The Academician

Salam.

We come to a crossroads at the end of our housemanship. Although we aim for posts with less work, most of us continue on with district MOship; others get admin jobs at health-related departments. Me? I took the road less traveled, quit  and joined my alma mater, USIM, to serve as an academician in Paeds.

Joining Paeds justifies having toys at your desk.

 It's not a popular move at HoSHAS (only 1 HO joined a university since 2 years ago), given the fact that the pay was not that good at that time, the job scope was unclear and that most of us still like hands-on work and disliked research. But I joined anyway. I love my university; despite not agreeing on certain elements, I still need to take care of it.

Damn, why am I so handsome?

Looking back, the first batch was often reminded to join and serve the university since Year 1 of medical school. The seniors knew that every first batch has a certain unwavering loyalty to the medical school (given successful past examples). A loyalty forged from hardship - the lack of teachers, the infantile administration, the uncertain future. We struggled as a trial-and-error batch and from that hardship, the faculty prospered into what is it today. After all that hard work, nobody wants to see it destroyed or neglected.

The Oath of the Muslim Physician.

So, after settling thick paperwork, I'm now back to Menara B, Persiaran MPAJ; only this time, I have a cubicle on Level 13, complete with a computer and telephone. I was also joined by my sidekicks - Hafiz and Miqdad - who, like me, are USIM graduates who just finished housemanship. Our job for now, according to the Deputy Dean, was to "help around, taste the academic life, understand that it's publish-or-perish!" and then, do clinical attachment in our field of interest before joining a postgrad programme within 2 years. 

Helped around, we did.

Every one I know is working their asses off and I'm just sitting here.. contemplating.

The first week was a culture shock. We were used to running around the hospital and being active, but after joining, we sat around doing nothing for the first week, punching in and out punctually daily while our colleagues in KKM continue to improve as MO's. I admit that I was a bit jealous and worried about being stagnant and rusty, but that worry slowly faded as work piled up little by little.

Baby Balqis also helped to give marks.

We briefed the Year 1 students about medical school life. We helped to teach systemic physical examination to the Year 3 students. We attended the clinical lectures (Hafiz even delivered one lecture!) and seminars. We followed the ward rounds and highlighted important clinical management and items that the students missed or were too shy/afraid to ask the specialist.

I shadowed a professor as he conducted short cases during the end-posting exams.

We  looked for patients for clinical exams at Ampang Hospital, managed the clinical exams and invigilated over the written exams. We also marked the case write-ups and tabulated the end-posting exam marks. We also squeezed out brain juice during a workshop to update the curriculum.

Don't ask us any questions because we don't know the answers ;-P

As for extra-curricular work, we attended the Medical Students Club annual meeting, set up the faculty Hari Raya booth at Nilai Indoor Stadium, got involved in the USIM Annual Health Conference (I was made to be the MC because I was handsome) and most importantly, played futsal with the students. 

We are also planning to set up a USIM medical graduates alumni soon. 

Baby-friendly meetings.

Oh, also, locums.

Of course, not all of the first batch mates are interested in joining USIM back. Some wanted to delay to get more hands-on experience first; some got extended during HOship; some sent the CV late because they underestimated the horrors of district posting life; some don't want to leave Kuala Terengganu. 

But no matter how much negativity we took from the undergraduate life, all of us still want to serve USIM within our means. Because we love FPSK USIM.

The Emergency Medicine Posting

Salam.

The Emergency Medicine posting is the last piece to the whole housemanship experience.

HoSHAS Emergency Dept a.k.a the de facto hospital information counter.

During this posting, one will learn, experience and manage the whole spectrum of medical diseases as a preparation for MOship. When I say 'spectrum', I mean all diseases and conditions covered during the five previous major postings, from the mundane outpatient cases to the adrenaline-inducing emergency cases. 

Think oneself as a junior MO instead of a final-posting HO to get the brain firing up in preparation for the wild world of district posting.

So, that's why it's important to familiarize oneself with the common cases, procedures and drugs during each posting. Alas, that epiphany only comes the first time you see a patient in the consultation room and wonder what the heck you should do with such cases. Before you experience that regret, I'm telling you now: jot down important notes in a small notebook during each posting. By the time you come to A&E, you'll avoid significant anguish when you have five notebooks readily available all the time.

I prefer to use the abbreviation A&E which stands for Accidents & Emergencies (it unofficially stands for Anything & Everything as evidenced by the retarded number of unnecessary green zone cases). ED which stands for Emergency Department sounds impotent. 

