oncallz

Probably one of my best call last night.

Bed sore grade 4. Ha-ha! No new case overnight, all patients were stable and I get to sleep well till 5 in the morning, just 2 blood coming morning to be taken. Alhamdulliah, what a wonderful night! 

This is my third call in orthobots. 

My tens call as a doctor, cannot remember dah how many. 

But I can still remember my first night call, disaster! 

11 cases overnight, there was unstable patient in acute, on NIV settings, desaturated. Called for my mo, and he's busy, so I just managed whatever I could, and alhamdulliah nothing worst happened. Blood coming morning hmm, I like almost all patients in the ward, blood had to be taken. The most difficult and irritating part in blood taking is when you gotta take blood from chronic illness patient plus very old one. Susah sangat. Especially in ESRF patient, then need to spare one limbs, while the other already bruising everywhere, veins collapsed, the only thing you can withdraw from is from the artery. And it is DAMN PAINFUL man. I tell you, because you just poke blindly into the area which you feel the pulse most palpable. I like to take from radial pulse and brachial. If it is damn too hard, my next and last resort preference would be the femoral line. 

That night, most of the new cases were pneumonia. So...when there is infection going on, we need to take blood culture and sensitivity, done under aseptic technique, need to wear apron, sterile gloves, need to maintain the sterility lah if not the result will be affected, because the blood already contaminated. I took a total of 7 blood c&s overnight. Blood gases pun banyak. I went back at 3 pm the next day. Barai nak mati. Not lying. My oncalls in medical were eventful in which no time to sleep or chill a bit T.T My highest number of new cases overnight was 14 hmm...

Jonah. 

It is not a medical term. I dont know where does this word come from. Jonah used to describe someone who has the ability to turn things from calm and chilly situation into a rainstorm. Like when the person come, a stable patient suddenly become unstable, desaturated requiring high flow oxygen, or worst case scenario, CPR need to be commenced. A chilly ward suddenly a flood of new cases come. Whenever you feel like you're free, dont ever express it, wow so chill lah no patients, freenya, rasa boring pula. Dont ever say that. Out of no where, all of sudden you dont even have time to sit! Ha-ha. Seriously! 

My oncalls during lockdown paling heaven. Few or zero admissions. Most of the time can lepak and tidur. Yelah siapa je taknak oncall yang chill chill kan? :p However, no matter how well I slept in the night, I still feel sleepy the day after, sooo every post night I will sleep! At least 2-3 hours pun dah already enough for me. I dont need a long nap pun. 

One of the best thing here we can request for off day before or after night call. Some days I would prefer my off day prior my oncall, some the day after. Thank God, in my hospital we get a solid day off weekly. I heard there are some hospitals dont allow their houseman to get a solid off, their reason, not enough staffs. Hmm. No commentlah.Whateverlah, yang penting our hospital give us a solid day off :) 

I would recommend those who are currently waiting for housemanship, come do your ho-ship in Muar, sebab best sangat, just joking ha-ha. My advise will always be the same, choose the one that is close to your family. Apa- apa hal senang, because housemanship is a tough time, you really really need a good support system, and having your family close to you is a bless. 

Nanti-nanti, 

:) 

deep thoughts

Fast forward 3 months, currently I'm in my 5th posting, Orthopedic, which leaves me one more posting to finish housemanship. Almost a month in orthopedic and I think I have totally adapted to the system in this department. Still missing O&G sometimes, I miss the smell of newborn, just freshly out from their mummy's womb, I miss being part of the beginning of motherhood, I miss the smell of liquor too ha-ha, the sound of baby's heart beat, the anxiousness whenever seeing there is a deceleration in the CTG, the excitement to cheer the mother to PUSH! PUSH! Sometime, when I look myself few years later, I'm seeing myself as an O&G medical officer, some other time, in an alternate future, I'm seeing myself as other than O&G doctor, maybe psychiatry, or working in Klinik Kesihatan. When I think I have made my decision to be in O&G team...suddenly I feel like am I suit enough to be one? 

It's okay, still have plenty of time to think. 

Now let's talk about wedding preparation. 

To be honest, I'm worried the wedding might get postponed. Look around, the COVID-19 cases keep on rising, up till yesterday the cases was 1400++. Of course as a woman I have my dream wedding. Even if the government allows only up 100 guests to be at one time, we would take that chance and do the ceremony. The problem is that, if, if the government make the rules NO GATHERINGS INCLUDING WEDDING on the date we have chose to get married, then only the solemnization would be held. The wedding? Postpone until the date to be determined later. What worries me is that what if it get postponed to months later and we were no longer in the mood to hold the wedding? 

