Rolling in the Deep

In my mind, these few days.Haunting me, but I'm looooooving it.

Sex kills

Caution: If you're of mental age of 18 and below, kindly refrain from reading further. Consider yourself being warned.

Thus far, personally, the only sex-related injuries that I had attended before is post-coital vaginal injury.
3 patients.

1. Referred from casualty for heavy menses for 4 days. Intrigued by the history of having previous regular menses and just had her menses 1 week ago. Additional history confirmed the bleeding started postcoital. My fingers were able to felt the posterior uterus on vaginal examination. Unable to believe my tactile finding, confirmed it with a nearby pelvic ultrasound. Repair done in Operation Theatre. Unremarkable recovery.

2. Straight from Casualty to OT, white as sheet of paper. Young patient. Massive vaginal tear up to part of cervix near 3'o clock (the point for massive maroon tide). Sutured well up by my skillful specialist. Suspected the involvement of inanimate object in the sexual practice, did not confirmed it, though. Massive transfusion. ICU observation. Unremarkable recovery.

3. Referred for heavy post coital bleeding by a bright house officer at Casualty. Unable to find the bleeder by speculum by a bright house officer in ward. Bells rang. Repeated confirmed speculum revealed a small superficial 3cm superficial laceration. Packed with flavin-soaked vaginal pack. The next morning, still bleeding, pulse rate gone up and clinically mild pallor. Repacked again, sent to OT for repair. Removed the repeated packing, no more bleeding. fml. put in a 'reassurance' stitch. Unremarkable recovery.

Sex is indeed lethal. Sex kills and hurts in more way than you know.

It goes from the triggering excitement of sex or orgasm to induce a heart attack or intracranial bleed,
to a gentle good night kiss with a super-allergen on the lips OR firing away a carotid embolus,
to traumatic injuries to the genitals for both gender.
(female: vaginal laceration, male: captivating penis captivus)


If you're depressed and sad because sex (or lack of) has hurt your feeling, perhaps you should be grateful that you came out of it alive and uninjured.

So, do you have any interesting lethal sex story to share?

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Interesting write-up by Chris Nickson below.

Ask not: "is this love?" Ask: "is it dangerous?"...

No, I’m not talking about revenge killings by jilted lovers, sexually transmitted infections, or the intrinsic hazards of extramarital dalliances. Love itself is dangerous. If you don’t believe me, read on to learn about all the ways amorous acts can threaten life, limb and… other body parts.

Banerjee A. Coital emergencies. Postgrad Med J. 1996 Nov;72(853):653-6. PMID: 8944205; PMCID: PMC2398623.

1. Neurological — benign coital headache, aneurysmal subarachnoid haemorrhage, cerebrovascular accidents
2. Urological — penile fracture, priapism, preputial tears, penile vessel rupture
3. Cardiovascular — sudden cardiac death, myocardial infarction
4. Soft tissue — soft tissue wounds, soft tissue infection
5. Immunological — local allergic reactions, anaphylaxis

Risk of sex death
Data on the risk of death during intercourse aren’t great. One retrospective study found that of people that die, about 1 in 500 were having intercourse at the time (or thereabouts). One suspects the rate could be higher: do you routinely asks the bereaved, “So, were you having sex at the time?”? The cause of death during intercourse is usually myocardial infarction, although intracerebral hemorrhage and subarachnoid hemorrhage must not be forgotten.

• Parzeller M, Raschka C, Bratzke H. Sudden cardiovascular death in correlation with sexual activity — results of a medicolegal postmortem study from 1972–1998. Eur Heart J. 2001 Apr;22(7):610-1. PMID: 11259149. [Fulltext]
• Reynolds MR, Willie JT, Zipfel GJ, Dacey RG. Sexual intercourse and cerebral aneurysmal rupture: potential mechanisms and precipitants. J Neurosurg. 2010 Jun 11. PMID: 20540599.

So far, so good. What we’ve discussed so far has been fairly standard. But seriously weird and bad things can happen during acts of love… As you’re about to find out.

