saw it. The family jewels. The stick and berries. The bird and the eggs. My heart nearly exploded with pride, seeing a long snake the length of the baby's arm.

Yeah, that's what I'm talking about!! Like father, like son!

But no, as it turns out it wasn't some macropenis; that was the umbilical cord.

Finally the tech zooms in on the crotch area....

Yup, we're expecting a girl!! (which was what we were secretly hoping for all along, but didn't want to make it public)

So you readers were right!

You knew it was a matter of time.

Taken from NEJM:

To the Editor: In 1990, Brasington described "Nintendinitis" in a patient with pain over the extensor tendon of her thumb after 5 hours of playing a Nintendo video game. Nintendo next released the highly popular Wii games console that includes a wireless remote capable of detecting movement in three dimensions. Clinicians began to see patients with "Wiiitis." There do not seem to be reports of associated bony injuries, although interactive gaming has been reported to aid in the rehabilitation of patients after fracture.

In the United Kingdom, a healthy 14-year-old girl presented to the emergency department at Horton General Hospital in Banbury (near Oxford), having sustained an injury to her right foot with associated difficulty in mobilization. She had been playing on her Wii Fit balance board and had fallen off, sustaining an inversion injury.
(The Wii Fit replaces handheld controls with a pressure-sensitive board about 2 in. off the ground that lets the user participate in tricky games that can improve balance.)

On examination, there was soft-tissue swelling around the base of the fifth metatarsal, which was maximally tender to palpation. A radiograph showed a small fracture of the base of the fifth metatarsal (Figure 1). The patient was treated conservatively with the use of crutches and was referred to the fracture clinic for outpatient follow-up. The fracture probably resulted from the pull of the peroneus brevis muscle during inversion of the ankle.

What we all need next is some idiot to file a lawsuit against Nintendo...