response | responsibility II

Post call today.

At 1am last night, never been more frustrated. Ever.

A lady was sent in for C-Section because of hypertensive crisis at term and with 1 previous scar and suspicious CTG. I say it is suspicious because personally i think it was reactive. But then the intravenous antihypertensives was given without reservation just to get the blood pressures low enough for her to be 'stable for op'. stability can be pretty subjective, especially if you're at my hospy. Always running out of 'high risk consent' form.

At some point, the mother's diastolic dipped down to 60. And once blade to the uterus, muddy greenish meconium pooring out. Paediatric colleague was alarmed. She was at the other end of the hospital. I shouted 'thick meconium' and reminded the recipient nurse to prepare meconium aspirator. Both of her hands only with towel, giving me the blind look.

Once baby was out, not much of breathing effort. I quickly delivered the placenta and clamped the bleeders. Attempted to do direct suction.

"Switch on the light,please"
"Err... Dunno which is the switch."
"Give me the meconium aspirator..."
"I'll go get it"
"WHat?!?!? ETT and laryngoscope?"
"Getting it... " (went to other OT)

Before baby taking deeper breath, all was left was vigorous oral nasal suction and supplementary oxygen. Suction revealed thick meconium.

Couldn't wait any longer, re-scrubbed quickly and sutured up. 200cc blood loss.

Last seen, baby breathed rapidly, attended by my Paed colleagues and admitted neonatal ICU for observation.

Professional nurse with maternity post basic couldn't even make sure the warmer/baby's resuscitation trolley is fully equipped.

That's simply lame. Lame. Lame. Pathetic. Appalling.

Might as well keep the manicure set above in the warmer.

Maybe it is just that 1 person.

Maybe. Just maybe. Should have send her away on the bus below.

Ramadhan and me | 2

continued...

In the gynecology clinic, especially, every vaginal/speculum examination or order of collection for semen analysis requires a careful reconsideration.

During last year, I remember this conversation with my patient in fertility clinic.

Puan: Can give me Clomid?

Me: I will re-start you on Clomid induction next month, since you not having intercourse during this month. (Clomid induction is to induce ovulation by taking clomiphene citrate to increase fertility, and usually taken on Day 2 to D6 menses)

P: Err…

Dr. N: Not really lah. No intercourse during fasting hours only lah. (N is my colleague who overheard, or eavesdropping, i can’t really tell)

M: Oh.

P: Ya, Dr. N is correct. But then again, after a day of fasting and my husband attending long prayers at night, usually he’s too tired at night and we rarely have intercourse during this month.

N: Now, that pretty true as well.

M: Err… Why don’t I prescribe you Clomid, and you discussed with your husband, whether to use it during this month or next month? Can?

During Ramadhan, there will be a handful of ladies, at certain times of the month, which will be hiding and eating during those supposedly fasting hours. Do not mistaken them as the deviant group of Muslims who break religious practice. They are probably having their menses and not allowed to fast.

I remembered going to the boutique with my dearest in Queensbay Mall few weeks back. I (and so does every customers at the shop) overheard a conversation between the Chinese lady boss and her Muslim sales attendant. The boss was being nice, but at the same time ignorant.

Boss: I beli makanan untuk you buka puasa, mahu tak?

Salesgirl: Terima kasih. Tak payah lar, hari ni tak puasa.

B: Kenapa tak puasa? Mana boleh tak puasa?

S: Tak boleh puasa. Tak boleh lah. (Look at her boss in one kind, hoping she understands)

B: Apa tak boleh. You tak sakit kan.

S: Boss, tak boleh lah. Nanti I bagitahu you. (silent ‘Ishk’).

Some people can be pretty lost, at times.

Not that having menses is illegal or dirty or cheap, women just don’t want the whole wide world to know that they’re having menses. Similarly, for men, you don’t really want to let the whole universe to know you got body fluids (other than urine) coming out of your genitals, do you?

But then again, there was this fasting rule that I only knew this year.

I was seeing this auntie, new patient, who came to us with prolonged menses. Not heavy, just prolong. And at her age with 4 children, she had never been screened with Pap smear before. Her menses came since few days before Ramadhan and continueing everyday till now, a few days before Raya. By this time, frankly, I should really rule out those nasty gynae cancer, and ask her if I can proceed with perineal examination in view of the fact that she is not practicing puasa on that day.

