my third posting

i am now in orthopaedics..so currently i'm in my third posting after having done with medical and o+g ..it's been approximately 10 months since someone called me doctor in Klang hospital
my entries seem to be getting darker tones and scarcer than ever, but believe me i am the same man, though i couldnt help but bear a grudge for having to extend another 2 months of my already two-year-long housemanship training while i was in my 1st posting in the medical department.
truth be told i do enjoy my work, other than what i said just now, i like being a HO, even the 2 long months of extension was beneficial in a way (I had more time to do more procedures than normally a houseman in Klang Hospital would.)

I found myself more relaxed doing stuff, and some people seem to think it’s a big deal i finished those 2 previous postings, but i wouldnt say I’m ready for ortho just yet...every dept is different and it’s helpful to know what exactly you are doing no matter how many times you’ve done something similar in another department.

Orthopaedics is a great relief in comparison, finishing at 5 is only 2 hours earlier, but after coming home only after 7 every weekday, it’s so refreshing.

I’m actually doing tagging calls, which means i have to stay until 10pm (in the other departments its up to 11pm, but who’s complaining right), but the feeling of going back early is just too great, I’d still go back 1st, rest,eat and pray and then return to look for something to learn.

The calls are also something i’m looking forward to..4 to 5 calls per month- approximately half of what i’ve been doing in my previous postings (approx. 7-9 calls per month in medical, 11-12 calls per month in o+g which usually means a train of eods throughout the month)

The ratio of patients per HO is also so little in comparison i could’nt help but smile whenever i think of it.

It doesn’t mean starting as a HO in ortho would make you less of a HO though,IMO. I know a few guys who were really smart coming from ortho, who could do their jobs in their new depts just as efficiently.

Life is changing...the guys who got married are mostly expecting. I finally bought a means of transport and will soon move out of this old skool hostel.I’m starting to contact my old buddies especially those near me. Facebook is a great tool for this (besides fster). We’ve been laughing off electronically (no, not as if in the transformers voice, though it'd be cool if i could) as we look at some of the more comical moments in our student lives in zam’s photo album.

The kids in volgo are coming back again, and some fresh blood will enter the service of the Ministry of Health...mmm..fresh blood..

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an entry to wrap up 5 months and get some crap outta my head

5 months.
if i was truly faithful to this blog.it would have been filled with entries, love/hate stories of my life's work, how it changed me, touching goodbyes to my overdue stay in medical, the new department i came into, my newfound struggles there, my recent assessment, hopefully my expected leave from the o+G department, the new phone, the new car im planning to buy, my latest exploits, the upcoming wedding of my friends, my ex-roommate's birthday, my gourmet adventures with my current roommate, my exciting, fun and definitely enriching experiences in the labour room the past month, and how much i miss my university life, and how thankful i am they taught me to be a doctor, especially dr alexander zharkin and the other professors who taught me exactly what i needed to be an accoucher (to this i defer from a friend of mine's comment to me in private that what he learnt did not help him much- it helped me TREMENDOUSLY, in fact, what they taught me was more than what i learnt here).of course, here is where i learned to BE a doctor. take responsibility (however little it is now,thankfully) and train to become a good one, or at least a functional one who knows what he's doing.
my struggles in the medical department taught me the hard way that here i need to learn the local medical jargon, learn how to present them correctly, how to work with the system, and the current local protocols and management.and it works. and also to keep studying. even the consultants take time to read bak once in a while...it'd be egoistic for me not to study just to prove my university taught me well enough.which i did for a short period, for which i hated myself for taking in too deeply coincidentally hearing what some arrogant colleagues of mine thought of the supposedly inferior doctors the government sent to learn in some foreign country or other.
i'm actually smart enough to keep it to myself, brewing it in and occassionally annoying (hopefully not) my roommate- those comments which made some actually nice people into annoying jerks whenever i thought about those few dumb words they talked that day. i mean, it's okay to have pride in your university, but downgrading others just to show you're better? any high school kid can pull that off, and anyone with any common sense can see through that ruse.
the only thing we can do about it though, is to show them what we've got.just give those 'inferior'
docs a few months, and, in my case, i'll be just like any doctor you can point to. sitting with me in that conference room. believe it. (yeah i kinda still hold a grudge- it's a good motivational tool, see)
as for you guys still in my alma mater. have faith and study well.be motivated in learning, which i know most are.try to do the practicals here when you are in the clinical years. we are not high school kids who suddenly become doctors in hospitals. i know my six years were not wasted. i only had to learn the common local terms, investigations, and protocols (which are actually really simple compared to our textbooks)

oh and the original thing i was thinking about:

8 hours a day, no calls, 10 beds 2 housemen, intense cases and lotsa cute babies - LABOUR ROOM ROCKS! Read more!