If only the solemnization allowed in February, no wedding, I pray that we have the chance to choose the venue, and please be it HOME. Just please, so that I could have a mini wedding dais, so that we could take photos together with our families and loved ones for our own keep later. Ameen ameen inshallah. 

I agree with the fact that COVID-19 is surely a test to us all. 

Many loss their job, no money to put food on table, to keep the roof over their heads, some loss their family members due to this pandemic. I really really hope 2021 would be a good year. 

Now we are already in December, with the case shows no signs of improvement, I mean look at the numbers, everyday it is more than thousand cases, so my question is would 2021 be a good one for us? 

And the answer, 

Only Allah knows. 

Let's pray for the best

May Allah grant my prayers to get married and hold a wedding ceremony in February 2021. 

Inshallah. 

:) 

housemanship: 2 months in obgyn

2 months in OBGYN. Feels so fast. Tak sampai sebulan kena obstetrics ward, now dah turn gynae ward. Masih lagi banyak taktau. Masih tak pandai nak jahit episiotomy wound, aku macam tak boleh nak imagine macam mana nak dapatkan bentuk asal yang cantik lepas dia dah jadi macam tau fu fa. Datang kakak midwife, wow macam tak pernah beranak! Haha cantik je jahit. Experience matters in surgical based posting ni. What to expect from someone who just 2 months in obgyn? Lepastu bukannya hari hari sambut orang beranak and menjahit pun. 

My oncall last night was so eventful. It was my first time in charged labour room during oncall. Lepastu time tulah full house, then CTG semua nak poor tracing siap insertkan internal CTG lagi and then boleh tercabut pula because the patient was toooo restless! Primid. First time experiencing contraction pain. Must be tooo damn painful lah sampai dia pun dah macam apa tak keruannya. Yelah aku manalah pernah rasa. Since labour room kicap habis, 2 patients terberanak dekat ward. SO JONAH LAH. Ya ampun. 

My anti jay didnt work last night. Usually I can sleep during my night call, at least 15 minutes lah, but last night didnt even have time to scroll instagram! Ha-ha. Glad there were medical students help us throughout the night. They timed the contraction, open up the delivery and VE set, jaga CTG. Kalau takde diorang, aku taktaulah apa jadi dekat aku malam tadi. 

Hopefully ke-busy-an dekat obgyn ni menolong aku untuk mendapatkan bentuk badan ideal sebelum kawin hahahaha. Makan pun OD je sekarang. OD = once daily. Breakfast- lunch- sekalikan dengan dinner terus. Tak menyempat langsung bila dah berkicap sangat tu.

And I just had my first CBD few days back. The question was. 

26/ G7P6, unsure of date 

Unbooked, unscreened

All previous child were homebirth.

Brought by husband unconscious, you are MO in district hospital without specialist, what is your further management. 

I had thought block at first. 

This is a case of maternal collapse with perimortem Caesaren section.

First thing first, assess patient! 

Vitals unrecordable. Pulse not palpable. Start resus, insert two large bore branula, take blood for investigations, start fluid resus. Intubate patient, commencing CPR. No signs of bleeding. Uterus at 28 weeks. Scan, no retroplacental clot BUT FETAL HEART ABSENT! You are the team leader, you need to give command to your team. While CPR ongoing, see patient;s husband, ask regarding the event prior to the incident. Turned out husband taktau. He said bini okay je tetiba tengok dah tak sedarkan diri, tak pernah ada sakit apa- apa pun sebelum ni. 

I was asked regarding how to do CPR in pregnant lady. 

3 mins CPR, still no signs of life. 

Update specialist oncall. 

Proceed with perimortem Caesarean section. 

Tetiba specialist punya kereta tak boleh start pula. Kaulah yang kena buat caesar dekat ED tu. Bagitau husband, just verbal consent, no time for signature semua, the golden hours is 5 minutes. 

From RCOG Maternal Collapse: 

The concept of perimortem caesarean section was introduced in 1986,61 along with the recommendation that it be initiated after 4 minutes of maternal cardiopulmonary arrest if resuscitation is ineffective, and be achieved within 5 minutes of collapse. The rationale for this timescale is that the pregnant woman becomes hypoxic more quickly than the nonpregnant woman, and irreversible brain damage can ensue within 4–6 minutes. The gravid uterus impairs venous return and reduces cardiac output secondary to aortocaval compression. Delivery of the fetus and placenta reduces oxygen consumption, improves venous return and cardiac output, facilitates chest compressions and makes ventilation easier. It also allows the heart to be compressed easily through the diaphragm against the chest wall by placing the hand behind the heart (with the diaphragm closed) and compressing it against the posterior aspect of the anterior chest wall. This improves cardiac output beyond that achieved with closed chest compressions

Once kita keluarkan baby, cardiac output mother will improve by 60 %, dengan kuasa Allah, mak boleh revive, hidup semula. The c-section tu kena buat while cpr ongoing. Bayangkan in that situation. 

