Mar 31, 2011

life's a breech

One of the reasons for the rising rate of Caesarean Section was the declining vaginal breech delivery following the post-Hannah term breech trial era. And the skills and attempts for external cephalic fortunately still alive, but skeptically was not attempted that enthusiastically because of the accompanying complications, or rather due to the nature of human. It is the nature of human to fear what we can’t see, what we can’t explain and what we have to wait and wait to finally hold the breath of relief.

To go through with the abdominal delivery, things are definitive. Cut, baby out, close. Baby alive and kicking. No waiting game.

My first clinical encounter with regards to ECV was an intrauterine death following ECV by my specialist few years back in my previous hospy. Subsequently, which I vividly remembered, even a presentation of advocacy of ECV following Green top guideline by my respected senior medical officer and further encouragement by the departmental leader wasn’t enough to turn the tide over. The idea of ECV was usually shot down prematurely during the counselling of options and followed closely with the overemphasis of the fetal heavenly safety with the Caesarean.

In this hospy, the best (informally recognized) cephalic versionist was a junior of mine, yet his tai-chi kungfu is well-known. His first successful ECV promised the mother the safety path away from the horror of Caesarean gone wrong, only to have death clenching tightly on the mother through a motor vehicle accident in the famous Tun’s highway. And this maternal death went to the media, for a common reason why so many things in life went to media - politicized, and not because of its close resemblance to the movie ‘Final destination’.

My first attempt with ECV was few months back with the great specialist-teacher, Dr. S. It was a successful attempt simply because she intervened at the point where the lie was tranverse and resistance was at its maximum.

My second attempt was during last Saturday. She came in with weak contractions. The mother and her husband weren’t so keen on Caesarean for reasons only known to them. I went through her antenatals and subject her to careful sonographic assessment, simply to exclude any contraindications or factors that will reduce the success rate. I treaded on cautious ground, as I made sure the couple fully understood all the risks and the subsequent possibility of Caesarean. An ECV which probably equivalent to nose-picking to others, started to be appear like a complicated vascular surgery to me.

As I swept my hands at both the lateral sides, within few minutes, the version completed.


Fetal health reassured with the immediate cardiotocogram. But the head is still floating.

I spared the couple of false hope, telling them that the fetal head might still turn back up.

Fortunately, it didn’t.

She was induced for prolong leaking and subsequently delivered vaginally uneventfully today.

My advice for her before discharge - make sure who ever driving, to drive carefully.

Yes, at times, the roads can be more lethal than going under the knife.

At least, intraoperatively, thanks to the ever-ready anaest colleagues, one will be pain-free.

Now, that’s my brief story of me and ECV.

Mar 21, 2011

foresight or insight?

house officer: this lady claimed passed out product of conception at home, but did not bring. but scan today fetal heart is positive, shown to her. now, totally no more per vaginal bleeding.
me: so, what could possibly be the diagnosis?
HO: incomplete miscarriage.
me: that's like half already came out, will the heart still be beating?
HO: (thinking)
me: OK, let just imagine a part of you being chop to half and i took away your lower half, will your heart still be beating? I think you really watch too many magic shows or cartoon.
HO: oh, so it's threatened miscarriage.
me: yes (thinking: unless it is a miracle.)

Technically-speaking, if there was not any prior scan showing a singleton, distantly rarely possible, it can still be a possibility of complete miscarriage of a first twin and threatened of the remaining one. But I shall not cross into the unfamiliar territory with the juniors. Not today.

Mar 12, 2011

do not be complacent

Japan Earthquake fireball

The Richter scale went bullish from 7.9 to 8.9.
Death tolls rocketed.
Sympathy and attention from the whole world centralized on the major quakes area.

I thought that my heart bled facing the disastrous my department's house officers' work ethics.
I thought that it's perfect agony facing the Friday preholiday jam with a blinking almost-empty fuel indicator.

But nothing compares to what Japan is going through.

Anyway, this is not a post to pour my heartfelt sympathy to the millions of unfortunate victims.

I was scouting around the news so far. I guess the government had been hard-at-work in making sure Malaysians in Japan get back to our motherland in one piece.

I was wondering when the government will gear up in preparation of earthquake in Malaysia. Perhaps, it is distantly impossible for our country to be shrouded with quakes, no one should ever be so cock-sure.

We were once upon the time, pretty blardy sure that we won't have tsunami, and well, the last time tsunami 'mildly' hit us, it took away several lives.

I hope everyone when reading the news, looking at the horrendous videos and pictures of the disaster, can think for a milisecond that it could happen right here, right now as you are reading this in front of your computer.

Start preparing in the mildest paranoia, and start cherishing whatever in life that you love so much.

Mar 1, 2011

broke and broken but still smiling

the 3 days intensive course is finally over. Broke, broken but smiling.

I got so much to say but I forgotten to hand in the feedback form.

What can I say, I am getting old. Anyone getting younger?

Being postcall, I rushed to airport at 5am, thanks to SY's voluntary cover for few hours till 8am.

Upon reaching the East Coast, the airport cab Daytonaed me to the HUSM, only to have me going around the hospital in circle for 15mins, trying to figure out where is the place of the course. Somemore, the people that I asked for directions gave me contradicting directions till I met someone who are willing to take me there.