Troublesome patients, troublesome job

“We are not witch-hunting, this is only a learning experience, please dont take it badly...will the houseman and mo responsible for the patient please stand up”

You’ll hear this a lot from our HOD of Medicine during our Friday mortality meetings and whenever there is an issue, or a mistake made...
Make no mistake, I believe the HOD is a good man, and he means what he says, and believes it to be true.and it is..It usually really is a learning experience, and not once did any mistake got out of that meeting unless it couldn’t be helped. Our medical department really does protect their doctors.
The only problem is, no matter how you cushion it, or cover it with sugar, spice and everything nice, it’s still putting blame on someone, and I doubt anyone who gets up likes it.
Fortunately I haven’t had that rather uncomfortable experience – yet.

An interesting thing that happened in our recent meeting was when he produced some actual complaints from ex patients or a powerful relative..
One such criticized the referral letter done by a HO. It was badly done, as the HO had just started, didn’t really ask, and the MO didn’t notice.
Another one was an email sent straight to the MOH, and incredibly stated the name of the HO the patient was complaining about. It was about the unethical ill-mannered way a HO handled the patients in the dengue wards. The houseman wasn’t there, was already scheduled to leave the department the next day, was already a 3rd or 4th poster, and later denied ever taking care of the patient more than blood taking once, without even an exchange of words. But that particular HO could only deny that point, as the HO was known to be brash, and at times ignited the ire of not just the patients.
At that particular moment, the HOD couldn’t even get himself to read the letter, so he asked someone else to read it. The moment the email was about to mention the HO’s name, probably all the HO and maybe some of the Mos held their breath or skipped a heartbeat, including me...everyone had a skeleton in their closet they’d never want to recall.

At one point in my work, I developed that tendency to get mad at every patient complaining of pain/sob all the time....even to the point of patronizing them for disturbing my and the nurses’ work. A patient I once admonished expired during the weekend about two months ago...nothing medicolegal or complaints happened...but it was a painful lesson in a way. Now the worst I could do is be indifferent, but the old temper can still be ignited if rubbed the wrong way, so I became careful. Now I almost don’t sleep during my calls, and I keep going back late, double checking to see if everything’s well. Thankfully my experience the past few months helped me a lot in deciding on management issues.

In another point of view, some patients are troublesome in itself. Those ‘manja’litis patients, or those afraid of needles, or those who even have the nerve to refuse and even get angry at the doctor trying to get a line (which is sometimes hard,depending on the HO’s experience and the patient’s condition). These are the guys whose drug charts would state brenula required instead of the usual initials signifying some iv treatment had been administered. And the MO the next day would have a headache and if on a bad day, would scold the houseman.
Sometimes it’s the relatives that are the problems..the ones nurses complain that they think they’re so important they deserve every minute of the nurses’ attention. Quite frequently these are relatives who are doctors , and they would quite often question the decisions the doctor in charge makes, especially if they know he’s a houseman, and a first poster like me, although they know it’s unethical and they shouldn’t interfere in the relative’s treatment
Usually it’s with these patients I let go of my reins completely. I become really indifferent, I’ll nod at every suggestion, but never really follow them, because that’s what they really want, for me to follow instead of decide. Usually in this case I’ll let the MO decide even the simplest decision, as apparently, that’s what these relatives really want. Of course if they want to do the blood taking, I let them. Less work for me, and less chances of needle prick or another unsatisfied or patient in pain for me.
Not that I couldn’t manage. I have every confidence that I can, to a certain degree, manage simple cases on my own. To disagree with them would only incite anger in me, and just further misunderstanding. To follow their opinions blindly would be stupid. I let the MO discuss and handle the situation.
Of course what would you do if it was your parent in the ward, right?
I try to keep that in mind in every case I handle. But humans can forget.