Love bites
A recent report from New Zealand described a case of partial paralysis due to a ‘hickey’ or ‘love bite’. Excess suction was applied over her internal carotid artery, resulting in thrombosis…

• Wu TY, Hsiao J, Wong EH. Love bites — an unusual cause of blunt internal carotid artery injury. NZMJ. 2010; 123(1326) PMID: 21326406 [full text]

Two views of the internal carotid artery in the affected patient. The arrows point to thrombus. Longitudinal view on the left, transverse on the right. From Wu et al (2010) (Click image for source)

Love allergies
Allergies and love do not mix. Steensma has described how a good night kiss, from a shrimp-eating boyfriend, nearly killed his shellfish-allergic girlfriend. Furthermore, women can actually be allergic to sex. Acute systemic hypersensitivity or localised vulvovaginitis can occur as a result of allergic reactions to semen. The sensitivity is not partner specific — condoms or abstinence are the immediate options for cure. Also, exogenous allergens (such as Brazil nuts, for example) can find their way into semen, and cause allergic reactions in receptive partners. Finally, there is an odd condition that can affect men (@DrVes told me about it) known as Postorgasmic illness syndrome (POIS). POIS is a combination of local allergic symptoms and transient flu-like illness. It may be that POIS is triggered by ejaculation and results from hypersensitivity to the male’s own semen!

• Allergy Notes: Sexually transmitted allergy to Brazil nuts. [link]
• Jones WR. Allergy to coitus. Aust N Z J Obstet Gynaecol. 1991 May;31(2):137-41. PMID: 1681800.
• Steensma DP. The kiss of death: a severe allergic reaction to a shellfish induced by a good-night kiss. Mayo Clin Proc. 2003 Feb;78(2):221-2. PMID: 12583533.
• Waldinger MD, Meinardi MM, Zwinderman AH, Schweitzer DH. Postorgasmic Illness Syndrome (POIS) in 45 Dutch Caucasian Males: Clinical Characteristics and Evidence for an Immunogenic Pathogenesis (Part 1). J Sex Med. 2011 Jan 17. [Epub ahead of print] PMID: 21241453.

Love emboli
Air emboli from sex can kill. The risk is probably higher not long after birth (especially if amphetamines are taken prior to intercourse), as it may take a while for those big uteroplacental arteries to involute after birth. However, vaginal tears from consensual intercourse, irrespective of pregnancy status, also have the potential to cause fatal air emboli. As always, any paper written by Batman is a must read:

• Batman PA, Thomlinson J, Moore VC, Sykes R. Death due to air embolism during sexual intercourse in the puerperium. Postgrad Med J. 1998 Oct;74(876):612-3. PMID: 10211360;  PMCID: PMC2361003.
• Moreschi C, Da Broi U. Paradoxical air embolism through patent foramen ovale during consensual intercourse in a non-pregnant young female. J Forensic Leg Med. 2009 Nov;16(8):482-5. Epub 2009 Aug 7. PMID: 19782322.

Traumatic love and its complications
Vaginal injuries from consensual intercourse can lead to other problems. Pneumoperitoneum was reported following ‘conventional’ intercourse, with a 4cm vaginal laceration identified as the culprit. There was no mention of whether genital jewelry was involved. Another nasty complication from ‘normal’ coitus, as described by Ijaiya et al (2009) is rectovaginal fistula formation. The victim was later divorced by her loving husband.

• Manchanda R, Refaie A. Acute pneumoperitoneum following coitus. CJEM. 2005 Jan;7(1):51-3.  PMID: 17355655.
• Ijaiya MA, Mai AM, Aboyeji AP, Kumanda V, Abiodun MO, Raji HO. Rectovaginal fistula following sexual intercourse: a case report. Ann Afr Med. 2009 Jan-Mar;8(1):59-60. PMID: 19763010.

Penis injuries are a bit ho-hum for the seasoned emergency physician. But, it is probably worth mentioning posterior urethral injury as a cause of hematospermia after intercourse and to provide a link to a nasty case of penile fracture associated with urtheral injury. Some blokes need target practice… or less acrobatic partners.