Unfortunately, the patient passed away. 

And actually this is based from true story experienced by my MO masa dia kerja dekat district. He taught me, masa first time jumpa husband lagi kena tekankan, 

"Encik, encik bawa isteri encik ni dalam keadaan yang sangat sangat kritikal. Secara perubatan dia dah tak ada. Kita dah start tekan dada isteri, kita nak cuba bawa dia kembali hidup. Kita akan buat yang terbaik" 

 

Kena bagitau husband yang dia bawa isteri dah nyawa nyawa ikan dah, but dengan empathy. Pemilihan perkataan tu penting. 

"3 minit dah berlalu daripada kita start tekan dada isteri, tapi isteri masih tak menunjukan tanda-tanda hidup, jadi encik kita akan proceed dengan pembedahan untuk keluarkan bayi dan selamatkan isteri encik" 

 

Just verbal consent, dalam time ni husband pun akan angguk je apa-apa yang terbaik untuk isteri saya doktor. Not to forget, kena mention yang baby dah tak ada juga. Akhir sekali, 

"Encik, kita minta maaf, kita dah cuba yang terbaik. Kita dah tekan dada selama 1 jam, tapi kita tak dapat selamatkan isteri encik. Saya minta maaf ya. Harap encik bersabar" 

 

This all things kena document elok-elok. Obgyn is all about medico-legal. Benda yang kita tulis hari ini mungkin masuk dalam court 10 tahun nanti, siapa tahu? 

Okaylah, macam tulah assessment first aku. Nak kena prepare untuk assessment berikutnya and CME on this coming 16. 

Nanti- nanti:) 

well, I'm engaged!

Let's forget about Covid-19 for a while, well...I'm engaged! 

To the same guy I keep on falling in love with each and every day since 9 years ago, 9 years and almost 7 months to be exact :p 

Yup, up till this moment we still wishing each other happy anniversary on monthly basis luls. 

Inshallah few months left before our solemnization. 

May Allah ease. 

Do pray for us. 

:) 

housemanship: OBGYN so far

3 weeks in OBGYN. 

Still new. So much things to learn. 

Had my first oncall last night. 

Alhamdulliah not so jonah :p 

Still able to sleep for a minute- two ha-ha. 

3 weeks in OBGYN so far. 

My first time conducting delivery of baby, I was scared to pull out the head. In the process of labour, after the baby had gone into the stage of crowning, baby will naturally rotate their head so that the occiput will be in line with the spine. Once the head already in position, we have to check for any cord round neck before pulling out the head, and then proceed with the delivery of anterior shoulder. To be honest, I still feel scared to pull out the head, afraid that I will break their neck. Because theyre so fragile. SO SOFT. The moment I saw the seniors did it, OKAY so the baby can just withstand the force ea? Wow. I did it softly haha macam mana kepala baby nak keluar? 

Now, talking about delivery of the placenta. 

The question is, what is the signs of placenta separation? 1. 2. 3. GO! 

First you'll see gushing of blood, second, lengthening of the cord and the fundus will look globular and hard. Once all these 3 appears, you can now pull the placenta out BUT in a controlled manner we call it Control Cord Traction. One hand put at the fundus, while the other hand pulling the cord in a gentle manner side to side. This to prevent uterine inversion from happening. The first time I did it, I was being scolded by the seniors "Tarik kuat sikit dik" hahahaha I was really afraid the cord would snap! Adoi-lah. Maciam-maciam. 

Vaginal examination. 

The patient will ask you, 

"Doktor jalan dah buka berapa cm? Lama lagi ke?"

The most important thing you need to differentiate between 3 cm and 4 cm. 3 cm still in latent phase of labour, can still admit patient to ward whereas 4 cm indicates its already active phase of labour, let's go to labour room! The baby's coming! 

For my finger, 

1 finger = 1 cm 

2 finger = 2 cm

3 cm I still feel tight 

4 cm ada lax sikit 

Yang lain tu agak-agak je ha-ha

Os fully = 10 cm is when semua dah lax, dah tak rasa cervical lip, kena pusing-pusing jari rasa sekeliling os tu. 

