Housemanship: Finishing Paediatrics

Inshallah I’ll be finishing paediatrics in 3 weeks on 6^th of July. My next posting gonna be Obstetrics and Gynaecology (O&G). Finishing paeds means I have 1 more year to finish housemanship. Still long way to go. I hope I can grasp as much knowledge as I can before being a medical officer. Scary much thinking of being just me during oncall. “anxious face.jpg”

Well, first time is always the difficult one. Every time entering a new posting, most of the time I would be a clueless little kid. I would go attach to seniors asking here and there. First day in paeds, I remember I reviewed a neonatal jaundice case. It’s just a simple case actually, but for a first timer, I kept on asking my seniors questions like,

      1.      What is the significant of asking about feeding history?
2.       If the mother’s breasts still feel engorged after breastfeeding, what does it means?
3.       How to calculate total fluid per day?
4.       How to look at the total bilirubin chart?
5.       How do you calculate intensive phototherapy?

And many more.

On my first day, I learned how to take a newborn blood. It was hard at first, obviously. Day by day practice, alhamdulliah it is manageable. When things get hard, there’s seniors, akak staff nurse and sisters, just call their names, they’ll surely help. In adult you can feel the veins very prominent, in newborn, I just depends on my eyes, but this akak-akak staff nurse I tell you what, they’re very good, I didn’t even see any veins, they just poke and walla the blood flows fast! Not lying. Even MOs sometimes ask their help to insert art-line. Art= artery.

Tagging period is always the exhausting ones. Everyday going to work 7am-10am , one off day. Need to study for off tag some-more. I worked 9 days straight during tagging, it was tiring. The only thing  in mind when reaching home is SLEEPING,  I need to squeeze in some time to study for off tag. The first session was the worst. Thank goodness, my MO give me another chance the next day and I nailed it ha-ha. I think in paeds I studied a lot more than my two previous postings, ya lahhh got 6 assessments in total, no time to play. 

My first time assisting long line insertion and UAC/ UVC insertion, I need to look at my notes while preparing the stuffs for the procedures. Hmmmm now I guess I remember 50-50 kot ha-ha. It was fun in NICU. During oncall, the scariest thing ever when intubated baby suddenly desaturated, and when labour room calls for baby flat! Adrenaline rushed. I ran to labour room. Glad when I came in the baby already crying.

In NICU, the most important topics that we (house officers) should know are:


 -         Neonatal jaundice
-          Neonatal sepsis
-          Neonatal hypoglycaemic
-          Fluid management in newborn
-          Premature babies

These are the bread and butter in NICU, which frequently asked in assessments; off tag, mo, theory, and specialist assessment. 

Usually they’ll give you a situation like,

Day 5 of life, referred from KK Sungai Mati with high bilirubin level. TSB 305 (after x17). Birth weight 3.4kg, current weight 3.32kg.

First we start with taking a full history; ask regarding the jaundice itself, the risk factor and causes of jaundice, detailed feeding history, rule out any family history of blood disorder and liver diseases. Next, proceed with physical examination. Look for the causes of jaundice eg; cephalohaematoma, signs of sepsis, the level of jaundice, then signs of acute bilirubin encephalopathy.

They’ll give you answers to each of the questions which will lead you to the provisional diagnosis. The next questions would be investigations and management. Usually it won’t be a straight forward case. It can be a baby came in with neonatal jaundice (NNJ) develops fever during admission or any signs and symptoms of sepsis. So, you have to take all the septic workout and start antibiotics.

I have seen a baby with NNJ developed fever and behavioural changes during admission. We diagnosed her as presumed meningitis. We did lumbar puncture and started antibiotics that covers central nervous system (CNS).

Some questions need you to calculate total fluid required per day, feeding and IV and type of fluid required. 

Other cases that I’ve seen in NICU include: 

      -          Respiratory distress in newborn
-          Congenital heart diseases; cyanotic and acyanotic heart disease
-          Persistent pulmonary hypertension in newborn (PPHN)
-          Hypoxic- ischaemic encephalopathy (HIE)

I had fun in NICU. Throughout my time in NICU especially when MCO started implementing, there were many premature babies, and there were 3 sets of twins admitted. And today I heard there’s a set of triplets babies! Wow! I always dreamed of having twins 😊 I know it’s already tiring with one baby, imagine having 2, double the tired anddddd double the fun!