• Boncher NA, Vricella GJ, Jankowski JT, Ponsky LE, Cherullo EE. Penile fracture with associated urethral rupture. Case Report Med. 2010;2010:791948.  PMID: 21076536;  PMCID: PMC2975082.
• Cheng YS, Lin JS, Lin YM. Isolated posterior urethral injury: an unusual complication and presentation following male coital trauma. Asian J Androl. 2006 May;8(3):379-81. PMID: 16625291.

The mystery of penis captivus
Finally, we wouldn’t be living in the fast lane if we didn’t mention the most enigmatic of all coital conditions, penis captivus. Here are some relative modern reports from the BMJ suggesting that, yes, the condition actually does exist.

• Taylor FK. Penis captivus — did it occur? Br Med J. 1979 Oct 20;2(6196):977-8. PMID: 509182; PMCID: PMC1596579.
• Musgrave B. Penis captivus has occurred. Br Med J. 1980 Jan 5;280(6206):51. PMID: 7357285; PMCID: PMC1600543.

I have a high degree of suspicion regarding the spuriosity of the cases in Taylor’s review. One in particular stands out:

“Kisch, in his Sexual Life of Women,- speaks of “more or less credible instances of penis captivus” being on record. He mentions an account by a medical man called Davis, not otherwise identified, who was one day called to a couple found in this “most compromising position. All the endeavours of the pair thus surprised to separate proved ineffectual, and their attempts to draw apart caused them intense pain. Davis… ordered an iced douche, which, however, failed to liberate the imprisoned penis. Release was impossible until the woman had been placed under chloroform. The swollen and livid penis exhibited two strangulation-furrows.”"

A medical man called Davis? Who could that be I wonder? Perhaps an ancestor of UCEM’s PR Supervisor, the famed psychiatric surgeon Assistant Sub-Professor Egerton Y. Davis IV? Surely not? Read penis captivus and decide for yourself… As for the letter by Musgrave, one cannot help but wonder about medical doctors and their overactive imaginations. Indeed, the BMJ was clearly having a good month for letters back then — the letter immediately preceding it concerned ‘The Interesting New Zealander‘.

Conclusion
Life is a risky business. It is for the individual to decide if how they live it is worth the risk. But, what would life be without love?
Safer, is one answer.

Jangan jeling-jeling

Overheard in clinic

Jangan jeling-jeling,
Jangan tulis-tulis,
MC bagi saya tulis,
Time slip pun tulis,
Janganlah begitu, 
Sebab saya spehsiarlis.

Sang to the tune of Kalau Berpacaran.

A tribute to miscommunication.

Sacrifices...

Shown this picture to wifey today

Wifey: If it were us, it will be you inside the 'tong', because you don't have a motorbike license.
Me: (=,=")

For the record, despite being busy playing all her important roles in our lives, wifey managed to help me in the biggest way. Both of us were mentally-stressed, mentally-drained and mentally-relieved now.

The passing of a house officer

Public announcement should not be made out of convenience.
Decision should not be made out of 'knee-jerk' reaction.

Dear Health Minister,

Your statement surrounding the death of late Dr. Lee taken all of us by surprise.
Mainly because a person of your stature and status, we were expecting more professionalism.

None of us were given the accurate information regarding circumstances around the death of late Dr. Lee.
And yet, the reflex statement had successfully labelled all the medical officers, specialists and Consultants as the main source of depression, leading to the unfortunate death of late Dr. Lee.
Is this a fair judgement to all doctors, except house officers, to be falsely accused?

As opposed to what was reported in The Star, late Dr. Lee was not a graduate from Uruguay, but from Ukraine (Crimea State Medical University) and the reason his service was extended to 3 years because he went absence without official leave or MIA for 9 months.

I believe Health Minister should revealed to us what was his reason for the 9 months absence and how was his performance as a medical graduate from Ukraine. The controversy about CSMU in June 2005 should also be given some attention.