You know the first time I did VE I was confused between vagina and cervical os. Aiyoo. Vagina memanglah terbuka gitu, but cervical os you need to go deeper, and you'll feel another opening. Every woman's different. Some you just insert your finger je dah rasa (axial), some need to go deeper (posterior). 

Perineal repair. 

Still learning. The difficult part when there's too much tear. The moment akak nurse compliment me, "cantik dah ni dokter jahit" I feel proud kejap hahahahaha. Still need to improve a lot! Barang nak pakai lama kenalah jahit cantik-cantik. 

Cases that Ive seen so far; 

Most of the preggy ladies will come with, 

Leaking liquor, contraction pain, and show. These are the signs of labour. 

Hence, the common cases in clerking bay are: PROM - air ketuban pecah bila baby dah matang more than 37 weeks, PPROM- air ketuban pecah sebelum masanya which baby tak matang lagi <37 weeks, latent phase of labour, active phase of labour some datang dah os fully straight away we push to labour room, some tak sempat thus terberanak dekat clerking bay!, thereatened preterm labour, false labour, pre eclampsia, elective admission for induction of labour (IOL), postdate, hmm lagi apa ya? GDM kencing manis masa mengandung referred from KK for BSP optimization. 

Have you noticed I mentioned labour so many times? 

Latent Phase of Labour

Active Phase of Labour 

Threatened Preterm Labour 

False Labour

This brings to the favorite question from my superiors, 

WHAT IS LABOUR? 

When there is strong regular contraction, that leads to the descending of the presenting part, cervical dilatation and effacement and delivery of the baby and placenta. 

From the definition itself, it explains all the 3 stages of labour. 

These are the next favorite question after the definition of labour! Ha-ha. 

- So latent phase of labour is when the lady at term gestation (37 weeks and above), come with contraction pain mostly irregular and +/- other labour symptoms eg leaking liquor/show and the os is still 3 cm and below. 

- Active phase of labour, usually contraction dah regular, then os is 4 cm and above. 

- Threatened Preterm Labour, when the mentioned things above occurs in a lady at gestation <37 weeks

- False labour is when the definition of labour is not fulfilled.

- When the patient come with leaking liquor, irregular contraction, os closed it's either PROM or PPROM depends on the gestational age. 

Need to get the diagnosis right, different diagnosis, different management. In OBGYN the management is case to case basis, not solely from textbook. I have encounter some mother with premature gestation come with labour symptoms we didnt give IM dexa/tocolytic agent pun, we just allow the labour to progress. Tapi ni kes yang bukan severe prem lah of course, borderline prem dalam 34/35 weeks. So much things to learn and I guess I started to enjoy this posting. 

Hopefully I will survive this posting. 

Ameen ameen inshallah. 

Okay,

Happy fasting for those fasting today

& 

Happy Eidul-Adha people

:) 

housemanship: a year has passed

7/7/2019

My first day being a medical doctor.

I will always remember my first day. 

I was clueless. I was very slow. 

I was assigned to Ward 8 Male, which turned out to be an active ward that day. Meaning it was the busiest ward. I was in charge of cube 5, where chronic cases like ESRF, congestive cardiac failure, COPD, AEBA were in. I came at 5 am, it took me 3 hours to review 8 patients. It was very hard for me to digest things. I introduced myself to MO and Specialist during round, first poster, day one of life, please guide me. They convinced me, 

" If you survive medical, you will survive all" 

Post round, I needed to request for MRI brain. Heck no. Straight away fancy investigation. On my first day some more? How am I suppose to do this? With the help of my senior, I went down to MRI suite. Feeling clueless, I just watched him presenting the case to the radiologist, and granted. The next day onwards, I tried my luck and the moment they said "okay, bring the patient down" I felt like ACHIEVEMENT UNLOCKED. Ha-ha! 

Endorsing medications on PHIS were troublesome for me. Took me almost half an hour. Like I said, I was very slow. Next helliest thing was blood taking especially when boss ordered multiple blood investigations for just one patients, then you multiply by 3. I need to remember each colored bottle stands for specific blood investigation. For example, purple is for full blood count, HbA1c, coombs test. Grey is for fasting blood glucose. Red is for therapeutic drug monitoring. And many more. The minute boss ordered many blood investigations in one go, many times I had trouble to calculate how much blood I need to withdraw, and taking ESRF patient that need to spare one limbs- while the other limbs already had branula with drips/ drugs - and other veins already collapsed- which lead me to the last resort- I need to poke the artery- into account, I need S.O.S STAT.

Yup, my first few weeks in medical was hell. 