After 2 months in NICU, the ward rotation begins. I was shocked on my first day in ward. Wow, so little patients, just a single digit. Usually before MCO ward is full with patients, up to the point they need to put extension beds in the TV room. Now we rarely seen bronchial asthma, acute bronchiolitis and pneumonia patients. I’m glad during my tagging period as MCO hasn’t started yet, we could see the mentioned cases. Like everyday theres new admission.

We talked about NICU common topics, now the bread and butter in ward are:

-          Respiratory cases; bronchial asthma, acute bronchiolitis, pneumonia, epiglottitis even it is rare need to know to differentiate it from croup
-          Gastrointestinal cases; acute gastroenteritis, food poisoning, dysentery
-          Seizures; febrile seizure, epilepsy, meningitis
-          Renal cases: nephrotic syndrome, nephritic syndrome, urinary tract infection

Apart from that, we need to know regarding shock. For example, patient with AGE with severe dehydration can lead to hypovolemic shock anytime.  

If you were assigned to day care, you can see thalassemia cases.

Same as NICU, the bread and butter cases surely will be asked in MO and specialist assessment. As in my case, I was asked regarding asthma, and seizures secondary to brain abscess.

When talking about paediatrics, not to forget neonatal resuscitation protocol (NRP). There is specific exam for it, anddd specialist will ask you during assessment. My suggestion read the 300 pages book. It tells you the steps of NRP in detailed manner clearly. I like that book. In fact I love it! Ha-ha. Easier to understand. I read it during 1 week quarantine in Pagoh. Yasss all the house officers in Hospital Muar needed to be quarantine for 1 week in the early April. Have you heard about Hospital Muar cluster? Alhamdulliah, its over already!

With that, I end this post with,

Bye :p

Picture taken with mommy's permission. 

speaking about sexual assault in childhood

It was the morning of my off day when I texted my friend to ask regarding a new scan case admitted to our ward. It was my first time. One of my friends, doing an amazing job in digging the crucial information from the child, in which the child could describe each of every event in a detailed manner.

“How’s the siblings? Got molested too?”
“Ya, from the history”

Seriously man? It’s a young kid we’re talking about. They got sexually harassed by a known person who is closed to their family, someone trusted by their parents, in their own house, and it has been happening for multiple times until one night the elder sister suddenly asking the mother,

“Mommy, why uncle put his penis into my mouth?”

Disgusting right?! This fella is totally a monster!

Good thing is, the mother believes the child and lodged police report first thing in the morning and that crazy monster (you may insert any curse words that you have in mind) got arrested on the same day. May he rot in jail and of course the lowest part of hell! From the history itself, penetration had  occurred, evidenced by old tears over labia minora from the physical examination. 

I feel enraged, disgusted and disappointed.

What’s exactly in his head, what was he thinking?

In this case, I would like to blame the parents and of course the perpetrator himself. It was the parents at the first place letting the man to come and go whenever he wants and even got him a room to stay. You shouldn’t let a friend to live with you in a house together with your wife and daughters, even how loyal and trusted he is. Most of the rape/ sexual harassment cases occurred is done by a known person; they can be a close family member like your own siblings, your in laws, your father, grandfather, uncles, or even cousins. There should be a limit up to what point we can allow a friend to mingle with our personal life. 

Most of the time, the child would remain quiet. When asked they’ll say because the perpetrator threaten never to tell anyone or else something bad will happen to them. Now, what can happen to a child after multiple episodes of sexual harassment?:

1.       They might show some behavioural changes. A child who’s previously cheerful turning into an introvert, they keep quiet, socially withdrawn from others. They might show symptoms of depression or post- traumatic stress disorder (PTSD). Some may develop fear to the opposite gender, even to their own family members. They might having sexual related psychiatry disorder later on in life.

2.       They might grow up thinking this kind of thing is OKAY. Especially when they’re asking for help but no one believes. In some family where the guys are the solely breadwinner, the other woman in the family tend to keep quiet, because what they have in mind is “if I lodge police report, what will happen to our family, he’s the only one working, if he’s going to jail, no one’s gonna provide us food, money, shelter ” No report done, child keep on getting harassed sexually again and again up to the point she thinks this is OKAY. When she gets into high school she might doing it with her friends.  And… another problem raised, teenage pregnancy.

Scary isnt it?

This is why SEX EDUCATION is important.

However, it is still a taboo in our society.