The A&E is divided into red, yellow and green zones plus an observation ward. Patients who come to A&E are triaged accordingly. Triaging is one of the basic principles of Emergency Medicine. All A&E staff can and will do it anytime/anywhere. Its purpose is to determine who deserves prompt treatment and who doesn't. 

For example, a 40-year old smoker presenting with chest pain:

• If he were breathless and clutched his chest, the triage MA will, without asking a question, automatically think of myocardial infarction, grab a wheelchair and rush him straight to the RED zone. 
• If the same patient comes walking in and complains of chest pain, then he will be sent to the procedure room first for ECG then re-triaged depending on the ECG (or sudden deterioration depending on your luck). If the ECG is mildly abnormal or vital signs are not stable (e.g. very high BP or tachycardia), then he/she will be sent to the YELLOW zone for further workup.
• If the ECG is normal and the vital signs are normal, he/she will be sent back to the GREEN zone for proper consultation.

That means if you come with fever, cough and sneezing, please shut up and wait while we attend to guy with the broken neck or the lady with excessive menstrual blood loss. 

Empathic pain - can you feel it?

There are other red flags signs and symptoms that warrant immediate management e.g. unconsciousness, fitting, or very rapid breathing. Pregnant ladies in late pregnancies involved in non-obstetrics conditions are also sent to the A&E. Referrals from KK and smaller hospitals also get the same triaging; they are usually referred for further workup or further management.

The UK NHS Choose Well campaign aims to reduce unnecessary A&E cases and hence, the posters above. But can such campaigns work in Malaysia? Can people recognize simple URTI, AGE or allergic reactions? Do they know what medications they need and are usually prescribed? The answer is no, yes, yes. People will still flock to the A&E because they want the best treatment for such ailments which is a government MC.

Typical day in the green zone.

As for my 4-month HO experience, I found that each zone has its own learning curve. The red zone is a place for immediate diagnosis and management; the patients have clear-cut symptoms and signs; treatment usually follows guidelines e.g. ACLS for heart cases, EGDT for septicaemic shock and primary/secondary survey for trauma. The yellow zone patients are usually stable and have masked or less dramatic symptoms; it's a place for thorough examination and investigations; if you miss something, it will come back to haunt you. The green zone is where the drama takes place; patients who don't understand triaging and complain about the long waiting time mentally write their complaint letter in the green zone waiting hall.

Once a life-threatening condition has been ruled out or unstable patients have been treated and stabilized, the A&E team will refer the case to a primary team. While most cases are usually accepted and admitted, there are times when cases are rejected or asked to refer to another team first. Sometimes, argument ensues between teams when both teams don't want to accept a case. When that happens, we sit back and enjoy the show.

The end of Emergency Medicine posting signals the separation of friends, the trial of the bonds forged during hardship and stress, the pursuit of further career advancement, the end of the gauntlet of clinical life and the beginning of a life filled with responsibilities.

Last day in HoSHAS. Will be back as paeds trainee lecturer at USIM.

Good bye and good luck, peeps!

The Nostalgia Post

Salam.

We often neglect the photo-snapping that we do on a daily basis. It's when we move on that we realize how much we value and appreciate such routines - happy or otherwise.

It's nearing the end of our (the first batch) first posting. Some may pass, some may get extended. But most importantly, we will graduate as one complete batch. Can't wait to meet you guys this December :)

Are you ready? It's Nostalgia Overload Time!

And here's the last kicker:

The Games of Life

Salam.

I'm already 3 months into the medical posting; only 1 more month to go. A lot has happened in that time; so, here's a long post to summarize what I've gone through.

I've covered periphery (which can be translated as long walks along the hospital corridors all day long while getting irritating calls from O&G for medical review before discharge); the CCU/ICU/HDW (where the lucky critically ill patients end up; the unlucky ones get the acute beds in the general ward); the MOPD (sitting down while seeing stable patients is fun!) and more interhospital transfers.

BFMP course - what fun!

TAGGERS

As I enter the second half of the posting, and as the seniors advance to other postings, and as first posters join the Medical Department, I get entrusted into the role of senior medical houseman.

Honestly, I still have a lot to learn - I have yet to master the basics of Internal Medicine and definitely am not qualified to guide - but seeing the way new housemen come into the ward: awkward, disoriented, stressed out, slow - it reminded me of how much I deperately needed guidance when I first arrived. And my seniors helped me. And so, like it or not, I had to teach the freshies. Nasib la kalau dapat silap ilmu - muahaha.

Foggy morning run is a blast in Temerloh.. at least, that's what I've heard.

