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It is not going to be easy when people watch your back while you are doing procedures. The idea that someone is watching your every steps, even thou it is a routine procedure, can be quite disturbing.

ISO is something that many people fear, in the hospital. Of course not the patients.

It is well known that a lot of procedures are designed and forcefully implanted into our brain in order to protect ourselves.

I do understand the concept and concern behind it. However, I do not agree up to a certain point.

Okay. For example, the blood taking procedure.

The idea is pretty simple. You take the syringe, make sure that certain investigations were ordered by the MO, and you walk to the patient, inform him/her regarding the procedure, and take the blood. Easy right?

No!

You have to remember to wear the gloves. You have to remember to bring along the sharp bin so that you can throw the needle you used straight away after the blood taking. You have to use the proper tourniquet to type the patient’s arm.

1000 things can go wrong!

Once there was this product specialist who came to give a talk regarding blood samples for investigation and the correct technique and etc. She did kindly show the power point and the studies conducted by people that actually much percentage of investigation error happens at the pre-analysis stage of a blood sample - which means the time of the HO taking the blood, label the sample, send it and up until the blood sample reach the lab.

Honestly, she was quite sinister regarding us HO.

First of all, if you are not our boss, you don’t call us houseman. You call us - doctor. That itself already put the presenter in a very bad condition. And it wasn’t a surprise that most HO leave the talk before the end and none was enthusiastic at all to answer any questions.

Secondly, if you do not practice blood taking, don’t talk about it, like you are a phlebotomist. She was on and off commenting regarding the HO’s blood taking skill. And the silliest part is, even a slide was presented to show which vein to aim, a slide for how should the needle pierce into the vein and etc.

I was like ‘hello, if i got xray vision (with contrast) then i would have put in all the branullas and taken all the blood in one shot’.

Plain stupidity.

Come on, nobody wanna hurt another person without any reason. If a task was given, we would want it to be done fast and correctly. Who wouldn’t wanna get the blood they want in one go and who would want to spend hours on a patient just to get the needle into the right vein?!?!?!

She obviously think we doctors like blood sucking and like to do it with multiple attempts.

There are obese people whose veins are not visible and felt, how to take blood? There are chronic patients whose hands are swollen from all the blood taking and no veins can be seen, how to take blood? There are small kids who struggle and give you problem during blood taking, how to take blood? Not to mention the obese powerful strong 10 years old that probably can punch u can give u a blue black, how to take blood? There are tiny premature babies the size of my keyboard here with their veins so small you thought it is like thread, how to take blood?

Yet everyday litres of blood were sent. And the lab nicely rejected some of them which they thought are not labeled correctly or clotted or insufficient. Do they know that blood taking is hard? No. Do they know that there are simply not enough blood flowing from the veins? No. Do they know that the small amount of blood they happily labeled insufficient was taken after the 10th try and most probably taken in the middle of the night like 2 or 3am? No.

A lab tech simply put the sample into the machines, wait for result, and oh the computer screened showed that the blood is insufficient/clotted. Oh have to inform the doctor, and move on to another task.

The doc, have to explain to the patient/parents that why the blood was clotted or insufficient, ADMIT THAT IT IS THEIR FAULT WHEN HALF OF THE TIME IT IS NOT, APOLOGIZE, and repeat the whole blood taking procedure of pricking for maybe another 5-10 times before getting enough good sample from that hard blood taking patient. Label the sample, despatch and when we look back, oh 2 hours have passed and there you go - the precious sleeping time.

Lack of understanding. Lack of compassion. Too much bull shit.

Even thou the speaker in that talk speaks with accent. The whole talk simply shows a no-brainer. Sorry to say -lah.

Same goes for the management. If they want us to use tourniquet for blood taking, they should probably do a survey on how many tourniquet is available in which ward (not more than 3, if more than 3, most probably 80% of them are not in good condition).

The standards that they put down is simply ideas without any follow up.

