Paeds Ortho

Some update. I passed MRCPCH Part 1a and 1b. With good scores if I may add. I did work hard to prepare for this exam and I am so glad that my effort had paid off. I am proud of this achievement.

I am now 'floating' in the Orthopaedic department. I was actually unclear of my role. I am in the HO roster, assigned as the Paeds Ortho team's HO, as I have promised to help out since we are short of HOs at the moment. The difference is that nowadays I consult my seniors less and tend to just go ahead with what I think is appropriate in terms of clinical management. But I do not sign MC as I have not obtained my full MMC registration number, and I avoid signing on operation consent forms. Last Friday, we were chatting and I accidentally let slip to prof, who is also our head of department, that I am actually neither doing shift work nor oncall. On Monday morning, prof delivered the news that I will be assigned to do the MO calls. It was a mixed feeling. I am happy that I am upgraded to do MO's work and would be able to earn some extra cash. On the other hand, my luxurious ways of working office hours would be sorely missed. On the next day, we had a visiting professor from Indonesia joining our round. Prof introduced our team to the visitor and a sense of pride overwhelmed me when prof introduced me as 'one of our new MOs in our team'. I actually smirked uncontrollably. So embarrassing  Now I feel I have to really up knowledge and improve to live up the standard of being an MO. 

As opposed to my expectation, I really enjoy being in my team now. The main reason is the bosses. The two professors heading my team are great old school doctors who give much emphasis on how a patient is clinically to determine diagnosis and treatment, as opposed to fancy tests and scans. A 7 month old boy came in with high fever, not moving the left hip, all the signs pointing at septic arthritis but because the ultrasound concluded that there isn't one, the MOs did not treat for the condition. Prof listened to the story, took one look at the child and sent the boy straight to OT. Impressive enough, needle into the hip, pus poured out. It was septic arthritis. Unlike the MOs, prof trusted the clinical presentation rather than technology, and he made the correct diagnosis. I could have gave him a salute. There were other examples. In general, there is less unnecessary referral and requests for scans in Paeds Ortho team compared to the other Ortho teams because our profs are more sensible. I like learning proper medicine from these sensible old school doctors. It also reinforces my believe that Paediatric doctors (physician or surgeon) are simple cleverer and more conscientious doctors. Even though I am the most junior in the team, I have never felt the hierarchy preventing me to ask questions and express my point of view. In fact, prof would always ask what I thought I would do before he suggests his management.

However, ortho is ortho and I cannot deny losing interest when conversation starts to veer towards operative technique, anatomy... I am in the process of trying to continue floating in the real Paediatric department, where my real interest lies. We will see how this pans out. Should be interesting. 

There is a previously-known-to-be-stubborn kiddo in the ward now. Prior to this, we needed to change his dressing under GA or sedation every time as he would scream through the roof when anyone touched his foot. But, as of yesterday, I have managed to tackle him and we are good friends now. With me he was so cooperative that he held his hand out still for me to poke him to take blood, not making a sound and concentrated on his breathing just like I told him to. So cute. After that he even gave me a pack of his sweets. Today was not the greatest day. I messed up a case in my presentation. Prof wasn't happy and I felt disappointed with myself. But after that, I went back to the ward and played with this kiddo. He cheered me up and made my day.

.

Exam mode

I have foolishly signed up for the Paeds Part 1 exam to be held in Oct 2012. I am so not prepared and it has cost a bomb. O well. I will just have to do my best. At the moment, progress is ever so slow. The palpitation and sense of urgency, worryingly, has yet to set it.

I am now doing my last posting as a house plant in the Orthopaedic department, on my third week with the rehab team. It is really one of the most depressing attachments I have been through. The impression I get is rehab review = expensive equipments = cannot afford = refer welfare = chase welfare. I am on first name terms with the sales rep who provides these equipments. I feel like doing a daily round at the social work department.

It will end very soon!

.

So illogical I am speechless

I attended a meeting as a Paediatrics house officer representative with other specialist coordinators for housemen from all specialties and representative from the health ministry (KKM) to discuss about the implementation of the flexi hour system (working in shift).

Before I start, let me just say that in my hospital, unlike the KKM hospitals, there is no problem with excessive and overcrowding of house officers. We have just the right amount of housemen that at any one time so no one is idle. We have no complaint over the oncall system. We get to be attached to a team or a ward, our MOs and specialists see us every morning, we know the patient well and they can teach us something. Patient receives good care as the same house officers in the team who look after them from admission till discharge through to clinic follow up sometimes. We may be tired post call and might whine slightly, but we are happy with the current system as we are getting good training and patients are well looked after.

Then, in the meeting, this lady from KKM announced that the flexi hour system has been decided and all hospitals in Malaysia HAVE to implement it – there is no choice over this matter. It is an order from the Director General of Health – with a full stop written in permanent marker. No matter what we say now, the matter is closed.

Fine. In order to implement the flexi hour system, we will need more housemen to join us – at least 25-30 in each department. So, this hospital, which does not have a problem of overcrowding of housemen, will have such problem in the future, as we will be forced to take in more housemen just to fulfill this directive from the top. Rather than having the system to resolve a problem, we are creating a problem just to serve the system.