It is rather unfortunate that it is an open secret that the medical schools of Russia and Ukraine had always provided slightly inferior medical training, mainly because of the language struggle of our Malaysian students. Yet, more parents were happy to send their children there due to two main reasons. Firstly, the school fees which is just a fraction of price of well-reputed medical school. Secondly, the acceptance grade is never as high as others. The medical students there had to struggle in writing and answering in foreign language that most had failed to grasp the basic in medical knowledge. Nevertheless, those who had diligently overcome this are better doctors, compared to others.

When in the real working world, basic medical knowledge is a strict requirement.
It is similar to any working world.

Here's the analogy.
You want to be a clerk, you will need to have at least basic literacy knowledge.
Because the basic literacy knowledge is what is required in the line of duty.
Or else, you won't be hired. As simple as that.
You don't hire them, then expect the manager or supervisor to start teaching them ABC.
And if the office boy could not perform, he will receive a suggestion of tendering his letter of resignation.
There is no place for depression.
It is also beyond common sense for General Manager to meet all the clerks weekly to make sure they do not have depression.
Yet, Malaysia Boleh, anything also Boleh happen.

Depression is not a joke.
The passing of late Dr.Lee should serve as a warning sign to the Health Ministry and to the nation.

We need to uphold a standard before accepting everyone into the house officers' training and creating house officers' glut.
The Health Ministry should seriously liase with Higher Education Ministry and Public Service Department about this matter urgently.
If you decided to allow primary 6 students straight to University and expect them not to be depressed, you're out of your head. And when there is a death, his blood is all over your hands.

The government should uphold the previous half-baked moratorium on medical schools seriously.
Stop fooling with the medical fraternity. 

Lastly, medical officers, specialists and Consultants all over Malaysia feel like as if we are running medical schools in our hospitals. Yet, we continue our struggle, we continue to strive to make every house officers better doctors for the future.

Public announcement should not be made out of convenience

Thus, it is only appropriate and respectful for the Health Minister to apologize for the baseless generalisation and to refrain from such statement in the future.

Signed,
Pilocarpine

Attached: reference articles below

A trainee doctor was found dead in a restroom at Kajang Hospital.

Police believe he had overdosed on an unidentified drug.
Lee Chang Tat, 29, was found dead in the men's room of the paediatric ward at 7am yesterday by hospital staff who went looking for him after they noticed that he was missing.
He was found with a used syringe beside him, which police believe he had used to inject himself with a drug to fight off fatigue.
It is learnt that Lee, who had been working at the hospital for the past three years, had been working on call for five consecutive days.
Selangor health director Datuk Dr Azman Abu Bakar said hospital staff, who found Lee, tried to resuscitate him but were unsuccessful.
“He was rushed to the emergency room but it was too late,” he said.
Lee, he stressed, had no previous medical problems.
A security guard at the hospital said they found him when someone tried calling Lee on his handphone and heard the ringing tone coming from the restroom.
“We broke into the toilet cubicle and found him lying there with the needle,” he said.
Kajang OCPD Asst Comm Abdul Rashid Abdul Wahab said Lee, who studied medicine in Uruguay, had been complaining to his family about the hectic working hours.
“His family said he had also been planning to go on a holiday to Cambodia soon with friends,” he said.
ACP Abdul Rashid confirmed that an initial post-mortem indicated that Lee had died of an overdose, adding that the case was being investigated as sudden death.

Houseofficer found dead (II)

The Star, like China Press got it wrong as to where the late Dr. Lee was trained. Checks with the MMC website shows that he graduated from Ukraine (CSMU), and not Uruguay. We’ve posted quite a few times in the past about CSMU and given that there are concerns about the training graduates from CSMU receive, and that such training may not adequately prepare them for life as a doctor in Malaysia, one cannot help but wonder if this added to the “stress” the late Dr. Lee endured. Other details emerging from the Dobbs doctors forum are that it was reported in a Chinese daily that he was AWOL for nine months during his training and, after appeal, he was made to repeat his training from scratch. 