I didn't know how to manage my job-list. Blood taking STAT, requesting urgent imaging, tracing blood investigations, discharging patients, clerking new cases. I didn't even have time to eat! 3 days in row I ate nothing. Not lying. Because I seriously couldn't find time to eat. Multiple times I sought seniors help. Especially blood taking and branula insertion. It was hard. Some willingly offered their hands to help, some just ignored me. Many days I wake up feeling empty. I felt like how nice it is if I cant wake up in the morning, like let me sleep forever, I don't want to go to work. There were days I felt regret for requesting medical as my first posting. I felt like I am a burden to all since I was so slow. 

Nevertheless, I am grateful that I chose Hospital Muar to do my housemanship. My family is always with me. They were there on my gloomy days, I cried a lot. My parents woke up early in the morning to send me to work, and waited for hours in the car up till the middle of the night. Yeah on papers they said tagging is from 7 am - 10 pm, hell no! you can only go back after you finish all your jobs. There were days I ended up going back at 2 am, slept for only 2 hours, at 530 am I already came to work doing morning reviews. My parents sacrifices their time for me. My father never stopped motivating me every single morning while on the road to work. My grandparents prayed a lot for me too. 

Thus, my only tips to those who are currently waiting for housemanship, choose the one that is close to your family. No need to read reviews on this-this hospital. Just forget it. In any hospitals, there will always be shits, malignant seniors/ superiors that you need to face, so whatever it is you need to adapt fast to the environment. 

"It is survival of the fittest" 

It is my family and endless prayers from them that keep me going through this field.
And for that, I am thankful enough to Allah. 

Till then :) 

it's july already

Well, it's July already. 

Means it's just months away before forever begins inshallah :) 

Tonight will be my last oncall in paediatrics department, soon I'll be moving to Obs & Gynae where I will witness the tears and joy of giving birth to the little creatures. I am so nervous. It is the usual feelings whenever I'm moving from one department to another. Surely, I'll be missing paediatrics like what happened to previous postings ha-ha. Hope I will learn a lot. 

July 7 marks the first year of me being a medical doctor. 

It feels like yesterday I received the email for e-houseman, choosing Hospital Muar for my housemanship, the nervousness to start working, the anxiety every time waking up in the morning, felt so tired and exhausted at the end of the day but still need to get up the next day and be a full functioning doctor, sometimes felt like quiting and just do nothing at home, alhamdulliah I survived my first year. 

But still...a long road to go. 

3 more postings. 

Inshallah this too shall pass. 

Forever begins in few months from now. 

Please do pray for us. 

Feels pretty relieved now that everyone can hold their wedding ceremonies. 

Hoping the best for next year. 

Hopefully it is much more easier than the current SOP. 

Till then :)

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. 

housemanship: assessments

Well, I had passed all the assessments in Paediatrics a week before raya. There are a total of 5 assessments in Paediatrics.

1. Off Tag
Need to pass within 2 weeks of tagging. There are NICU and Ward topics. I remember I worked 9 days straight because I wanted to get a day off on Saturday so that I can see Shahrin but turned out MCO started luls. This 9 days of working really burnt me out, I hardly had time to study, eventually I made it. I sacrificed my precious sleep time, I burn the midnight oil. Paeds is a new thing to me. It is totally different from previous posting, I'm dealing with fragile one now, no silly mistakes allowed here.

2. MO Assessment
This one is usually after 5 weeks in Paeds. For NICU, I were asked regarding Severe Neonatal Jaundice secondary to Presumed Sepsis.
Day 3 of life, born term 40 weeks with birth weight of 3.5 kg, current weight 3 kg, came with yellowish discoloration of skin with TSB of 420. Looked lethargic, generalized hypotonia and inconsolable crying.
For Ward topics I were asked regarding Moderate AEBA secondary to Bronchopneumonia complicated with Left Pleural Effusion with underlying newly diagnosed Severe Persistent Bronchial Asthma. The second question was Right Cerebral Abscess with Metabolic Acidosis and Hypokalemia (causing the fitting episode). It was a case based discussion. My MO gave me the situation from the initial presentation and question me my next plans.

3. Neonatal Resuscitation Program (theory & practical)
I started my rotation in NICU. So of course when labour room calls for baby flat or standby, I need to go. This NRP thingy prepares us for things like this, step-by-step algorithm on how to deal with newborn, term and premature. I managed to finish the 300 pages book of NRP during 1 week quarantine in Pagoh. Thank goodness for the free time. During practical session, the MO will give us the situation and assess on how we manage the baby mannequin.