If they want us to throw our needles stat after blood taking, then supply more sharp bins! 2 bins for a ward is seriously insufficient. Not to mention 2 bins for a whole 30 patients ward with 50% blood taking happening almost everyday.

-_-’

Now, there would even be a team to monitor how HO take blood.

Sigh.

Houseman nightmare.

Sorry i almost forgot my wordpress password. It had been so long since i typed something here and i think people had already think i officially abandon this blog.

Actually, not writing here means there are too much to write about -lah! The extra-internet life is a bit too busy for me to even update here. Duh. Now I’m biting on my dinner (the verb is used because merely wanna make the food particles smaller so that the swallow mechanism can take place and I wouldn’t get any regurgitation later). I don’t even know what this rice tastes like.. hmm.. okay.

Not to say that I’m hating the busy life. But if it drags long enough then I’ll feel like exploding. Those episodes did happened but it was suppressed forcefully thru some unknown mechanism, for example spending a lot of money for UNNECESSARY things.

Nowadays a lot of social problems lah. Everyday i’ll see a baby whose mother is not married or is a teenage girl. Almost EVERYDAY lah. So teruk. Why can’t people use condom?!?! Ops. That’s not the point.

Some even more teruk one is that they don’t even know they are pregnant until the baby is out! Reminds me of lottery a lot. It’s like Kaboom! and hey you got a newborn to take care of and please be careful because you might even break a bone or two if you are not careful *sinister*.

*just noticed that the whole packet of rice only got 1 prawn. Damn TIPU punya!*

Ok finished with dinner.

Beh tahan need to do rounds in another 30mins. I just came back like 45 mins ago leh!

Definitely no mood to share any interesting or non interesting rant here today because it had always been rush and rush and rush and RUSH! Any free time will be used to do this and that laa and the only time for myself is fully utilize for myself only like locking myself inside the hostel room or sleeping. My entertainment bar (like in the Sims) is quite low. Social bar oso must be in yellow colour now. Power might as well also be in yellow bar.

Hmm.. The next holiday that I’ll be hoping for will be next month. Ahhhh so long away. Yet I hope April will not come (for some reason). Ok my stomach is full, time to go work again. DAMN.

First of all, this new year will be different. Why?

1. Am spending it with a zoom lens, a prime lens, and a wide angle lens.
2. Will be having quite a long holiday :P
3. Will be in Bali this time with family.

I can foresee a lot of nice things to take picture of! But I still don’t have the time to sit down and research on what to do in Bali and what to see there!

Anyway, tomorrow will still be working in nursery. Will be rushing home after 5 and hopefully not many cars on the road. It is quite scary to drive on a jam packed 2 lane over 100km/hr.

Already 2 weeks in paeds. And already had 2 calls indeed. It can be quite taxing working in the nursery as things can get really hectic and sometimes you got tons to do! Trace this and that, make sure this and that is done, and of course, make sure that they are alright and you wouldn’t miss out something crucial. Looking at their faces can be quite satisfying and calming but it doesn’t happen all the time. LOL. And I think working in the nursery certainly develop some sort of skills that you know what the babies want and how to calm them down. There was once that the mother failed time after time to calm the baby down but miraculously the baby went quiet when she was in my arm (either I’m really scary, or it is the other way round).

However, of course, this is another department where I’m suppose to learn something and hopefully utilize them in the future. And I’m glad that I’m consciously learning things and let’s hope that this would last for a long time.

Of course, standing in the shoes of an O&G houseman (just a few weeks ago), delivery some how means the solution for a lot of your problem but in the shoes of a Paeds houseman, it usually means the beginning of a lot of problems. Therefore, it is not hard to understand that we need to work in a team.

I hope I can upload all those funny cute chubby pictures that I took here but I think it is kinda like a privacy and I certainly wouldn’t want any mothers accidentally identifying their babies on my sites and sue me. So if you happen to see me in person, it will make me happy to show u some of those cute babies on my phone.