Housemen still being overworked and bullied, sending some into depression

KUALA LUMPUR: The Health Ministry will conduct checks on the shift system for housemen in hospitals in the wake of reports that trainee doctors are still being overworked, bullied by seniors as well as suffering from depression.
Under the Graduate Medical Officer Flexi Timetable system, introduced last September, housemen can only work up to 60 hours a week with two days off. But implementation has been reportedly poor at some hospitals.
Health director-general Datuk Seri Dr Hasan Abdul Rahman said the ministry would seek explanations from hospitals found overworking their housemen, adding that the ministry was willing to help them implement the system effectively if they were facing a shortage of housemen.
However, he said he had checked timetables in Kuala Lumpur Hospital, Ampang Hospital, Serdang Hospital, Klang Hospital, Selayang Hospital and Sungai Buloh Hospital but had not seen any houseman made to work for more than five days a week or to do double shifts.
Earlier, Malaysian Medical Association president Dr Mary Cardosa urged the ministry to review the shift system and conduct a study on the mental health of junior doctors.
On the death of Dr Lee Chang Tat, 29, who was found dead in a restroom of the paediatrics ward at Kajang Hospital with a used syringe beside him, she said there was no data to show the number of housemen who suffered from depression due to their long working hours and stress.
“There should be some kind of mechanism to assist troubled doctors, whether they have personal or work-related problems or can't handle the stress.”
The Malaysian Medical Council, meanwhile, reviews an average of five cases of doctors with mental health issues each month. It is learnt that there were 20 cases last October.
“Most of them are housemen, but we have also heard cases on medical officers,” said former Health director-general Tan Sri Dr Ismail Merican.
“The types of issues range from psychiatric problems to anxiety and coping problems,” Dr Ismail said.
Dr Ismail, who is also former MMC chairman, said the working hours for housemen may not be as demanding as before the shift system was implemented, but they were exposed to other sources of stress in their work including demands from patients, their superiors and other colleagues,” he added.

System that’s a burden to many housemen

PETALING JAYA: A 27-year-old houseman lamented that although the shift system was good, it was poorly implemented at his hospital.
He claimed that it was up to each department to implement the system.
The houseman alleged that when he first joined the hospital, he had to work 92 hours a week and on 24-hour shifts for up to one and a half months.
But things improved after someone brought up the issue to the management.
However, for departments that lacked housemen, they had to work long hours and without on-call allowance.
This was because allowances were not provided for in the shift system and housemen were not expected to work more than 72 hours a week, he added.
The houseman said they were paid a fixed RM600 a month but without the RM100 to RM200 allowance for each on-call duty.
He also claimed that eight housemen suffered depression and were under psychiatric observation as they could not take the bullying from senior doctors, whom he said constantly shouted and belittled them.
They were also burdened with a training duration that was extended from four to six or seven months for each department.
“One houseman went into depression after he failed his assessment twice,” he said, adding that some housemen got themselves transferred to another hospital or just resigned.
Another houseman Dr G.M. Pillai, 28, said Ipoh Hospital was trying its best to adhere to the rules set by the Health Ministry.
“We work 60 to 65 hours a week and sometimes up to 70 hours. But if we have to work up to 70 hours, we are given less hours the following week,” he said.
Before the shift system was introduced, he had worked up to 36 hours.
But, after it was implemented, the hours were capped at a maximum of 20 and they get a whole day off the next day, he said.

Housemen to meet hospital director weekly: Liow

KUALA LUMPUR: Housemen in goverment hospitals nationwide will have a weekly session with the Hospital Director or Deputy Director to iron out issues pertaining to being overworked, bullying and depression, said Health Minister Datuk Seri Liow Tiong Lai on Saturday.
He said they should express their views and complaints during such sessions with a view to improving their training.
"I am very concerned about all the problems faced by housemen including working hours and workload. I will make sure that their welfare will be protected," he told a press conference here.
Earlier, he had opened the Nutrition Month Malaysia 2012 which is jointly organised by the Nutrition Society of Malaysia, the Malaysian Dietitians Association and Malaysian Association for the Study of Obesity.
Noting that the quality of doctors was very important, Liow said the housemen should be given ample time for training and that the ministry may review the current two-year training period.
Malaysian Medical Association (MMA) president Dr Mary Cardosa had recently urged the ministry to review the shift system and conduct a study on the mental health of junior doctors.
The Graduate Medical Officer Flexi Timetable system introduced last year requires housemen to work up to 60 hours a week with two off days.
Elaborating, Liow said the ministry would probe allegations of poor implementation of the new timetable system.
Nevertheless, Liow said he was pleased with the response from housemen on the new system, which allowed them adequate time to learn and rest. Bernama