I get the question of 29 weeker, with weight 1 kg, born flat. And I forgot about the plastic wrap and the baby didnt survive. I nearly failed the assessment. Fortunately, the MO gave me another chance and I made it.

4. Theory
Just answer the questions lah, MCQ, subjectives and some calculations.

5. Specialist assessment
The scariest of all obviously. Cant believe I nailed it ha-ha. There were 2 parts mini cex and also case based discussions. For 10 minutes mini cex: abdominal system. I were asked regarding causes of finger clubbing, causes of hepatomegaly, causes of bilateral pitting edema, causes of hypoalbuminaemia, the pathophysiology of edema in nephrotic syndrome and congestive cardiac failure.

As for case based discussion, I were given the situation in which I were a MO in district hospital dealing with prem baby born flat. My specialist is a very detail one. She asked regarding anatomy of self inflating bags, she wants to hear every detail event in resuscitating the baby like how we connect the suction catheter to suction apparatus, how we make sure that the bag is functioning well, how we dilute the adrenaline and more. Same goes to the next questions of status asthmaticus, severe AEBA, she even asked me how to dilute magnesium sulphate. Luckily, I managed to catch a pharmacist prior and she taught me how.

Nevertheless, I had passed all the assessments. May Allah ease the rest of my days in paeds. 1 month more inshallah. Next posting shall be O&G ^^,

Till then,
:)

what happen in 2020 so far?

Cant you believe how quick this year feels like?

Ramadhan left us already and now Syawal has come, June in few more days, half way through 2020. From early this year the only thing that taking over the news and all is just Covid-19. It's Covid 19, not even Covid-20, man! You get me? Ha-ha. Now Covid 19 has already become like a norm to us. Everything wont get back to normal, the days before Covid, believe me it takes years to settle this pandemic. We will get used to it eventually. Now that MCO isnt as strict as the first time being implemented, I can see countless cars on the road, people already went out like it's nothing, we can even cross the states, provided we have a pass and a strong valid reason.

This Covid thing has robbed so much things from us, you name it. Freedom, jobs, families, well last time I went out for movie and shopping was in December. Wow that was 5 months ago! and I havent seen Shahrin for 7 months now. Miss him already. I'm glad I'm working in Muar so I get to stay with my family. Some people didnt event get to see their parents for a long time, didnt even get the chance to go back home for Raya. Some people lost their jobs, can no longer provide food on the tables, some need to face the lost of their loved ones, children can no longer get proper education from schools, big exams like SPM and STPM need to be dragged to a year ahead of unknown dates. SPM kids from the year 2019 should  have already by now get a placement in matriculation/ foundation/ A-level etc, yet they're still waiting. Gladly students from universities, colleges that had been stranded for months finally get to be sent home.

What else? Not to forget those who need to postpone their wedding ceremonies or worst case need to cancel it. The saddest part is when the MCO implemented few days before their weddings. If I were in their shoes I would cry to death. Imagine all the efforts, the preparations that they had made go wasted. Not only that, all the religious activities need to be stopped. No more congregational prayers. This Ramadhan feels so fast since there were no more solat tarawikh, no bazaar ramadhan, no solat hari raya. We cant go visiting our relatives during raya, that's our tradition.

The funny part is, this is the year we have been waiting since our childhood, while singing Wawasan 2020, we wondered how 2020 feels like, we imagined there are flying cars as in futuristic movies. Heck no. Other than this Covid thingy, minimum salary for fresh grads still 1.2k, houses getting expensive, doctors that are previously considered as critical jobs now are no longer critical, from permanent position changed to contract, just because I was born in 1993 makes me stuck in this kind of situation. You see, people born 2-3 years before me get to secure a permanent position in goverment no matter how suck they are at doing jobs, while us born later no more permanent dey. Last time they said, if you maintain good attitude, and excellent CCP and if you pass a paper, you would secure a permanent placement. Now, in your dreams. No more! Even already finishing housemaship still UD 41, last time after 2 years of housemanship directly straight away to UD 44 with a raised, now the salary is even lesser than house officer.

Sometimes, I wonder why I were not born in 1990? If so, I would be a permanent medical officer by now. But then, I might not meet Shahrin. Meeting him is one of the greatest blessings. Hopefully we can have a proper wedding ceremony next year or else we just do a simple solemnization with our small families. I'm still hoping for miracles to happen. Just please let us have a proper wedding so that we can invite our big families and friends. It's a celebration of course you wanted to bring joy to others. Well good food makes people happy!