That’s all for now. Have other things to do. Will post more next time regarding my trip!

The very typical post of most bloggers, and I’m do it as well. It is cool to read back some posts and see what had I achieved this year. Let’s see.

1. I think this year I didn’t blogged much.
It is a total of less than 100 posts this year. The main reason is of course - work. So it is a down trend for my blogging life. And to think that blogging is like writing a diary and I don’t even have much mood to write things down, you can expect the same thing with my social life. LOL.

2. It is a up trend for my number of friends.
A lot of hi-byes when I work longer and longer in the hospital. Familiar faces increase by numbers everyday. It is not something bad actually. I have more friends compared to when I just started working. So this should be considered a kudo to me.

3. Chilling out -up going trend.
Very good towards the end of the year. Having out much more often with human being but it also means hanging out less with the books, since spending time on patients can’t be discounted!

4. Family wise.
I should say it is good. Brother settling down with his work. Another one scored well in exams. Parents healthy. Hope health wise maintain like this until 40 years later. Buddha bless.

5. Religion wise.
I do remember. I’ll not say that I remember less. But I’m trying to hold on to more. Life rocks.

6. Love life wise.
Clear as water. LOL.

7. Financial wise.
Boom. I’m very happy considered that I achieved something which I never thought I could. That is indeed my pride. This kind of things can’t be mention online right?

8. Gadgets wise.
Not enough space on table to put. Maybe buying another table? LOL.

9. Health wise.
Trying to get rid of my wisdom tooth. Sigh. Fear of dentist is implanted in the brain like microchip. Otherwise, back pain occasionally for all the bending downs during writing and sole pain for all the walking. Not plantar facitis thou.

10. Work wise.
Changing new department. So it is a whole dumb ass growing up story again. But hopefully things turn well. I do have some idea about what I want to do or what I would prefer to do but like I always say, sometimes we try with our luck, and the government determines the rest. I hope I wouldn’t end up in some ulu KK or what few months down the road, so I’m really gonna cherish my housemanship life now. Rocking with babies next posting. Very geram if they don’t cry. LOL. But I wouldn’t know if i can handle the ’symphony’.

11. Traveling wise.
Only manage to go to Vietnam and some of the other local attractions this year. Well. I don’t mind. Some how the back packing idea is totally out of my mind and I can’t believe what I did when I was touring europe in Russia. Walking around in backpack in another place feels very foreign to me. Maybe because I hate walking so much during work that I hate walking totally. Or maybe all I need is a new pair of nice walking shoes.

My world-dominating plan.

Next year would be a year of staying cool (is it even possible?). Things that would definitely happen is me changing from a HO to a MO. Well. Hope that works out smoothly. Other wise, no any bombastic traveling plans, no gigantic money consuming dreams that I need to achieve for the time being except that changing a car (depends on the automobile market it is).

And very importantly, to stay safe, and patient, and alert.

The word that I would need the most for next year would be…

Patience.

And hopefully next year will be even a more bombastic year. So in summary, I’m happy with being me this year. Well done.

Had this BBQ session with my colleagues few weeks back. It reminds me of BBQ-ing in Volgograd!

Because I saw familiar faces as well. Haha.

Ain is very hardworking and very serious about serving people food.

Just part of all who are present. These will be those food lovers who can’t get away from the food.

From evening till night.

And the real dish is up. But too bad I gotta drive back for night rounds (which is almost 30-40 mins drive from Pantai Puteri).

Games were played but too bad I wasn’t there. New plans about going to Bukit Tinggi coming January so awaiting to see what it will turn out to be!

I was observing a delivery today in one of the delivery room. Had a bad headache since morning, and on top of them, having some mild URTI.

Decided to stand out of this delivery due to my condition. So I passed the chance to the other staff nurses to conduct the delivery. Was a bit worried for this mother as she was shouting for pain for quite some time already. Decided to give her another dose of analgesia but was happy to find that the os was full. A hunch for VE.