The whole course was kind of a repeat for the USMers, where they already had it for the duration for 2 weeks much earlier.

It is now a 3days course, which made it much much much much much (enuff of 'much'?) more intensive.

Here's my feedback for the course.

The course co-ordinators: funny and praiseworthy
Dr. A and Dr. A both diligently preparing everything required for the course. Dr. A was particularly a spontaneous humorous person making all the right comment at the right time. The most memorable was "Dr. xxx is going to talk about gonads. Ah, yes, gonads."

The course: Testing our attention span.
The whole roster of one lecture after another, after another, and another from 8 am till 5pm with small breaks and lunch break doesn't really fit into the model of effective learning.

Personally, it is more of like 'lets do this compulsory thingy and get over it'.

Nevertheless, collecting from here and there, I am graciously thankful that they managed to let us see a clearer picture of the scope of the coming exam, which is fundamentally-based on applied science. Seriously.

It is like basic science is part 1, clinical is part 2,
and so, this coming exam is sort of like Part 1.5 for applied science.
At one point, we're being told that it is essential for us to master intubation for adult patient and to think like orthopedics in another question.

Therefore after this 1st year, our 2nd till 4th year, we can kick back and relax and focus on the unfinished 0.5, consistent with the old adage saying 'Bersusah-susah dahulu, bersenang-senang kemudian'. Afterall, we should do much much more when we're young (I mean, less old), right?

The mock exam: Mockingly uplifting
The only reason it is being called mock exam is because it is mocking at us.

Breaking Point WIP

MCQ: almost pass, Essay: fail miserably, OSCE: comfortable pass. Once a while, being mock at can be an uplifting experience. Now, I am getting back my mojo after some much-confused times. And I starting to focus on studying back. Not that I have other choices, anyway.

The city: Laidback
Relaxing suburb. Everyone just lepak. There's absolutely nightlife here, just that they don't come in the form of clubs/pubs/karaoke but instead the people here, young and old, will hang out at premium 'Old Town'-like eating place till late at night and chit-chatting. At some point, the noise level plus the mozzies was intruding into my well-needed slumber. Nothing much, otherwise, because no wheel and no will to wander.

Luckily, got ample WiFi to connect with my dearest back at home.

The course charges: probably consistent with fuel/commodities inflation.

  • Fee of RM3oo per person X 29 = RM 8700.
  • Room and items: free (from faculty)
  • Speakers from faculties(16 lectures + 3 mock exam sessions = 19): probably RM 200 (200X19 = RM3800)
  • Booklets n bags: sponsored
  • Food (2tea breaks & 1 lunch/day & candies): probably RM 20/day/person (20X3X29 = RM1140)
  • Miscellaneous (couldn't think of any) but just allocate RM760
Required balance to offset possible inflation: RM3000 (No kidding)

And the unofficial news was that we're supposed to pay RM500 for coming May exam.
That's a debit of RM500X29 = RM14500. Really couldn't wait to see the breakdown of expenditure for that.

We're supposed to attend total 6 courses [4 compulsory courses (stats,basic surgical skill, basic ultrasound,basic laparoscopy) in Year 1 and Year 2, excluding intensive course and Part 1 exam] but only allowed to claim for 2 courses per year, meaning we need to break our wallets for 2 courses.

Probably some discount is warranted, because our wallets can be pretty fragile.

The extra co-curricular activities: Books and discussion.
Together with 3 coursemates, went hunting for well-known shop of MERBAU PHOTOCOPY - N6.13383, E102.24120.
They have most of the photocopy of the lastest edition of premium medical books, selling at near-dirtcheap price.

And had our only Chinese food in the Chinatown of KB before going back to our respective budget temporary residence near HUSM. The price of the food are shockingly as expensive as KL's standard.

Otherwise, over meals, the four of us will discuss about our work frustration, mainly with the house officers and some superiors, our career focus, our exam focus and our family updates. Kind of build up the camaraderie between us, although being away in different hospital scattered over the peninsular.

I will be back here in May.
Hopefully that's the last time till my final.

If it isn't the last time, I will be broken but not smiling.

flat tyre

My last 2 on calls were perfect reminders of my active on calls back in my previous hospy, where the exceptional ninja skills of body-splitting can come in handy. Just that in this new hospy, I had to split further, across the road, to the maternity hospital.

It is always a proud thing to be placed in a position to be called 'wise', but somehow when crisis cropped up simultaneously in both sides across the road, it somehow felt 'otherwise'.

I don't need others to tell me the above fact, my (actually my wife's) apple green Myvi indicate to me in the most obvious way ever. The right rear tyre went limp the next day, after commuting to-and-fro during ungodly hours the day prior.

I wish I can have a new tyre just like that.

Tired out myself.
Tired out the car.

Break my wallet for the extra petrol consumption and tyres change.

If this have to continue, probably I will have to hitch hike on the white ambu.

P.S. Thanks to Dr. S's advice. I think she's right. We shouldn't take everything in, there's always another person. Let that person have the dignity of doing his/her job. Respect.