My seniors said that I picked up fast for a first poster. But that's because I get scolded a lot, by various people. Sure, it's depressing to be called 'mangkuk ayun' in the middle of the night, but it's a blessing in disguise because I learned a lot from such incidents. Also, while it's good to learn from your own mistakes, it's better to learn from other people's mistakes.

MIDPOSTING ASSESSMENT

It's viva assessment by two specialists. They toss you two/three scenarios (emergency or clinic setting) and you answer. Simple.

Anyway I failed the first but passed the second one.

Shocked? I was, when my HOD summoned me to his room to deliver the bad news and ask whether I had personal problems that I would like to share.

I said no.

WORK

I'm getting more adjusted to this lifestyle. Getting scolded has become less frequent as new targets start to appear *insert cheeky smile here*. Work has become relatively less. Reviews has become faster (not as fast as some of my seniors). ABGs much simpler to take nowadays. I've set up femoral lines but have yet to muster the confidence to offer myself for femoral or IJC insertion.

Juniors commented that I was unapproacheable in the first two months. I've got to admit that's true - the stress of working made me focused and less attentive to my surroundings. Also, grumpy-looking. But now I'm able to approach the juniors and chat with them (whenever I get the free time lah).

So, to those who commented that I look happy, yes, I am happy :)

Oh, did I mention that gossiping with the nurses is done on a regular basis? It's fun to hear the antics of the previous HOs, MOs and even the HOD. The one thing I've learned throughout my working experience is: never, never ever mess with the nurses.

MARRIAGE

I'm just 3 months away from getting hitched.

Transferring patients does have its benefits.

I've settled the necessary papers, now it's just to get the clothes done and work to earn a decent, halal salary to fund the whole affair. I'm saving hard, skipping lunch or dinner at times (sometimes it's because I overslept, sometimes it's because I wanted to save money, sometimes it's because I got bored from Temerloh's lack of variety). I've yet to even buy my own home theatre system plus the PS3. Heck, I've yet to repair my RROD-ed Xbox 360.

And oh, since I started working, I haven't played a single game despite having Crysis installed on my gaming laptop. I don't know whether it's because 1) I'm subconsciously trying to fit into my adult shoes, or 2) playing instead of studying makes me feel guilty, or 3) Internal Medicine is so damn tiring.

No gaming craving for now.. until Gears of War 3 and Assassin's Creed 2 Revelations come out for the PC, that is.

MVA

I had a near-death experience a few days ago when I lost control of my vehicle (the family's 17-year-old  blue Proton Wira), hit the right divider, turned and crashed into the left divider and subsequently plowed the hilly roadside.

I suffered a cerebral concussion (LOC for a few seconds, I think), minor cuts here and there.. and that was about it.
 
I was lucky (Mom said that God still has purposes for me) but the Wira wasn't. It suffered severe damage to the engine, frame, and boot. The cost of repairing it was beyond its present value, so we decided to let it go.

It was like losing a friend - a friend of 17 years.



 

Taken with Yunus' Galaxy S2's native camera.

So long, my friend..

The Real-life Medical Syllabus

Salam.

Today is my 57th day at work.

The wall art reads, "Dr Yusoff was here." 

I realized that I haven't been writing about the medical posting itself.

Internal Medicine in the real world is all about medical emergencies. And when we say medical emergencies, there's only two words associated with them - Sarawak handbook.

It's the ultimate guide to medical life, used by MO's and HO's everywhere.

What you find in there is what you'll find out there. From the very dramatic status epilepticus to the very silent hypertensive emergency, every topic is covered and presented well. Plus, the mid-posting and end-posting assessments will cover medical emergencies usually.

Another awesome mini textbook is the Oxford handbook - complete, concise, can fit in the white coat pocket.

If you're tech-savvy, then your smartphone should already have Medscape.

SYLLABUS

ACS (UA, NSTEMI, STEMI), CCF, APO, CVA (ACA, MCA, PCA; SAH, SDH, EDH), AEBA, AECOAD, URTI, CAP, HAP, HCAP, PTB, DM, DKA, HPT, DF, ARF, CKD, CLD, AGE, UTI, RVD - to put it simply, those with abbreviations are encountererd on a daily basis*.

My post-shift jajan binge collection - also encountered on a daily basis.

The main diseases need to be understood thoroughly - from the various presentations to the investigations to the management and progress.

Honestly, it's hard to focus on the subjects of the posting if you're a first poster since you'll be more focused on adjusting to the system and the associated life (or lack thereof).

To overload or not to overload? - that is the question. 