I think it's not too late to wish Selamat Hari Raya people! This year is my first year celebrating raya as a doctor. First raya in hospital, I worked on the first and second raya, so I brought raya food to work. First time giving duit raya to family members, it's kind of hm what we call it, I feel happy when I see them happy. Thought can meet Shahrin and his family this raya like the last time, but Allah knows best. Hoping for a better tomorrow.

#fightcovid #kitajagakita

Me and my colleagues at work on second Raya 

is blogging still relevant?

Few days ago, I happened to talk to Shahrin expressing how excited I was when I started writing back on this site, and the first question came out from him "ada lagi ke orang main blog sekarang?"

Well, the answer is obvious.

I used to blog a lot back then. I remember going back from classes, feeling so much enthusiasm with tons of ideas on my head, started writing, blogwalking and such. It was way before instagram, the time where twitter was still using an egg as a twitcon, and where facebook was meant for youngsters. When I write, I feel happy. It was like an escape for me from reality. The moment I started medical school, I blogged lesser and year by year blogging is no longer relevant. 

Yet, here I am still writing.
Luls.

Years later, I will go back here reading my old self expressing herself and wonder oh this is how I was in 2020. Like walking down memory lane ha-ha.

Okayss time to sahoor and revise for my next assessments.
Alhamdulliah, few more assessment to go. May Allah ease everything, can feel chills down my body whenever I think of my specialist assessment, inshallah this too shall pass. As we are in Ramadhan, the month of blessings, just keep on praying, like a lot, He hears, fuhh fuhh (like casting a spell luls) a bit inshallah she shall become very soft and pass me hihi.

This assessments remembers me of my medschool life, endless exams till we already became immuned ha-ha. Inshallah this too shall pass.

Later ^^,

the head key

I had just finished the first season of Locke and Key, a Netflix series. It has been in my list-to-watched-series since the day the series was released, but  only had time to watch it recently. Hokayyyhh, so Locke and Key tells about a Locke Family who possess magical keys. They were created by The Locke hundreds years ago, for whatever purpose it is, I hope they will reveal in the next season.

Out of all this keys, if I had had the chance to be one of the keepers, I would like to go for the Head Key. This key allows the person to walk inside their head/ others'. How? It's magic. Well, basically every single person in the series got an invisible key hole at the nape of their neck that will only come to appearance the seconds they hold the key near it. Once the key clicked, a door come into sight. Just go thru the door and walla you're now inside your/someone's else head.

I would like to go strolling around the sections in my brain, and go into the memory lane. I would like to visit my childhood. I guess I would go to this particular time often the moment my oldies were no longer here. If I were to describe my childhood, it was wonderful. I would like to visit other pleasant moments too like the day big exams result were announced where I could see the happy faces, bundles of congratulatory messages, the day I became a doctor etc. This reminds me of About Time. Tim go back in time to meet his late father, repeating the things they did in the past. There are also time where he did go back to correct his mistakes and as the consequences changes his future. Butterfly effect. In Locke and Key the situation is different. They cant go back in time. For each memories, they are only able to experience it as the third person, as they are watching their past old self. Like watching a movie.

There was a scene, where Tyler Locke goes inside his head, leaving behind a book: Massachusetts,  and he suddenly mastered the history of Massachusetts. Imagine if I could do the same, dont need 5 years to study medicine! Is this consider as cheating? Luls.

Other amazing thing about this key is that you can see your own fear. Sometimes your own fear manifested in a monster form and it is real scary! Wonder how Kinsey had the courage to fight her own fear. She dragged the fear out of her brain and buried it alive. Subsequently she turned into someone different, by throwing away her fear she became somewhat self centered, didnt even bother of other people that at one time putting her friends in great danger. Fear can be a good thing.

To think again, I dont need the key to visit my past memories, it is always here in my heart. Whatever happened in the past makes me who I am today. Things that hurt me, had make me became stronger and grateful for everything that I have now. I dont need eidetic memory to succeed, hard work is all I need. Okay feels burning inside! Ha-ha.

housemanship journey so far

It's good to be back. I used to blog a lot back then. Feels so old enough. This time I'm going to express myself again after so long living in the cave. Okay, lets get started. 

I'm going to share with your my housemanship stories. 

Tomorrow marks my 9th month of being a house officer. As what been told by who've been gone through this phase that housemanship is kinda hell. I would like to agree and disagree on that. The fact that I'm still surviving makes me believe this too shall pass. Survival of the fittest. There are days that is full of shit making you started to regret your decision choosing this path and some days you feels like I'm good being a doctor, especially when you've done a good job, patients thanking you, and your superiors praising you. 