“Saya puasa hari ni…”

”Mai kotor boleh puasa keh?”

“Jika lebih dari 15 hari, boleh puasa balik sampai Raya.”

“Oh...ok, lepas Raya, baru kita periksa balik”

“Baik.”

Learn a new thing this Ramadhan. The great teacher is always the patient.

At times, it can be pretty enlightening.

Ramadhan and me | 1

Post call today. Worst call ever yesterday. Ever. Ever.

I might as well be walking around with a noose.

As an MD in the hospy, unlike in the health sides, public holidays may not be public holiday per se. We gotta stay back and do on call, so that my Muslim colleagues can take their Raya break.

I could say that it was a blessing that I had only one Chinese colleague in my department. Therefore, I could take a longer stretch of break during the festive season. It is good as that will be the once a year time when my dearest will get to go back to her hometown. What makes her happy, makes me happy twice. Perhaps thrice.

I did not make it seem so obvious, but I kind of like her place very much. Small suburban place. Lotsa green. Pretty layback. It is just like those relaxing beach place, minus the roaring sea and the sandy beach. A good place to sit back and do nothing.

I guess lots would have agree, a bit of ‘nothing’ once a while, or once in a blue moon is such a wonderful thing.

Just ask yourself, when is the last time you have yourself the perfect ‘nothing’. Sort of like a retreat.

Yeah, I know it is 5 months away. But, a man, you know, gotta think ahead sometimes.

As a Malaysian for more than 20years, I thought I knew all about the Malay and Muslim tradition, culture and practice – all the songkoks, masjids, Al-Quran, 5 prayers per day, no alcohol, ketupats, khalwats, pahalas, dosas, polygamy if mampu (now, I heard it’s polygamy if nak mampus), quota system, infidel, and so on and so forth.

During my primary school times, my best vivid memory of Ramadhan is when the headmaster announced this piece of instruction during the morning assembly.

“Now, students… Listen up. This is Ramadhan month, when all Muslims schoolmates fasting. So, if you’re eating or drinking, make sure you’re not within sights of your Muslim schoolmates.”

And so for years after that, I learn to go into hidings whenever I am having my meals. Since that time till now, I was programmed that way every Ramadhan.

I kept discovering more and more, especially when I am treating patients who were Muslims.

Do correct me if I am wrong. I didn’t have this information from ulamas or top religious leaders, but from layperson Muslims.

During my uni years, the only thing that crossed the path of Islam and OBGY was about the miscarriages or abortions as makruh. I bet makruh does contain a large definition and meaning, but in simple term, my friend told me it was something that is not dosa (sin) but still it is not encouraged to do it.

Something about dosa, correct me if I am wrong. Muslims believe that the soul is within the body and when one dies, the soul will leave the body and back to Allah (The one and only God). With every dosas being committed, there will be a nail strongly hammered onto the body through the soul. Therefore the process of the soul leaving the body, the excruciating pain will equal to the tearing of the soul at each dosa nail site.

In the month of Ramadhan, the fasting month, the Muslim patients presented to us with several challenges. These challenges to some medical practitioner may seems like a difficulty or a meddlesome affair, but being religious, and sticking to it in a good way (good way meaning saying no to abusing severed cow head) can be pretty spiritually and mentally awesome. Needless to say, the mind precedes all thing and forerunner of all things. First lesson in Dhammapada. (Yes, this is a little bit of Buddhism)

The basis of challenges is that the Muslims will be fasting from sahur, around five thirty a.m. until they buka puasa (or break fast, not breakfast) around seven thirty p.m.

During sahur and buka puasa, it would be the feasting time.

During the fasting hours, there will be no eating, no drinking, no intercourse and no smoking. I totally dig the no smoking thingy. Not only it is good for their health, it is environmentally friendly.

The main challenge over the antenatal clinic would be to monitor the blood sugar profile (BSP) for the diabetics mothers, even the gestational ones, who may in the spirit of Ramadhan, commit themselves to binge eating during the 2 main meals of sahur and buka puasa. In the usual case, the four readings of BSP is capillary blood glucose taken 7am fasted whole night, and at 11am, 5pm and 10pm fasted 2 hours prior. The four readings, my centre accepts 5/6/6/7 mmol/L, but during Ramadhan, practicing fasting, we’ll have to give leeway, and accepts 7/6/5/7 mmol/L based on the heavier meals at both ends of the day.

