Obs & Gynae

Ever since the very beginning of medical school I have visualised how one day I'll be able to help welcoming new lives into this world.  I had imagined scenes that would sound somewhat like this: me congratulating the parents for their cute baby and they thanking me for my hard work and inviting me to take a family photo with them, whilst asking for name suggestions for the crying baby. 

It's when I actually stepped into the labour rooms that I realised the process of relocating babies from the safe and ever comfortable womb to this cold and harsh world(yet warm and beautiful at the same time if you're with the right person) can be daunting, and it involves lots of human excreta, blood, tears and sweat(literally)! 

Obstetrics and gynaecology are essentially about taking care of female patients. Stories of patients refusing male doctors are not uncommon in our relatively conservative society. It's a popular belief that male medical students will have a more challenging time sailing through this rotation, due to the constant need of having a female colleague as chaperone. Personally I have had my own worries and prejudices too. During the first few weeks, I would get slightly discouraged whenever I saw patients who're accompanied by husband, especially those who're not very friendly-looking ones. The nervousness in me that somehow arises upon looking at pregnant abdomens made things worse. Thankfully I have yet to encounter anyone who was unwelcoming or hostile to me. I am very grateful that most patients and their relatives that I've had the privilege to learn from are mostly kind and pleasant. As for the arts of feeling for babies' heads, I believe I've gradually gotten more comfortable with it under the guidance of brilliant tutors.    

I can still vividly remember during my first oncall, there was this lady who was under my care and the progress of her labour wasn't going particularly well. She had history of two previous miscarriages and any mischance for this current pregnancy would be the last thing we wanted to expect. Despite hours of encouragement and oxytocin infusion, the poor and exhausted mother was eventually pushed into the operation theatre for an emergency caesarean section in view of foetal distress, leaving the father anxiously waiting outside, with his hands tightly clenched.(they always say the most sincere prayers are often heard in the hospitals) As a first-timer who was eager to assist his first spontaneous vaginal delivery, the fact that I probably won't be getting any signature that night for logbook was the least of my concerns. I decided to get into the theatre. I wanted to stay by her side, to continue praying that both she and baby would be safe.  

I was equally anxious.   

In the end it was a happy ending I guess. To be honest I can't even remember what gender the baby was(they're wrapped like dumplings), but I knew that he/she turned out well and pink. That night, I didn't manage to guard the perineum or performed a controlled cord traction, but I got my first 'thank you' from the first-time papa and mama.  

The nights spent taking care of the mothers-to-be have taught me that as long as I genuinely care about the well-being of a patient, there is no reason for me to take a step back and be extra self-protective. As a reminder for my future-self, the arts of obstetrics isn't about the cervical OS size, but how much you care.   

And to my mom, thank you for bringing me to this world. Making you proud is all I want to achieve in life.  

********************************* 

Serendipity: I got a rather random text message in the midst of my second oncall and the next day the sender delivered me my new scrub which I've donned for my next few night shifts. I would like to thank her for all the encouragements and companionship. 
我想告诉你，你在我心里。  

Are you fitting well?

In a seizure/epilepsy long case, there are 3 essential clinical questions to ask:

1) Is it truly a seizure?
2) What is the cause of the seizure(s)?
3) what triggered this current seizure?

Could it be anything else other than seizure. Consider hypoglycaemic attack, cardiac and vasovagal syncope, transient ischaemic attacks etc etc.
Causes of seizure include epileptic seizures(epilepsy), meningoencephalitis, autoimmune encephalitis, electrolytes imbalances particularly hyponatraemia, cerebral venous thrombosis, uraemia, hepatic encephalopathy etc etc.
Examples of triggers are insomnia, alcohol, drugs, stress and metabolic derangements.

Ask if there was any video recording during an episode of seizure.

Consider Juvenile Myoclonic Epilepsy in young adults.

