Friday, June 28, 2013

Congratulations, Sis!

End of June.
End of the fiscal year. And for those of us in medical education, end of the academic year. For some, it's promotion into a more senior year of medical school. Or no longer being an intern, but an R2. Or perhaps advancing from being a 'resident' to a 'fellow'.
It's the changing of the guards in the hospitals nationwide; for Monday comes a fresh set of greenhorns (note to self- avoid getting sick in the next few weeks).
I'm particularly proud that my sister completed her final day of fellowship today. Almost a decade ago, she decided to leave Malaysia to pursue her medical studies in North America. After getting her medical degree, she moved on to train in internal medicine and then palliative medicine at two of the top hospitals in the country.
Slogging on thousands of miles away from family, and from her significant other.
Now, after 5 years of medical school and 4 years of postgraduate medical specialty training, she is done.
She finally gets to go home for good. To start a new career, and a new life with her fiance in Malaysia. And my parents finally get their 'baby' girl back with them again. Though part of me is saddened to think that my sister will no longer be living in the same continent as I am, I am nonetheless happy and excited for her.
She has done our family and friends proud. And someday I am sure she will be a huge asset to Malaysia.
Congratulations, sis!


Monday, June 24, 2013

Happy Birthday Allison!

It's surreal how time flies.
I remember it like it was yesterday. I was seeing my 8AM prolactinoma patient; a 20-something year old woman who presented with amenorrhea and breast discharge. I got a phonecall from my wife shortly into the consultation, but I cautioned my patient that my wife is pregnant and I'd have to take all calls, and she graciously understood.
When Kristin said she was 3 cm, I jumped. Quickly wrapped up the visit while my nurse informed the reception to start cancelling/rescheduling my appointments for the rest of the day. I rushed home, grabbed my gear, and took off for the 2-hour drive. Kristin was doing a clinical attachment in a neighboring hospital (we didn't think she would come 3 weeks early).
By the time I got there, she was 8 cm and almost ready to go. And to my horror I realized that being the moron that I was, I forgot the camera. The contractions distracted my wife enough to not say what she was thinking: that I was the biggest idiot in the world. Thankfully, I was able to borrow one from one of her colleagues. And then sometime midafternoon, came the 5 lbs 13 oz that came to be Allison.
Seems like it was just a blink of the eye, and today (well, we had the party yesterday) she turned 3.
3 years of energy/hugs/kisses/michievous laughs wrapped up into a firecracker. It's true they say- the kids grow up before you know it. Though in part I think it's a human mental defensive mechanism- you block out those times when you were exhausted or ready to scream to prevent PTSD. And so you're left with a sensation that time is going by faster than Warp 9.
I think Alli had a blast. I know we did. We organized a small party for her and some of her friends. She's into Hello Kitty, so we got all kinds of Hello Kitty things. Family and friends showered her with gifts, but much more so, made her feel so loved and special.
Happy 3rd Birthday Allison.
With much love, Mom, Dad and Ava

Sunday, June 16, 2013

Happy Father's Day

This year it's gonna be more fun. Allison's old enough to kinda understand what Father's Day is.
After having been a dad for 3 years, you realize how much work (and money!) it is to be a parent. I'm perpetually exhausted; I don't sleep long anymore. I've aged significantly, numerically and physically, in the last few years. I've lost most of my hair, beating even my dad (in that picture, circa ~1980) so far. I worry- about boring things like life and disability insurance, college savings funds, school systems, and the general state of the world.
Yet, despite all the work, it's a blissfully magical thing to have your princesses give you hugs and kisses. To have a crappy day at work but to come home and have your kids make you feel like you're truly the king of the house.
Happy Father's Day, to all the dads out there.
To mine, and also (wherever he may be) HIS dad.
(that's dad holding me and my older brother)
(me as a newborn in my Ah Kong's arms. Damn I had a lot of hair then)

Friday, June 14, 2013

Social Media and Patient Confidentiality

I'm motivated to blog about this after a recent posting I read in one of the social media sites. With how fast things are evolving, it's pretty common these days to get a 'curbside' from colleagues via the internet.
Either emailing, or posting clinical challenges, lab results, radiologic or physical exam findings. After all, it's good for patients for us to be able to reach out to experts elsewhere, and it's good education for us doctors too to share cases.
However, with the ease of sharing these diagnostic dilemmas, comes the potential for misuse or downright abuse. A few recent events I read on a certain website comes to mind. The first was a series of pretty graphic pictures of the genitalia showing some pathology. Though this was not identifying of the patient, many doctors who belonged to that group was unprepared to see those images in such a public forum and found it offensive. And while I imagine the doctor who took the pictures had asked for the patient's permission, I'm pretty sure it was not exactly proper informed consent: "Please let me take a picture of your genital for me to post on Facebook..". The second incident was an image of a test result; the person who posted that image in all its glory conveniently forgot the patient's name and DOB was listed for all to see. I am also reminded of a blog of a medical student who some years ago started to post pictures of his pediatric patients with their faces clearly visible. Though permission was "obtained", these were children who were not able to legally able to provide proper consent.
As physicians, we are in a priviledged position, of being privy to a person's deepest, darkest secrets. We leave a person with very little remaining modesty as we poke and prod and push and percuss and auscultate and do other unmentionables, while they lay there vulnerable. We have taken the Hippocratic Oath, which among other things, to "respect the secrets that are confided in me, even after the patient has died..." (OK, to be accurate that was the Declaration of Geneva version).
And so, it's easy to forget that in a brisk click of the mouse, we may be revealing more than we should, and that we might be betraying the trust given to us. Even if it was done with no malice but with total beneficence for the patient. It's easy to think, "Hey, this is a really cool MRI, let me share this" without realizing the patient name is clearly visible. Or that picture of the goiter also happens to reveal a person's face.
We owe it to our patients to be more discreet about these things. The truth is, in some parts of the world people are fired or sued if they are found to have done some of these things. So, before you share your pictures, or X-ray images or whatever it might be, do take a moment to ask- is this suitable for social media? Am I overstepping the scope of the consent the patient has given me?