Blood taking or taking any injections are considered breaking the fasting practice.

Therefore, we advise our diabetic mothers to inject the twice daily subcutaneous insulin, once before sahur. And the other dose after eating/drink a bit during buka puasa and continues with the main meal.

However, there are always exemptions from the fasting practice. If one is unhealthy, and deprivation of medicinal injections or delayed diagnostic blood investigations may lead to deterioration of health, one will be exempted from practice.

Exemption from practice means you got to ‘pay back’ later.

to be continued...

wishing upon a shooting star

Ever wished upon the shooting stars?
Some called it the lucky star... By lucky, it should be a good thing
Some called it the falling star... By falling, it should be a bad thing, unless it is falling in love...

One must not mistaken... Look carefully at the photo above...
Not all star with a long streak is the shooting slash lucky slash falling star...

It is called Constellation Urion.
It is actually a space shuttle executing a water dump for the whole wide world to see...
Yes, really bring 'Holy Shit' to a brand new level... simply an astronomical toilet flush...

Some say it was "pristine" water (the shuttle fuel cells' by-product is water) and other reports said it was "waste water and urine". No matter what, it was a large dump of 68kg, and we have Clair Perry to thank for sharing his images.

Wondering will those shit water hit earth? No, it won't.
Waste water usually freezes upon jettison into a cloud of tiny ice droplets, and when the sun hits, the ice sublimates directly into water vapor and disperses in space

So next time, when you are making a wish upon a 'shooting star', make sure you're not making a wish over that stellar shit water...

It's as silly as making a wish after you flush your you-know-what down that you-know-what

internet is killing doctors?

Someone in UK actually came out with a list of 50 things that are being killed by the internet, and down on the list on number 28 is...

28) Respect for doctors and other professionals
The proliferation of health websites has undermined the status of GPs, whose diagnoses are now challenged by patients armed with printouts

I guessed it would be a rare occurence, at the very least, at the part of the world where I am serving, to be seeing an uncle or makcik taking a stacks of internet printed information and challenging our diagnosis or management.

The changing medical world of today has actually slowly evolved, rejecting the paternalistic type of medical practice. But it is still quite alive in Malaysia. If you are wondering what is paternalistic medicine, it is the kind of medicine where you are the doctor, you are always right, and what you say is the best, and therefore the patients should follow every damn single thing that you say, without actually given a glimpse of other options, not to mention the pros and cons of each options.

Somehow this way of medicine kind of made our life much much much much, and yes, much more easy.

But then again, when the medical professionals are being put to bed, suffering from serious illnesses, then they started to question and insist that all the variable multiple options be served up to them like the royale banquet buffet. At times, our over-intelligent (or believed to be over-intelligent) minds may even be ccoking up some options which is purely imaginary or non-existence, at least at the time of treatment.

At this moment, a simple phrase would sum it all - double standard.

Nevertheless, it wouldn't be double standard if at the end of the day, the only thing running in the mind of the terrified mentally weak patient would be "I don't care a damn about the long list of choices, you're the bloody MD, please give me the best choice."

I wouldn't really say that the internet had undermined the credibility of medical practitioners, it simply pushes us all forward, pushing paternalistic medicine into the backyard.

From the solid evidences, the RCT randomised controlled trials, opinions of multiple boards of super Consultants, one may choose the BEST treatment for the patients, translating the BEST prognosis for survival, then again, it may not turn out to be the patient's favourite choice or it may ironically be jeopardizing the patient's quality of life.

Personally, it would be really nice to have someone strolled in and look me in the eyes. Then, tell me that I am wrong.

At times, being wrong, ain't the bad thing.
Worse would be being wrong and being too late.

Worst would be being wrong, but insist on being wrong.
It probably equate to digging our own grave.

I remember what my lecturers used to err.... 'lecture' about. Besides the core knowledge, he/she will be going around telling us to read up more, go internet more, search latest information as internet is readily available to the patients, and we will lose respect if we look 'stupid' when such highly educated, internet savvy patient comes around.

Maybe one will appear slightly inadequate, but definitely not 'stupid'. The learning process is a lifelong experience.

As long as one willing to learn, from one another, and even from the patient, at the end of the day, we will not lose our respect or recognition as the healer.