I started off with medical department, the hellest of all, its what people had been saying. There are tons of ward works, blood takings, assisting procedures like lumbar puncture, peritoneal/ pleural tapping, some days there's bone marrow aspiration, femoral catheters, ijvc are like bread and butter when dealing with nephro patients, seeing patient get intubated and CPR is a like usual scene in medical. Every day there is active and passive wards. Active ward means when there is new case from ED, the patient will directly admit to the ward. It will be the busiest ward of all, the discharge rate is the same of new cases rate. We as a house officer need to settle discharge as soon as possible, and clerking the new cases at the same time. I started my housemanship during active day. Can you imagine that? 

It was my first day. I woke up early as I was nervous to death. At 530 am I already in the ward. I was assigned to cube 5, consisted of chronic cases like End Stage Renal Failure, Fluid Overload secondary to Congestive Cardiac Failure. Even before housemanship I went to Pre Housemanship Courses, they taught about how to review patients and presenting cases during round, when it came to the real scenario, I went blank. It took me 3 hours to reviewed 8 patients before morning round. 3 hours man. Damn slow. And this continued for few weeks. Only after 2 months in medical, Ive become confident enough. 

During rounds, specialist will order blood investigations, radio imaging  like ultrasound, CT Scan or MRI and this thing houseman need to spoken to radiologist, unlike other department where MOs is the one going down to request. On my first day of life, I need to request fro MRI Brain. Cant you imagine that? Glad I have a good senior, he went down with me, showing me how to request. Okay here's the list of what are the usual things that the bosses would order during rounds: 

- blood takings: from routine blood investigation like FBC/ RP/ LFT to fancy one like ceruloplasmin, tumor markers, young hypertensive workout and the list goes on. 

- radio imaging 

- medications to endorse 

- refer patient to other departments/ units. For example like patient with underlying Diabetes Mellitus, we refer to dietician, stroke patients to physiotherapist, patient with anemia ? upper gastrointestinal bleed to surgical team 

- procedures like pleural tapping, IJVC insertion. this one we need to assist MOs, once already senior enough can volunteer to do it under MO supervision 

- discharge patient; this requires lot of time writing and documenting especially in medical phew glad I already discharge from medical luls 

This all things you need to carry out by your own. Now imagine having 16 patients with all these plans. Yup surely there's no time to rest or even eat. Sometimes I even hold myself from pissing. Yup I once have a bladder of steel ha-ha. Okay now imagine having all these during active days and then taking care of dengue patients requiring FBC QID. Damn busy! Really need to be fast and know which one need to be settled first. 

First thing first is the imaging because boss would like to see the report in the evening. This will effect the management of patients. Yaaass obviously everything we do to patients will effect the managements as a whole. No need to mentioned that ha-ha. Here is the order that can ease your work things that you need to do first and later after rounds. 

1) request imaging 

2) endorse medications

3) blood STAT! STAT means urgent 

4) refer patients 

5) preparing procedures then assist MOs 

6) discharge patients 

Discharging patients will always be the last one until there's this one patient being impatient and started to curse you for delaying their time to go back home or maybe the relatives being impatient and started to viral you on the internet. Like hello can you just be patient for once! Please. When we say okay uncle you can go back today, doesnt mean you can just go home in a minute. We need to settle other important things first. Can discharge home means the patient is stable enough. There are other patients in the ward that are unstable requiring more medical attention. Please know that before you go posting your harsh words cursing us in the facebook. What a keyboard warrior. Heh. 

You cant go back unless you have settled all your works. During my tagging period, there was time I went back at 2 am. Like I said there were shitty days that makes you went home late in the night and the next day by hook or by crook you need to start afresh and go to work. 

I think I cannot go thru housemanship without endless support from my family T.T 

I would be mental without them. 

Wow it's nearly 9 pm and I still got lots to say, but... need to study for my NRP - neonatal resuscitation protocol - next week. I will continue writing another time. 

Bye. 

2020 already

Fast forward 6 months, 

1. Will be turning 27 this year in February.

2. 6 months of ups and downs as a junior doctor. Housemanship is surely tough but alhamdulliah it is still manageable. I cant believe i survived medical as my first posting! 

3. Our 9th year together, who knows we could go this far alhamdulliah. To many more years of us, S. 

4. Had a cute ginger cat named after my second cousin + her husband. We keep this cat inside our house, vaccinated and bathed every weekly. 

5. My mother retired officially on the last day of 2019. 

6. And many more good moments happened 6 months back, i am blessed alhamdulliah. 

Hopefully, i can write more and more this year. 

Sharing my housemanship journey and all. 

Till then, 

:)