The process was interrupted when another staff nurse came calling for doctor. The other patient few rooms ahead who came in some time ago also felt like pushing.

As usual, have to attend anything that people inform.

The headache was killing me.

When I reached, the mother was in her right lateral, trying hard not to push. So I wore my gloves, and told her to be in the proper position. A quick glance at the CTG shows quite a normal tracing.

I pulled the cloth over and try to tell her to stay calm. She slowly parted her legs. It was almost like slow motion.

And guess what I saw?

CORD. IS THE CORDDDDDDD…. Dangling there outside of the vagina!

This is the first time I saw cord prolapse.

I put my finger in while trying to push the cord back and prevent any compression. And I turned and shouted my MO’s name. LOL.

Then all hell breaks loose.

People come running. Bla bla bla bla.. And MO took over. All very excited (getting excitement just like how my consultant surgeon always say), gelabah and rushing like mad. Elevate lower body, insert CBD, fill up the bladder and etc. I guess the patient didn’t even understand why we were rushing all of the sudden. (Thinking back now, it was a bit hilarious after all). First MO practically ran to OT to standby, another one took over my position of putting her hand in. They pushed the WHOLE bed out of the room into the OT. LOL.

Caesar done stat.

(And deep down inside I was thankful that there was an assessment before I can oncall and another one on the 2nd month in O&G because that’s the time when I sit down and read and cord prolapse is always one of the emergency topic in front.)

That’s the excitement I had today, for being 2nd day of labour room in charge. This job is seriously tiring. Maybe I’m still new to all these but I think each deliver is still unique. You will never know what will happen. There can be multiple endings, and all we can do is anticipate, be careful and alert.

This job seriously need good knowledge since people are dealing with 2 lives at a time (well which one is not?).

Think this is still better than being in the ward, it is always cool to see something cool. But bad for the baby thou, heard that he/she is intubated in nursery. Will update tomorrow.

Will still be at the 3rd point. Diagnosis and management.

Well. I talked about the ‘tagging’ period in the last post. It will be the short time where you learn as much as you can so that you can more or less become independent instead of looking for help for the smallest thing.

In order to help in the process of oncall, guidelines can be very useful. For example, bring along your Sarawak handbook when you go oncall in Medical department, or some other form of notes and handbooks so that if you are in doubt, you can always check. And it helps when you have no idea at all. Well, a better guidelines would be one of the more senior houseman in the department as they by that time would know more and could offer better help, rather than you diving into the thick books looking for clues.

You will get the thing going once you started to clerk cases. So you should start early! Proactive definitely pays well.

Now, after you have done with the clerking, and manage to come out with a more or less usable management and investigations that you want to carry out, it is time to move on to another important thing that you shall be prepared for mentally - to inform.

4. Art of inform

This is an art, I think, because I’m still learning as well. The main point is you can’t go calling your MO saying ‘Dr. X, a patient is collapsing and please attend her now, I don’t know what to do!’. You might be smiling at what I write now but trust me, you can be so adrenaline-pumped or scared when people are theoretically and practically going into distress right in front of you.

Inform of this kind would definitely be fired back by sinister remarks or tone and you will know or your MO will make you know that you can’t be that stupid ass informing a case like this.

At this point if you think you are too scared to inform, the best way is find another HO to help you. If you made the decision that you will be the one informing, then first thing you should do is stay calm.

And then look at the case sheet, find out what the patient’s problem is. Quickly flip thru and pick up as much info as possible (those important ones), for example you wouldn’t need to read much regarding her family history of hypertension when she is having SOB in front of you. And then pick up the phone, with the case sheet in front of you (so as if they ask you any question, you could easily flip and look for answer), and present the case just like how you see HOs present their case in the morning rounds. It starts with age/sex and their main problem.