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Clinicians versus radiologists

This is purely from my experience, after 4 and a half months of being at the bottom of the pyramid of the professional caste of medicine.
The clinician and the radiologist – both possible future options for housemans and med students. First of all im really thankful i’m in medicine...there are so many possible choices for my career in the future...i feel like the little zergling worm that gets to become anything from a giant flying alien crustacean to a living disgusting zergling factory/fortress to a superunit in starcraft..
Anyway these two species rarely meet in this diversely intercorrelating small environment called a hospital..but both are crucial, like so many other aspects, in the treatment process of the patient..the central subject of our work.
So how do they interact? That’s where we house officers come in...our role as messengers have been embedded deeply into the programme called housemanship I’m supposedly “enjoying” right now. I dont mind having to go down every now and then, read up on the way (especially when it’s not my case- sometimes), and try my best to convince the ever-so-busy radiologist that this is an urgent and necessary intervention. But in some things,as with everything in this world, they are always at odds with their idea of what is urgent and what is not.
One “urgent” request i never could get urgently was the “urgent ct neck,thorax,abdomen and pelvis for staging”. I know, both parties have reasons why it is’nt/is urgent.
The clinician/specialist/mo wouldn’t want this ct study too late, as the earlier the cancer is treated, the higher chances of the 5year survivability rate..letting the patient go home first, take the scan a few weeks later, then deciding what kind of treatment is simply unacceptable in their minds..i tried to talk the out of it, but who listens to the houseman right? Some common replies from my pleas of not wasting my time in (in my opinion) a futile attempt to get the radiologist to do it on the same day of diagnosing the cancer was “of course it’s urgent. Are you nuts?” or something like that, or something along the lines of “why wouldn’t they accept it..it’s stated right here (shows the previous scan and/or u/sound) that they were the ones who suggested it”
After those brief conversations, the houseman/peon takes out his pen, dishes out the forms,carbon paper, etc, gets the specialist countersign, and prepares himself for the impending encounter with the radiologist downstairs..(on a good day, that certain HO even believes in his heart that this will work,and those helpful tips he got from the specialist/mo would prove fruitful)
He gets to the scan room, clears his throat, and does his best to impress on the radiologist the urgency of doing this.
Deep down, he knows why the radiologist would’nt want to agree..here’s a list:-
• There is no urgent or life-saving procedure no matter what the outcome of the scan (unless it’s a primary cancer- which is usually a coincidental finding or after routine screening, and without clinical symptoms already)
• Urgent for them means the patient’s life is in danger and severe permanent outcomes would happen if they didn’t do the examination helping in the decision for the course of treatment
• They would have to put aside extra time to check almost all the systems from the neck to the pelvis- precious time needed to finish their scheduled scans and reports before the clock turns 5.this might sound a bit selfish, but they do have a lot of work, and like everyone else in the hospital, they manage their time the same way – they prioritise.
So what’s my point?unfortunately i can’t recall another “mission impossible” task of urgent special examinations...but this one is clear, and the point is I hated whenever this examination comes up, because it would mean me wasting my time going down and up, sometimes multiple times, trying to get something they’ll never agree upon –maybe they would, when-um- stretchers learn to fly or something..
Dont get me wrong, i’d take a ct brain urgent TRO ICB or US KUB urgent TRO obstructive uropathy or any other necessary tests that requires urgent intervention any time and help save that poor patient’s prognosis. Especially when u get all the facts/reasons right, and everyone agrees it’s urgent.
The bottom line- why wouldn’t they just tell me to get a really-really early appointment, we’ll decide the date (usually within 1-2 weeks) and readmit the patients like how the nephro team does, and decide the treatment..as what usually happens anyway (actually, they get a TCA ward first, and THEN the MO would decide to admit the patient to start chemo, or to refer to ghkl or any other oncological department in Malaysia) instead of telling me to fight over something the other party would never see. Come on guys..agree to disagree..and cut the chase..at the end of the day i’d still learn something anyway...but with way less time and effort wasted
And here is the rest of it. Read more!

A day in my life

this was one common boring Monday
1. Reviewed 12 patients
2. Discharged 7a 7 8 8a 9 12
3. Followed MO reviewing my rounds
4. Traced all results
5. Requested for urgent ct scan
6. Went to mortality meeting
7. Went for Friday prayers
8. Helped put brenula
9. Helped someone clerk
10. Helped someone remove CVP
11. Accompanied patient for us urgent
12. Cxr reporting
13. Us urgent for patient which had cxr reporting
For the patients not leaving:
1. One had hypokaliemia and anemia for FBP to find out why (probably because he has diverticular disease too)
2. Another is supposed to be refferred to HKL for further treatment
3. Another needs 10 more cycles of PD before discharge
4. Another developed temperature just after my review...but probably it’s URTI and we’ll discharge him tomorrow
5. One just had ultrasound TRO AV fistula of the femoral vein and artery- which he didnt have..but still needs to be reviewed by the nephro specialist before discharge
6. Another still has signs of fluid overload – his EF is 23%, the swelling was noted in gp long before...i dont know when we’ll be able to discharge this guy..probably when we’re satisfied with th eresults (it IS improving) and then we’ll refer to IJN again (he defaulted follow-up)