The management part is a bit tricky in the beginning, but after a few encounters with the same disease in a variety of presentations, it'll become second nature. Understanding the disease process and pharmacodynamics of the medications will help tremendously, rather than blind memorization of the treatment.

So kids, learn your stuff well while you still have the free time.  

 Free time well-spent.

It took me around one month to get settled in - even then, I still get scolded at times for reasons associated with lack of comprehension of (and adaptation to) the system.

Holding on to important things in the crucial moments. 

As for the compulsory procedures, my logbook is still free of signatures (and my midposting assessment is next Monday, haha). So far, I've done one chest tube insertion and one peritoneal tapping. And oh, countless CPRs (personally managed two resuscitations by myself while the MO is busy somewhere else).

Learning the system, one leaf at a time.

There's a lot to cover in medical posting - and honestly, I don't mind a one-month extension as I can get more medical exposure and training.

*This list is not exhaustive - I can't find an abbreviation for epilepsy, leptospirosis, melioidosis, deliberate self-harm (paraquat, organophosphate, corrosive agent ingestion), alleged snake bite, dehydration, non-compliance. And let's not forget the medical emergencies.

The First Eid As A House Officer

Salam.

I hope it's not too late to say Eid Mubarak, everyone!

Today, I'm on my ON shift; it starts at 10pm until 10am tomorrow.

So I usually use the free time I have during the day to 'live' a little - I wash my clothes; I buy grocery supplies; I edit the pictures I've snapped and share them with you people; I write this blog; I take a joyride on the scooter, letting the road take me on an uncharted adventure through Kampung Paya Luas behind the hospital; and many other stuff unrelated to Medicine.

RAYA

Initially I didn't plan on getting any Raya leave as I've been taught that sacrifice in the early years of medical profession is a given.

But then, during the departmental Raya meeting, my off day was coincidentally on Raya day 1. So I thought, I might as well get leave on Raya day 2, so I can spend my last Raya as a single person with my family.

Iftar as a single person.

For my department, getting an off day meant working the ON shift the night before. In other words, I was to work on Raya night amidst the happy Takbir and cheerful firework sounds in the night air. Oh, how it'll hurt.

So I informed my parents of my two-day leave and Dad planned to come and fetch me after Raya prayers. I planned to finish my work earlier and leave for prayers earlier (at 9am). I was expecting little work on that night.

Usually as Raya day approaches, the admissions would drop, chronic patients would request for AOR (at-own-risk) discharges, and cases at A&E would request to not be admitted.

But not this year.

Iftar at departmental level.

When I reported for duty, there were more than 10 new admissions that night. What the..!

That's the number of admissions on a normal day until midnight. As it turned out weirdly this year, patients requested to be admitted, not many patients requested for AOR discharge, no deaths and no terminally ill patients. So the ward was choke-full of patients on Raya night.

It's not a problem to clerk new cases, manage them, take blood and present the cases to the MO. Plus, the specialist on-call planned to come the next morning. So, no pressure there too.

The problem was taking the routine morning blood for tests.

BLOOD-TAKING

That early morning, after finishing rounds with the MO (total new cases: 17), I only started to collect blood at 6am. Blood collection by a junior HO in the medical department usually takes 5 hours if done alone.

I take my jajan breaks and pray Subuh when I got bored or pissed off at veins of an IVDU patient.

I favoured the blue needle since it was small and less traumatic to patients, but I found that it was slowing me down if I didn't get the vein on the initial prick. Fatefully, the supply of blue needles on the blood-taking trolley ran out. So, I decided to use the green needle (a slightly bigger caliber needle).

Surprisingly, my work became a lot faster! It was easier to find runaway veins, hit arteries, draw blood, less sample lysis, and since they're rarely used, there's tons of them on the trolley.

But that deciding factor came too late. I finished at..

11am!

So, I missed my Raya prayers.

Dad, who came to fetch me as early as 8am, was forced to wait for me after Raya prayers for 2 hours. I felt horrible for making him wait, but he said that he made use of the spare time learning Arabic via audio CD, so I was a bit relieved.

I slept on the journey back home to Bangi.

My family spent one night and one day in Gopeng, Dad's hometown, visiting relatives, paying respect to those who've passed on and ate a lot of kuih Raya.

I'm sure my younger brothers missed the joyful mood of Raya this year but for me, I enjoyed this little time even more. Somehow, after talking to dozens of strangers, feigning interest in their lives, my communication skills with my relatives have improved.

That, or either I've matured (I don't think it's the latter).

p/s My first pay was spent on duit raya for my brothers and some smaller cousins :) 

p/p/s Me - taken yesterday. No weight loss or gain. Macho as ever.