Most of the time the MO will give you a plan. Maybe a list of things you have to do or maybe he will say that he will come and review the patient himself.

The next important thing is, document it down! You will have people reminding you about documentation as long as you are in this line of work. Documentation is king. Write down that you called up MO Dr X, roughly wrote down the details that you mention to him inside the case sheet itself and mention what plan he gave.

An example of chronological order of somebody informing you something would be:

It will start with a nurse informing you that Patient Y’s BP is 200/110 (for example :P)

After seeing the patient and reading the case sheet. You have to document it down! It will look like.

“13/11/10 Informed by staff nurse that patient having high BP 160/90. Attended stat. Pt is having mild giddiness and headache. Claims taken medication according to time. O/E patient looks well, fairly comfortable, alert, ambulating, hydration fair, not in pain. Reflex normal. No clonus. Repeat BP manually - 150/80. Plan: to inform MO, KIV for T. Adalat 10mg stat.”

That would roughly be the documentation if you are in O&G dealing with PIH patient. Most of the high BP should be informed.

(short forms - BP:blood pressure, KIV:keep in view, PIH:pregnancy induced hypertension)

So after that documentation, you pick up the phone and called up the MO to informed the case. Usually at this time, they would ask you what medication they are on, when was it served, whether patient is symptomatic and etc. After spoken to the MO, your documentation would be:

“S/T Dr X, case informed, patient symptomatic, on T. Aldomet 250mg tds. Plan: to serve T. Adalat 10mg stat, repeat BP 1 hour later.”

That would conclude your documentation, a prove that you had attend to the patient and a prove that you looked for help and a solution to the problem.

To be continue…

It had been quite a long time since I wrote something beneficial. Too many traveling pictures and lousy posts all over. Well, being a HO in Malaysia Health system means that one is actually quite at the bottom of the whole pyramid, and we are all constantly trying to learn more and sometimes forget to help others who are also in the process of climbing up the ladder.

That, inspired me to write this post, for all those juniors out there who just started working or going to step into working world, these are some points that I would kindly offer as advice and help.

For me, oncall is one of the many things that separates the health profession from others. People would think that being ‘on-call’ is just like switching your phone ‘on’ and allowing people to get to you when there is a problem. Well, technically there is some truth to that statement but the only thing that they don’t know is that problem happens ALL the time, and you (most of the time) CANNOT give an instruction over the phone.

I think I’ll start with the few simple tips before going to more important ones.

1. You know you will be hungry during midnight.

It might sounds stupid but that’s the first thing I encounter when I had my first oncall long time ago. It was a busy call in the medical department. I didn’t prepare any food for the call that night and end up getting really grumpy and hungry when the night gets late. I wasn’t smart to note the time so when I finally had time to eat, all the shops in the hospital were close and I end up eating nothing at all. Terrible experience.

So, stock up some food and drinks, a bar of chocolate or something, and you wouldn’t be too miserable. Not getting any sleep is bad enough. You wouldn’t want your stomach to suffer at the same time as well.

Sometimes the ward nurses will have people going out to buy them food and you can always ask them for an extra portion if they are doing so.

2. Scopes

On call in different departments have different scope of work. Sometimes even oncalls of the same department will distribute their work differently. There are people who will be allocated for Operation Theater calls, those passive calls in wards who manage the in-patient, those active calls in wards who clerk and settles with the new patients. And of course sometimes they have the male calls and female calls as well.

So, get to know the system early. Find out what you are suppose to do and what is the scope of your job. You have to ask your seniors about this.

3. Main bulk of work. Diagnosis. Management.

Same here. What you will do differs from one department to another. This is the main bulk of work, the things that you spent 6 years of med school to learn, the cultivated scientific brain.

Different hospitals have different way of working but in this case I can only tell you about how things are done in the hospital I’m working at.