Proliferation of medical knowledge with Internet is always a boon for the practitioners and the public. At which channel this knowledge will reach the practitioners, maybe from the MD's own self-study, maybe from discussion in Facebook, or simply from the rude knowledgeable internet-savvy patient, the public should know that no one knows everything all the time.

If that someone knows everything all the time, he/she is probably God or a bloody good liar.

Internet is more of an assistant, definitely not a killer.

P.S. Internet also help to relieve some stress. Just click on this AMUSING RED DOT.

if walls have ears

....It is quite clear that these "divisive walls" are built by Malaysians because of fear, not a problematic diversity. Malaysians turn to their ethno-religio-linguistic communities not because we don't share common ancestors, the same faith or the same language. We do so because we don't feel secure being individuals. We feel that we would be threatened if we don't have the numbers compared to "others".

We are always in a demographic rat race, or perhaps more precisely a rabbit race of reproductivity. After all, we care so much about our own community's reproductive rate to the extent that making love can be political rather than romantic or sexual....

Some reasons are natural. First of all, collective rights require economies of scale. If your community consists of only 50,000 people, you of course can't expect to have an Astro channel catering to just your needs. You may not have even a Wikipedia site in your own language. So, you end up not complaining about not having your People's Own Language (POL) class or being classified as "lain-lain" in census forms. The question is: how big is big enough to be entitled to collective rights in religion, culture and language? This question is important, because the divisive walls are not built by Penan or Orang Laut Malaysians, are they?

Secondly, democratic politics is a numbers game. If we have to divide resources by proportionality, then we need numbers, and we need walls. In fact, we will need to keep on moving our walls outwards to occupy a larger share of the territory, not unlike the Israeli-built wall in Palestine.

The third reason is arguably also reasonable but deeply problematic. We need the numbers from our own ethnic groups or our co-religionists because we are preparing for a showdown with "the others". In this sense, the real problem with the Shah Alam cow-head protest is not about offending religious sensitivities, but the threat of violence employed.

Any mad man or woman may get up to similar antics, but there is no need for society to jump and shout. But by signalling the use of violence to draw the ethno-religious boundary — "we constitute the majority here in this area, we set the rules; you follow or be prepared for bloodshed" — we are at the edge of returning to the barbaric pre-democratic world. We would be chopping heads rather than counting heads.....

Above is what Chin Huat's thought on wall...

Below is my take...

There’s just too many walls around us.

Some high.

Some low.

Some transparent.

Some with high voltage.

Some is just not physical enough to be broken down.

Some walls stays erected because of the wrong ‘walk’ that goes along with the right ‘talk’.

Just the other day, I was having this frivolous chat with the nurses while stitching up the bleeding uterus. Yes, I knew I was committing double sin. Frivolous talk breaks the 4^th percept and I shouldn’t be talking during surgery, although it was pretty much a straightforward, relatively dry operation.

Me: So, kak, raya tak de bonus ke?

Nurse: Tak de.

M: Tentu susah nak raya. Kan banyak orang yang harap bonus untuk beli benda-benda baru untuk keluarga.

N: Tapi, Najip senyum. Senyum makna ada harapan.

M: mungkin senyum sebab terfikir ‘apa ni, nak duit, mahu dari Balisan, bila undi, tak undi Balisan’.

N: Jika tak bagi, lagi undi Bulan. Kamu undi siapa?

M: Undi bulan kut? Bulan bagus kan.

And then, few days later, the news broke. Raya Bonus RM500 for all government servants who are Muslims.

Perhaps, it is just a rhetoric question.

Poverty hits us all, no matter Indian, Malay, Chinese, Chindian, Mamak, Bidayuh, Penan and etc.

So come next month, before Deepavali, can my Hindus colleagues expect a wave of bonus just for them?

Or will it simply be 1Malaysia, 1bonus and 1time only?

And yes, this is an entry about money and greed, something that makes the Chinese world turns around its axis, or perhaps it is more about the wall that Humpty Dumpty is sitting on.

And everyone (OK, not everyone) knows what will happen to that Humpty Dumpty sooner or later.

The higher the wall, the harder the fall.

P.S. I believe in true real solid 1Malaysia and to all my Muslims friends and relatives

Sale a mat Hairy Ray Year Eye Deer Fit Three
More Off Jar Hill Done Bar Teen

kaki dalam kasut, kaki dalam mulut

sometimes... just sometimes...

P.S. and yes, this is a shiok sendiri entry. some stuffs are best left confidential and abstract.