Well, actually sex education isn’t just about practicing safe sex. It’s wayyyyy more than that. It’s about:

1.       Human development including reproduction, puberty, sexual orientation and gender identity

2.       Relationship including families, friendships and romantic relationship

3.       Personal skills like communication, negotiation and decision making

4.       Sexual behaviour including abstinence and sexuality throughout life

5.       Sexual health including sexually transmitted disease, contraception and pregnancy

6.       Society and culture including gender roles, diversity and sexuality

Above is the picture on how we can protect a child.

What we can do are:

-          Tell them there are parts of their body that cannot be touched by other person. Chest, genitals, inner thighs, buttock. If someone touches it,  tell them to tell the parents, if parents not around, do shout and call for help. Teach them to remember their name, parent’s name and phone number and if possible home address.

-          Do not let them sitting on other people’s lap including our closed family members. It’s a no-no. A pervert can anytime slide their hand towards the forbidden areas.

-          Start separating them from the siblings of different gender. Do not let them sleeping together in the same bedroom.

-          Train them to be brave to speak up. Anything wrong happened, do not hesitate to tell, and as a parent, we need to be all ears and trust them.

-          Do not change clothes in front of them. Teach them to knock the door first before coming into parents room, and parents need to lock the door so they child won’t see things that should not be seen.

-          Get to know the people in children’s life. Know who the child is spending time with, including other children and adults.

-          Choose caregivers carefully. Nowadays, even babies being raped by the family members of the caregivers hmm. What a bunch of sick people!

Indeed, it is not easy to raise a child.
Surely, it takes a village to make it work!
And everything starts from home.


.

would you trade money for health?

“Makkkk, sakit makkkk. Adik dah tak tahan dah mak, asyik masuk hospital je. Tolonglah ya Allah sembuhkanlah penyakitku ini ya Allah, aku dah tak sanggup dah ya Allah nak tanggung semua ni. Tolonglah ya Allah”

Her scream filled up the procedure room while we were struggling inserting an IV line. Suffering from a chronic skin condition; chronic atopic dermatitis also known as eczema makes her skin thin and fragile that even a slight touch of breeze could make her life difficult. She was diagnosed with this condition since the age of 3. Since then, there have been multiple episode of relapses and hospitalization. Up to this year, almost every month the relapse occurs. The culprit can be anything, food, going outdoors, wind, sweats, dust you name it and this time around we assumed bacterial infection since she’s having a high grade fever, thus we started her on IV antibiotics and 3 day course of hydrocortisone.

It was hard enough to get an IV access. She couldn’t straighten her limbs especially when the skin are too dry. Most of the time, she would flex her elbows and knees. Eczema usually affects the facial and extensors area in early childhood. As the child becomes older, the pattern frequently changes to involve flexors area, up to the point when it is too dry, it causes so much discomfort and pain to extend the limbs, in which if remain neglected may result in contracture.

To tell you the extension of the lesion, it’s involving the whole body but palms and soles. Generalized dry skin with some area of raw skin, scratch marks, fissures and desquamation. I reviewed her the morning she admitted. While waiting her taking bath as I stood still beside her cardiac table, I could clearly hear her screaming and shouting and crying in pain from the bathroom. It was unbearable. It must be very painful the moment water meets her skin. Imagine having a small cut over your finger and put it under running water, it stings right. Now imagine, the cut area is extensive to the point it involves your whole body.

Google Image 

She’s small, she’s 9 yet looks like 6, probably due to ? malnutrition as a result of allergic reaction to many kinds of food? To compare  her to other kids of the same age, she’s matured. The way she speak tells a lot. She's got a lot of wisdom. 

Being a doctor, I get to see patients every single day except on my off day obviously. Whenever I'm seeing a chronic patients, makes me wonder how strong their mommy are, it must be hard seeing your child sick. Some mother needs to quit their job to take care of their children especially those requiring long stays in hospitals and frequent admissions to ward. Okay, it doesn't matter whether the condition is acute or chronic, the one sick is young or old, as long as it's your family members, of course it worries you much. You would do anything to ease their pain. If people could trade money for health, of course they would do it! No one wants to see their loved ones suffers. 

We would do anything for our loved ones. 

For every patients that I meet throughout my career as a medical doctor, I pray that Allah protect my family members; my parents, siblings, spouse and future kids, from any harm and diseases. I'm afraid I might be too busy taking care of other people's family that I forget to look after mine. I believe if we have good intentions, we ikhlas in doing our jobs, inshallah He will surely help us facing any obstacles in life. 

Inshallah.