International League Against Epilepsy(ILAE) 2017

Lethargy

Causes of anaemia in CKD
1) Decreased Erythropoietin
2) Anaemia of Chronic Disease
3) Uraemic Gastritis
4) Osteitis Fibrosa Cystica (bone marrow failure)
5) IDA due to malnutrition
6) uraemia causing bone marrow suppresion

Causes of anaemia in RA
1) anaemia of chronic disease
2) IDA sec to GI bleeding due to NSAIDs
3) Bone marrow suppression due to methotrexate(can cause folate deficiency too)
4) association with felty syndrome or pernicious anaemia
5) autoimmune haemolytic anaemia



Clinical Case for fun:
A gentleman with underlying ESRD on long term haemodialysis for the past 5 years presents to you with pain with numbness in his left hand, and on examination, he has got left sided median nerve palsy with positive tinel's sign.
Tissue biopsy of the affected site is taken. Amyloid deposits are positive for Congo red staining, showing green birefringence of the amyloid fibrils under polarized light.

Diagnosis: Carpal Tunnel Syndrome secondary to Dialysis Related Amyloidosis(decreased clearance of Beta2-microglobulin)

**long standing RA can cause amyloidosis too (AA- serum amyloid A protein)  

Community Posting

“The power of community to create health is far greater than any physician, clinic or hospital.” Dr. Mark Hyman

I viewed community posting as an opportunity to develop a better understanding on the roles of public health medicine in the context of healthcare. Since the beginning of our clinical years, I have only managed to spend time mostly in the hospital, learning how inpatient clinical medicine works on a tertiary level. I have been lectured countless times on how to initiate fluid resuscitation for a patient coming in with dehydration due to acute gastroenteritis, yet I certainly would have had no idea on what to do in the midst of a cholera outbreak. In terms of workload and learning curve, to be brutally honest, I have expected this particular posting to be a relatively relaxing one, at least when compared to core rotations such as internal medicine and surgery. However, it turned out that I was entirely mistaken. Fortunately, I have been blessed with teammates who are amazingly enthusiastic and kind. It has been a great pleasure working with them.

The time spent in the district health office has really opened up my mind. A good public health policy, when implemented properly, should theoretically be really effective in fixing public health issues, in terms of primary prevention of non-communicable diseases, for example. Public health specialists are therefore vitally important in health issues at a community level. They are the ones who deal with Hand Foot Mouth disease outbreaks. They are the ones who plan strategies in health screening of our school children. They are the ones who come up with recommendations for the government to execute better healthcare policies for our people. Having gone through this posting, I now have great appreciation for the people working in the field of public health. A physician treats the patient; a public health doctor treats the population.

‘Prevention is better than cure’, a phrase that we may have heard a thousand times, but it was after going through this posting that I truly understand the true essence behind this fancy sentence. As a developing country, the pattern and spectrum of diseases in Malaysia are largely similar to the ones in the western world, in addition of geographically specific tropical diseases. Non-communicable diseases such as cardiovascular conditions, obesity and stroke constitute a huge disease burden to our nation. During that one week when we carried out data collection on the residents of low-cost flats, I have encountered innumerable respondents who have very poor awareness on health maintenance. Most of them are obese, yet they are clueless on choices of healthy diet. A lot of them are smokers despite earning very little. It was very disheartening to think that one day they might unfortunately present to the hospitals with heart attack or stroke, which are conditions that could have been prevented if primary health interventions are implemented well.    

As peculiar as this may sound, I have found learning basic biostatistics to be rather exciting. I was thoroughly awed by how efficient and convenient the SPSS statistical software can be, once one has grasped the necessary skills on how to choose an appropriate statistical test, which is in fact to me personally, the most intellectually stimulating and challenging step in the process of conducting a research.  In the book ‘The Medical Research Handbook’ authored by Dr. Amar Singh, there is this sentence which I could not agree more: ‘medical research is best learnt by conducting one’. This posting has indeed served as a really good platform for us to learn the basics of clinical research and even conduct one. Moreover, our team has been extremely grateful to have dedicated supervisors who are always trying their best to guide us through. (How lucky I am to be able to conduct a discussion in a deputy dean’s office and have pisang goreng with her!) In the practice of evidence-based medicine, one is required to understand basic statistics well as having the skill and knowledge to appraise clinical papers and conducting researches are essential for us to be a good clinician. Being in community posting is therefore the first step towards our goal of becoming good doctors!

