Category Archives: Med Talk

“You are a good doctor.”

Over the past few months, since the announcement of the match. I have heard this compliment a few times directly and indirectly. I really wanted to reply,”It doesn’t matter, I just want to pass my exam, I don’t care if I am an awesome doctor.” However, all the replies I can muster was a sincere “Thank you.”

Today was another such day.

Just had a new batch interns rotating to my unit in General Medicine. We had a patient that had not been doing very well. At the bedside, we examined all the numbers, read through all his progress written, somewhat eligibly, in the rather worn folder that contained the patient’s notes, and I came to a conclusion.

Like a magician finally revealing his trick, I walked across the room to the patient’s wife who was seated in a chair. I went on my knee and explained what we have done, and what had transpired despite what we have done. I finally broke the news she wanted to hear.

“I think we are losing this battle. He’s dying. I do not think we can push it any further from here on.”

“I know. I’ve seen it over the last few days. I realised that.”

Then, I put my hand between her wrinkled hands.

That was the cue for the floodgates of tears streaking down her cheeks. That was also a sign that I might have outstayed my welcome.

“You take good care of yourself. We will make sure he is comfortable as possible as well as his dignity as intact as possible.”

She could only reply with a sob.

I got up and walked out the room with my heart wrenched. We made the necessary medications changes.

It was hours later, while having our lunch break, I think, after witnessing what I’ve done, my intern, who had only been with me for slightly more than a week, told me that ,” You are such a good doctor.”

All I can say was ,”Thank you.”

Arrivederci.

Thoughts on iPads

I personally will highly recommend iPad for medical professionals. Before I go on any further, I am a Windows user. I have been one for years and still am a Windows user. They still got awesome games!

I believe a tablet has its place as an “adjunct” to your main PC/notebook, rather than replacing your laptop on the go.

I was in the market for a device where I can use to mainly read my materials on the go. I stumbled upon iPad 1 at the Apple store, and I realised it suited my need for that device on the go, long battery life and a simple UI.

Reliability of iOS on iPad : I love customisation of course, but there are things in my daily life I think I prefer to keep it simple so that it can work reliably. I have jailbroken my iPad before, but I realised I just need it to work when I want to. Less customisations will result in less crashes and easier troubleshootings.

App store : At the time of my purchase, there were two applications I was looking for. A note taking app and a pdf reader app, which I can “sync” the materials with my laptop. I stumbled Evernote on the web and had to try a few pdf apps before settling on GoodReader. Both these apps remain my most frequently apps to these days. There are other excellent and frequently updated medical apps as well.

One of my biggest buy is an interactive Harrison’s Principle of Internal Medicine which cost me about AUD200, approx RM 600+ roughly the same price for the hardcover anyway. Besides that, if you are a radiologist, you will notice that many imaging companies have or are still developing apps for access to radiological images on the go.

Long battery life – it used to be a big selling point for tablet over laptops but less so now considering you have other tablets on the market. However, iPads have always been a leader in device endurance. A 9-10 hours use for those on the go. Of coz, much less if you are going to use for gamings(which I don’t do often)

Apple is here to stay – Being such a big company with almost infinite resources,I know that the device will last me over at least the next 2-3 years. We have probably seen some bad examples by other manufacturers such as the WebOS, or even Samsung nowadays. P.S. I also own a Samsung Galaxy Tab 7.7 as well, which annoys me a little because of the lack of official software updates (not saying they are better) despite it being a mid 2012 purchase.

Do not expect it to perform like a PC : A tablet, if I may quote the late Steve Jobs, is to be used to consume medias. I think he captured it very well. I never expect my tablets to perform like my laptop/PC when it comes to “creating medias” e.g. word processing, powerpoint presentation, writing articles, rendering movies. Not to say the iPad can’t, it’s just not very good at it, reserving its use to only urgent matters. I do still add bits and pieces of my notes on my Evernote.

Regardless of electronic devices you are going to use, it will only frustrate you if you do not learn how to be “digitally organised.” You must practice diligence in updating your medias on your PC as well as organise them in a systematic order. No device can do that for your automatically. You have to learn how to tag the articles so it can be easily recalled from your digital archives if need be in the future.

On the iPad purchase for medical professionals, I will highly recommend a 3G iPad 2. It’s a great value in today’s market. It’s lighter than the Retina iPad (maybe that’s why they still selling iPad 2) Unless you have cash to spare and plan to play a lot of high end and expensive games on the device, I would not recommend the Retina iPad. An iPad mini will be a good choice as well, if not for the fact that it’s quite overpriced at the moment. The idea of having a tablet with in your hands on the go is a very attractive proposition. However, from my personal experience, during work, if you have the time to read on an iPad, you would have the time to sit down with a cup of coffee and place the iPad on the table to slowly read through it. That’s why I don’t think the iPad mini represents so much of a value, unless you think the weight is a big issue (which I think it’s sometimes because I often read in my bed lying down, that’s why I got a mini as well:)

I might write another post about recommended apps in iPads in the future.

Arrivederci

Principles of Rehabilitation

I met one of my favourite consultant on the ward today, let’s call him Ben, on my ward round this morning. He works in the rehabilitation medicine despite qualifying as a physician.

I have much respect for him. Actually a lot of respect for him. Partly because while I was his registrar, he actually did a PR exam on the patient while my resident was writing notes and the NUM was cleaning up the mass. And me? I just stood there, whistling.