First of all, before you start oncall, you would surely need to finish this period of time called ‘tagging’. During this period of time (can be 1 or 2 weeks), you will start to learn how to function as a houseman during normal working time (6.30/7am - 5pm) from the other ward housemen where you will be allocated and your working time stretches till 10pm or later in order to learn what the oncall housemen do when it is off working time.

The very first thing that I advice you to pick up is how to ‘clerk’ a case. Well, ‘clerking’ a case can be a very fresh and new understanding for a lot of overseas graduate. We say you ‘clerk’ a case, meaning you engage with the patient in conversation to get information, and then proceed with your examinations and later on come out with a diagnosis, and investigations that you want to carry out in order to prove/rule out your diagnosis and subsequently a management plan.

Bare in mind. There is a system/chronological order of what to ask, how to ask, and what to ask first and how to write them down. THESE all you gotta learn from your senior. And since it is a ‘monkey see monkey do’ thingy, I advise you to try to learn from the good ones :)

Once you familiarized yourself with the concept and documentation style and is now able to ‘clerk’ a patient, try to practice it. Try to utilize the skill and try to be part of the family (as in help out your other houseman) during normal office hour. That way, you will know what you do is right and what you do is wrong. You will come to know things that you need to ask, and information that you have to have when patients presented to you with certain illnesses. It is okay to do mistakes because that is how we all learn.

Next, get yourself used to blood taking, branulla insertion and documentation. Try to learn the plan of management for common illnesses which you will surely utilize during your first call. How hard you work prior to your first call will definitely determine how your first call is going to be (whether you will be shouted at for doing some silly mistakes, doing something wrong, or worse - cause some unrepairable damage).

To be continue…

Even thou surgical posting is of harsh trainings, there are certain moments which I enjoyed. First of all, it is because of the tds rounds that we do so frequently that we know our patients better. And it is because of the tds rounds that we see our colleagues more than anybody else in this world. We share the same sofa or bed when there is time for a short rest, we share the newspaper when we need to keep ourselves up to date, we help each other out when there is a problem (well, if you make urself worthy as a member of the team, if u understand what i mean :P ).

There are also moments when our forever serious bosses accidentally cracked some jokes. Hopefully I got to remember most of them.

Specialist : Did you did per vaginal examination?
HO : Ops, I forgot.
Specialist : Do one now.
Moments later.
Specialist : So what is your finding?
HO : No discharge, no tenderness blablabla…
Specialist : So is there any bleeding at the cervix?
HO : No.
Specialist : Are you sure?
HO : *Looking unsure*
Specialist : Your finger got telescope ah.

Hope that the one involved is not reading this. Hehe.

And there was the Hb 7 point something story. Will upload the pic up next time. :)

I strongly as in STRONGLY think that I’m not fated/fit for end posting leave.

During my first end posting leave, I end up sick and gotta take all those antibiotics and stuffs, down with bad cough until my colleagues suspected TB and etc. Even took culture for my sputum but luckily turned out to be negative for any serious bug.

My second end posting finished with yet another even worse experience. I traveled to Vietnam and I fell sick there! Down with 3 days of high grade fever with only Panadols. Came back with an unresolved diarrhea and only to get well after few days of work! Siao!

And now I’m in my 3rd end posting leave. I was careful but this time I had a big ulcer at the edge of my lower lip and most dreadfully, an ulcer under my tongue! Never had any ulcer on my tongue before okay! And how come THIS time it has to be there! Even thou it didn’t take away much holiday mood (not like I’m going anywhere for holiday) but it takes away my desire to eat good food! As in I’m not happily eating away during my birthday and blablabla. Even at home when my mum tries to stuff me with some good stuffs I still can’t really enjoy much lah. How to chew properly. And to think that it is only starting to resolve today (a day more and I gotta start work). WTF!!

I still feel a bit lucky that it is not a fever this time. Duh..

Hopefully next end posting I’ll be healthier. Or maybe working keeps me going. And rest makes me sick? OMG.