So, you want to be a doctor

April 13, 2012

APRIL 13 — “A trainee doctor was found dead after an overdose. He was found dead with a used syringe beside him, with a drug used to fight off fatigue.” The Star, April 12, 2012.
For me, this is an issue close to my heart.
A few years ago, a friend of mine committed suicide by jumping from his apartment on the fourth floor of an apartment complex. He was a jolly good fellow, but faced a few bumps in his years as a medical student.
And throughout the years I worked as a houseman, two of my colleagues broke down and are under psychiatric follow-up, another four quit the profession while two others left for Australia.
My consultant used to call those who break down “collateral damage.”
I had my ups and downs those days. Some days I worked 36 hours straight, no rest, a Snickers bar in between, and was expected to be sharp, smart, alert, and to make the right calls at the same time. At one time, I remembered going home at 7pm, after 36 hours of working, only to be called back to the ward at 10pm because of someone else’s mistake.
No human should be treated this way. Expecting us to make the right decisions, and to treat patients well while depriving us of sleep and rest is ridiculous.
As if that was not bad enough, we were often subjected to verbal abuse in the wards, at times in front of patients and their family members. Some of us were even employed as security guards to chase away family members during non-visiting hours, and as a dispatcher running around searching for old notes.
I’m not sure what it is like now but those were the “good” old days.
Though the system produced good, resilient, disciplined, military-like doctors, there were a few who fell along the way from fatigue and mental breakdown.
Ten years back, we were short of doctors. Now, we have an oversupply of them in the hospitals. I used to take care of 16 patients in the ward and, now, from what I gather each houseman takes care of five to six patients only. And since some of the hospitals are computerised, they are no longer running around dispatching notes and results.
If this applies to most of the government hospitals, it must mean that their workload is markedly reduced.
I suppose the Ministry of Heath has begun to realise that housemen learn, think, respond better when they are well rested. I would rather have a few energetic, well-rested doctors treating me rather than more of those tired, sleep-deprived doctors at my bedside. On that note kudos to the Ministry of Health.
But then, as the working hours become shorter, and workload lighter, the quality of doctors we produce may now be an issue.
The Ministry of Health should conduct stringent tests before these doctors complete their housemanship. If they don’t perform or have an attitude problem, don’t pass them and keep them in the system for as long as it takes.
Revoke their title, bar them from practising if necessary, because what is worse than a tired doctor is one with a bad attitude and knowledge.
As much as housemen deserve better treatment, it should not be at the expense of our patients.
It is a good idea to make compulsory SPM/STPM leavers do community and volunteer work in hospitals, nursing homes, orphanages before applying to take up medicine. Aptitude and attitude tests are also a good way to judge someone’s character, but it is by no means a conclusive test to vet a person.
I mention all this because I do not want houseman to suffer from professional disillusionment. It needs to be addressed before they even step into medical schools or we may end up spending hundreds of thousands of ringgit training doctors, who at the end of the day realise ,”Hey, I do not want to do this for a living.”
Which is what we are beginning to see in our young doctors.
You may have a string of As in your exam but the passion you have in helping a fellow human being is the one that determines how good of a doctor you are.
Patch Adams said, “Our job is improving the quality of life, not just delaying death.”
A good working environment, and attitude is important in any profession especially medicine. And when the government is taking steps to improving their working condition, housemen should learn to count their blessings that they have been given an opportunity to serve humanity.
It is a privilege that not many have.
If all fails, then perhaps our SPM leavers should ponder on this quote by German born American physician Martin Henry Fischer before taking up medicine, “A doctor must work 18 hours a day and seven days a week. If you cannot console yourself to this, get out of the profession.”
Because when the going gets tough, it is the tough who get going.