Tuesday, June 11, 2013

Home Brewed!

Yup, I brewed my own beer.  And I'd have to say it came out pretty good, too. Nothing like a cool drink on a warm day. Especially one you brewed yourself!
This is going to be a new hobby....

Friday, June 07, 2013

5 Years

I can't believe how fast time flies.
Five years.
Five years ago I married my best friend (well, at least our first wedding in the USA- we did a 2nd wedding in Malaysia in July).
Now, 5 years later, we're settled in in the Midwest, with a rambunctious 3 year old, and a 10 month old.
Happy Anniversary, honey!

Thursday, June 06, 2013

Iodine: The love-hate relationship

As an endocrinologist, I don't usually have patient situations so dire that I fear for their lives. Sure, I'm frequently involved in sick patients, the post-cardiac surgical patients or the trauma patients who are steps away from death. But my patients, people I play a direct role over?
Yesterday was one such day. I hesitantly put her in harm's way, and referred her to see a surgeon- she was quoted a 10% chance of mortality in the OR. It was an extreme case of amiodarone-induced thyrotoxicosis.
As you know, about a third of amiodarone is iodine. Iodine is the substrate from which the thyroid gland produces thyroxine and triiodothyronine. As such, any exposure to high concentrations of iodine may induce hyperthyroidism (and hypothyroidism, but that's a different story) by means of an exaggerated Jod-Basedow phenomenon (also called type 1 Amiodarone induced hyperthyroidism) or thyroiditis (type 2).
Mrs. J was a 60-something woman with a history of hypertrophic cardiomyopathy, complicated by atrial fibrillation and other tachyarrhythmias. And so not surprisingly her cardiologist put her on Amiodarone in an attempt to tame the heart. After a year, her cardiac status did not get better- she kept going in and out of the hospital for congestive heart failure. During one such visit, she was found to be markedly hyperthyroid.
Her Amiodarone stopped prior to her visit to her. When I saw her, despite having been off this for 2 months, and having been on maximal methimazole therapy, her free T4 was above the upper limit of measurement for our lab (above 6), her free T3 was 12. Her levels were worse than they were the month before. And despite calcium channel and beta blockade her heart was ticking away at 120 beats a minute.
And so, this was a situation all endocrinologists hate. What the heck do I do?
The temporal sequence makes type 2 AIT unlikely, as thyroiditis is expected to have at least improved two months later. So we are likely dealing with type 1. You might consider the conventional therapeutic options for hyperthyroidism: antithyroid medications to slow down production of new hormone, radioactive iodine ablation or thyroidectomy. Unfortunately the norms don't apply here.
Because by the time you see them, the gland is already supersaturated with iodine from the Amiodarone, antithyroid medications have very little effect. Likewise, radioactive iodine will not work- one would simply pee out the I131 you administer. Which leaves you with surgery. But you'd need to find a gutsy (crazy) surgeon and anesthesiologist who would take a severely thyrotoxic patient to the OR.
You could wait it out, but the halflife of Amiodarone is 100 days, and it may take upwards of 10 months before they become euthyroid. Many patients can't wait that long. Mrs. J was one of them. Her cardiologist was nervous she was going to go into some fatal tachyarrhythmia, or die of congestive heart failure, if we did nothing.
Which takes us to yesterday. We admitted her a couple of days before the planned surgery to have a better hold of things. She spent some nights in the ICU, but on the day of surgery despite maximal doses of Esmolol, she remained tachycardic. But she remained strong-willed, and keen to have surgery. Despite the odds given by the surgeon, she was ready to proceed.
I saw her a few minutes before they wheeled her to the OR. She was in a room full of family, most of whom were in tears. Her husband held on to her, crying, worried this was the last time he'd see her alive.
I held her hand and told her she was in good hands- she had a good surgeon working on her- though deep in my heart I hated that we had no other option but surgery (some have published case reports suggesting plasmapheresis to perhaps be beneficial- but data is weak). I wasn't sure I would be able to forgive myself should something bad happen to her.
I came home from work worried and distracted. However at 3 PM, I got the call- she sailed through surgery and was in recovery. It was a big burden off my shoulder, and what a relief it was. I saw her before I started clinic today, and despite the JP drain in her neck, she gave me a hug.
But this was a reminder to me of what a challenge Amiodarone-induced thyrotoxicosis is to treat. As good as a medication it is, the truth is us endos have a love-hate relationship with this medication.