Things i found out
The patient at the back with chronic liver disease & massive ascites is transferred to acute d/t loss of cinsciuosness (E¬1M1V2)
The ex ivdu patient at the back with extensive tattoos and symptoms of gangrene 2o to emboli or DM foot ulcer is now in subacute
Half the Dengue patients are finally going back today
Anil might be extended
Kuhan will go to pediatrics
Why voltaren(diclofenac) could be dangerous (adv reaction- toxic epidermic necrolysis)
I’m still not sure what to do next
I’m pathologically addicted to mangas
I cant login to my ym messenger
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Happy New Year!!

This is actually a long ago post which wasnt published, but i'm not wasting time writing a new one...

What have I done for myself with my gaji?
I bought a fridge, a phone (the old one “collapsed”- i did manage to “revive” the old chap but it wasn’t working as well anymore), and lotsa food for each meal i could get my hands on..
Am planning to get some wheels, maybe a pda (the quick reference is really helpful in the wards), and i might move out some time this year.
Other than that I’ve been saving more or less...i still haven’t got my 4 months’ worth of on-calls (i get 8 calls every month) but I’m not really in a hurry to get it,they can give it in bulk later, I’m quite comfortable already.
Have you heard about the day off for the doctor on-call? No formal circulation is out, but the consultants doubt that it could happen..firstly if in HTAR, it would mean 7 housemen would be missing out of 20 something, and that’s not counting those taking their rest leave and EL..
Secondly if 4-5 out of 6 HOs in charge of one ward were on call that night, then the next day would be haywire if only 1-2 housemen were to take charge of 60+ patients, when previously they had only one cubicle..i had a similar day once (new housemen went for orientation,2 were on leave)..and it was not pretty
My personal opinion- how about giving those post-callers a half-day...they wont need to clerk any admissions for the day...just finish the rounds and any other issues in their cubicles, and go home early just like any weekend. It’s plausible..at least better than the day off idea...any qid monitoring or pm stuff could be covered by others in the ward.
Maybe I should get this stuff straight to MOH, and maybe I should iron my clothes too once in a while, maybe I should jog once in a while and maybe i should wait for that proverbial blue moon first.hehe..
PS: do you think I should stop using the READ MORE button for each posting?It seems to make us do an extra click to get to the full posting, a real pain in the neck if your wireless internet has problems catching up with a turtle in a race..heck, I can't even properly download my YM these past few months...
currently listening to: Aliff Aziz
Sayang Sayang Read more!

Selamat Hari Raya Aidilfitri!!

Maaf Zahir Dan Batin

here's to all who know me, and know me well enough to frequent this blog, even though it's been irregularly updated since the past 3 years - thank you

Im now a houseman in HTAR Klang,in the medical department, living in the hostel for 1 year
Im working 7 days a week, seven to eight on calls a month, with about 10 days of holidays for 4 months (including this 5 day Hari Raya break, which was a miracle i could get 5 days)

I had a needle prick incident on my 3rd or 2nd week of work...the patient was restrained by two policemen but still managed to kick me lightly- enough to cause the needle prick as i was setting his brenula. So currently Im on meds, Combivir to be exact..and boy does it have side effects
lesson of that day: assess the patient you're going to prick first

i've learnt a lot more but it would take too long to list everything.



A little advice for my dear juniors in Russia:

...lepas 3rd year try la wat attachment, especially kat hosp tertiery/besar
biasekan diri ngan hosp2 kite, sistem2 kite
aku blaja sistem rusia je..pening stat keje
tapi rugi la klu kite tolak sistem tempat kite blaja sendiri...byk bende yg bagus kat dlm sistem rusia...

(i copied it from a recent YM chat...got too lazy to rewrite everything)

PS: no i dont have a car yet, I'm not planning anything except trying to do my job right (and finishing off those discharge summaries piling up), I received my first rounded up paycheck about a week ago (found out yesterday), and I disowned my last camera and gave it to my sister who's going to USA next year, so currently I don't have anything to record vids and pics with...too bad


have a great hari raya everyone, hope you had a nice ramadhan this year Read more!