“Without a sense of caring, there can be no sense of community.” Anthony J. D'Angelo

All in all, being in community posting has been an exciting and fruitful experience. When the rest of the healthcare system are moving towards an era of subsubspecialisation, having the opportunity to get ourselves exposed to a relatively foreign field in medicine has been truly humbling, as it reminds us to not be ignorant, and educating our people to eat healthily is always better than trying to invent new novel drugs to lower cholesterol level.     

advices from Dr TSK

if differentials include respiratory problems, and the child is ex-prem, include this in the introduction

you wanna ask a good history and formulate differentials because you wanna manage, treat the patient! 

Dengue

Warning Signs of Dengue Fever

AVF LLLB

Abdominal Pain
Vomiting which is persistent
Fluid Accumulation Clinically
Lab (rise in HCT and drop in platelet)
Lethargy
Liver Enlargement
Bleeding in mucosa


SEVERE Dengue

HOP

Haemorrhagic
Organ Impairment
Plasma Leakage

Are you a fighter?

The first thing I did upon entering that particular floor was searching for the nearest hand washing area so that I could wash off the remaining stubborn pizza flakes that'd scattered all over my hands.

This place was meant to be as clean, as sterile as possible,. For it is where young warriors with fighting spirits higher than yours and mine temporarily take a break from their supposedly gleeful, carefree life.
A period of time which you and I can no longer go back. The best period of one's life. The period when they are supposed to be playing hide-and-seek under the showers of warm sunshine, or maybe with an ipad.

'Hey young man, great to see you!'

As usual, a pleasant welcome from Aunt Lily, followed by she asking me how my clinical postings had been.

'same old, same old, haha..'

After making sure that the hands're thoroughly cleansed, slowly, I walked into the mini toy museum which is also well equipped with story/comic books and art crafts, where young fighters who carry mobile drug infusion pumps can come in and have some fun.
Probably the only place in the entire ward where energetic laughter and gestures are more apparent.
A place where heart-aching crying sounds of children are more often heard.
A place where parents desperately wish that their prayers are heard.

Wearing a cute turquoise mask, she was playing with her toy doctors's kits.
An age of learning simple maths and Chinese characters.

'aiya I am sick ah Doctor, would you help me?'

We were acting as patients, trying to play along with her. Such irony.

After growing bored of it, we switched to another fancy but loud electronic toy.

As the box shaped thing vibrated, causing the tiny toy crabs to sort of  move and jump, we had to use the plastic scalpel to grasp them out.

Kids can be really spontaneous.

'Show you something funny'
No longer amused, she put down the toy as she was saying this to me, whilst both  of her hands reaching her head.

She pulled off a few strands of her precious hair and showed them to me.
Without difficulty. Without Pain.
As if she was trying to show off her awesome ability.

A part of my heart shattered.


****

And then I was playing western chess with another young girl.
An age when the rest of her peers are excited about the upcoming UPSR.

When asked, she proudly answered that she indeed played chess at school.
Excited, I was expecting a good match, after such a long time of not playing this ancient board game.
A game of war between two sides.
She has her own war to fight as well.
They all have their respective battles too.

It turned out to be a slight disappointment, haha. I had to think hard to fake my defeat, but not to the extend of being too obvious.

We are trained to be observant. Clinicians are supposed to be expert in observing, for we are always looking for signs in patients from time to time. Tiny white lines on the nails for example, may indicate that one is losing proteins due to problems in the kidneys.

I wasn't being observant that day.

It was approaching the time of the day, where the young warriors had to get back to their beds.

'aiya, it's time to go back'

She turned behind to grab her axillary crutch which I did not notice, and stood up.   
And I realised, she was standing, with her one and only leg.

Together with another aunty, I accompanied her back to her room. Her mother was already standing outside, waiting for her proud princess.

'she was complaining about not being able to have pets, this girl ah...'

'aha, you like animals ah?'

'I want to be an animal doctor!'



****

what are the odds of you seeing gulis nowadays!

she made me the cupcake, with free beer!

In life, sometimes you're at the top, sometimes you're at the lowest, 
but in the next round, things change.
Be kind to each other, make peace with everyone.

****

'Mummy why can't we go home yet?'

'This is how being sick is like, stay strong okay, dear'