It was quite funny alright.

Well, my hunch was right about the pathoneurology then – a spinal cord compression, which Ben and a bunch of brain doctors missed. He probably felt bad for overlooking such an important and simple diagnosis. Hehe…. definitely keeping this in my pocket for a long time.

“To achieve rehabilitation objectives, patient must have what I call the 3R’s – Relearn, Retain and Repeat. Thus the ability to absorb new information, retain them and put them into practice regularly.”
-Xiao_zhai-

Another round of Gen Med

I almost made a major major mistake today.

A fever and a rash and a headache. How can I, as a medical registrar, say it’s not meningitis without having a lumbar puncture?

Didn’t really matter if she’s been febrile at the subacute site for the last 48 hours.

The abnormal liver function test was a red herring, well, almost.

Saved by the LP that was clear. Otherwise, it would be a contact tracing for possibly hundreds of people.

Another lesson learnt.

Just when you thought you are doing well, particularly, as an experienced (i.e. failed RACP exam) medical registrar.

Shall keep that in another locker in my brain.

“Gen Med is very simple. There are always three issues with each patients. One, the reason they come in. Two, the reason they still have to be an inpatient. Three, the reason preventing them from their discharge destination”

-Xiao_zhai-

Anesthetic words of wisdoms

Thanks to Jellio I went looking for the book “How to survive in anaesthesia: A guide for trainees” by Neville Robinson and George Hall. Just a couple to add to her list 🙂

Never start ananaesthetic until youhave seen the whites of the surgeon’s eyes.

Always pee before starting a list.

If you are feeling tired the three ‘S’s’ is a good reviver – a shit, a shave and a shower (politically incorrect but we do not know the female equivalent).

ABC of anaesthesia: always be cool, always be cocky!

Remember KISS – Keep It Simple, Stupid.

Anaesthesia is ‘awfully simple’ but when it goes wrong is ‘simply awful’.

If in doubt, ask for help. There is no place for arrogance in anaesthesia.

Big syringe, little syringe, white knob, blue knob, big purple knob – good for most things.

First rule of anaesthesia, if there is a chair in theatre, sit on it.

Never panic. This applies particularly when the patient is trying to die and you have no idea why.

Where there is cyanosis there is life – just!

If in doubt, take it out. This applies to tracheal tubes and many other things in life!

There are three things to respect in anaesthesia: the airway, the airway and the airway.

When all else fails, disconnect the catheter mount and blow down the tracheal tube.

Careless ‘torque’ costs lives – don’t let breathing tubes kink.

The laryngoscope is a tongue retractor, not a tooth extractor.

Nobody dies from failure to intubate the larynx, they die from failure to ventilate and oxygenate.

Fix tracheal tubes as if your life depended on it – the patient’s life does!

The first five causes of sudden hypoxia in an intubated, ventilated patientare the tube, the tube, the tube, the tube and finally the tube. The tracheal tube may be dislodged, disconnected, blocked, kinked or the cuff herniated.

‘Sniffing the morning air’ position for tracheal intubation can be described as the position of the head when taking the first sip from a pint of beer.

Never say to the patient ‘just a little prick’ before inserting a cannula, you are likely to be told that is exactly what you are!

Thiopentone solution can look like augmentin and antibiotics do not induce anaesthesia.

For a rapid sequence induction always have two doses of suxamethonium ready in case one goes over the floor/ceiling etc.

Be professional – try to emulate Humphrey Bogart’s definition of a professional as somebody who can still give their best performance when they feel least like it!

Arrivederci

I walked out of the hospital….

I walked out of the hospital today, feeling a heavy load off my shoulders.

Twice, earlier in the course of the day, I had tears welled in my eyes. For two very different reason, as well.

First, was my patient. I considered her as my responsibility because, I was the one co-ordinating the various teams.  I ran the ward while my registrar was not around and down in the clinics. I spoke to the family, updating them.

After a month plus in hospital, we still couldn’t figure out the answer. I am afraid time’s running out. She was remarkably even when all the objective measurements seem to suggest otherwise. She is now in ICU on Norad to maintain her hemodynamics just 24 hours after we thought that things were looking much better. She must be septic, somewhere. But all 30+ blood/line/swap cultures had been negative! And she spiked temperatures no matter what antimicrobials she was put on. We had trials of Tazosin, Vancomycin, Meropenem, Fluconazole, Posaconazole, Caspofungin, Metronidazole treating for an assumed infection, somewhere.

The only clue we had are microabscesses in the spleen, which would be suggestive of fungal infections. She was put on antifungals with almost no effect. Was planning to go in with an U/S guided aspirate but patient was deemed too high risk for bleeding due to thrombocytopenia. Now that her cells had recovered, perhaps, we can go ahead with a guided aspirate for diagnostic purpose. Would she be fit for a splenectomy if needed, considering that she is now only 3 weeks post emergency laporotomy for perforated small bowel? Questions… questions… questions….

The second time in the day was after I walked out of the Prof’s room with his words still ringing in my ears

“You’ve done a remarkable job. I’ve got a meeting due to start 5 minutes again. So we will sit down with your registrar on Monday for a proper formal assessment. It would be a loss to our unit when you’ve moved onto another rotation.”

I think that was the highest compliment I’ve ever received. Straight from a Professor’s mouth!

Fantastico!

Now to keep things tight for one more week.

Arrivederci.

Which is easier? Be nice or just to tell the other person to just fuck off?