Nevermind that training will be compromised (even though the position house officer is created primarily for training).

Nevermind that patient care will be compromised.

Nevermind that the house officers themselves and their consultants who are immediately affected by this directive are all against it.

Nevermind that the mortality and morbidity rate will increase.

Nevermind that in the future the nation will be looked after by a generation of poor quality doctors .

As long as the flexi hour is implemented.

We argued at length. KKM wouldn’t budge. KKM said she receives letters from parents of house officers regarding their children working too long hours in the oncall system and those letters are often conveniently forwarded to the top shots like the health minister and the prime minister. On why these top shots think that they should entertain these parents, I am at a lost. (Separate post coming soon regarding this issue)  

I asked if I, and many other housemen who are against the flexi hour system, can also write similar letters to the KKM to counter these overprotective parents. The specialists and professors warned me not – fearing that my action would annoy the DG and I might end up not getting my full registration.

I became speechless at that point. Now I cannot even exercise my right to freedom of speech.

I am now more acutely aware that I am back in Malaysia. Sigh. Yes. Welcome back.

.

Crying babies

I am the eldest of five siblings (all girls). Mum may deny it, but I did spend a great deal of time as a child helping to look after my younger sisters, from the time they were newborn up to now when they are past teenagehood. Children remember compliments well and I remembered my aunts used to say that I am an expert in babysitting, from the way I carry children. I must have been about 7 or 8 years old at that time.

A few months ago, on a particularly busy day, I was asked to help out to see some of the Green zone (non critical) patients while working at the emergency department. The first file I pulled out was a 2 month old baby, who had been waiting for almost 5 hours to be seen. Mum was angry, almost throwing a tantrum as she walked into the room, uttering 'tunggu sampai nak mati', and not making any eye contact whilst speaking to me. I apologized for the waiting. She said baby has diarrhoea and vomiting and refused to drink milk. But it was because the baby wouldn't stop crying that she was brought to the hospital. She wanted the baby to be admitted as she cannot cope with the crying anymore. At first glance, this was a well baby, fully hydrated, alert, and definitely could not have been vomiting all her feeds like her mum described. Then baby started to cry. I saw how the mum tried to console the baby. 'Nangis lagi!', obviously irritated, she attempted to rock the baby and patted the baby so fast at the same time muttering 'sleep! sleep!' with a tremor in her voice. OK. The mum was only at her teenage and it was her first baby. I took over the baby, and the baby stopped crying, starting looking around and even gave me social smile. I demonstrated to her that the baby can sense the mother's anxiety and the mother needs to have already feel calm in order to coax the baby successfully. I taught her how to give small but frequent feeding to reduce the vomiting. She seemed relieved from the moment I took over the baby for her. But she has to learn to deal with the crying baby - sickness is part of growing up and babies would cry more during illness.

Yesterday, in PICU we had another girl who would not stop her grumpy cry. The nurses and mother had failed to stop the crying for the entire night and the morning. When a baby is inconsolable like this, we get worried in case there is some sinister underlying causes. I decided to try calming down the baby myself. I carried the baby, she seemed more comfortable, stopped crying and looked all around. Mum was relieved. I asked mum to take a rest as she must have been so tired from trying to calm her down unsuccessfully for the entire morning. For half an hour I carried the child, she seemed happy. I just rocked her lightly and muttered rhetorically questions softly, occasionally singing to her. After the rest, mum returned looking more spirited and came over to played with the baby. The baby smiled and laughed. After that, mum gave her something to eat, and the baby went to sleep.

I wonder why baby behaves like that. Is that something that they see in my face? Or is it truely they can sense the emotion inside me or the mother? Anyhow, it is such a great feeling to be trusted by little souls.


 .

Orphanage visit

I visited the orphanage near my hospital who always sends kids to our paediatrics ward. We were supposed to check the kids and babies that the staff are concerned about. There were no MO free to accompany us to the free on that day, so it was only me and two other HOs. We saw 6 kids - 2 with scabies, 1 failure to thrive probably suckling and swallowing incoordination, 2 with URTI, 1 with some skin problem probably viral. It was good fun.

The last child had global developmental delay. There was a bony swelling on the left side of the head prominent enough to be noticed at first glance. History taking was a big problem as the staff doesn't know how did this child end up here. Notes and documentations were split between the admin office and the nurses office. For this child they didn't even have a date of birth, so we were unsure his exact age. I was discussing with my friends if we ought to refer this child to our child development clinic. They were not keen, saying that we ought to just leave it. I was disappointed. I thought if this boy belonged to a parents, there would have been someone concerned for him regarding all these and be brought to the attention of a doctor. For unfortunate kids like him, it is up to us to protect their best interest. The centre itself was unorganized and the staff had too many children on their plate. As doctors, if we cannot act as advocate to the few children that we see, what were we there for?

.

Reward in my job

Being in the endocrine team, we have a few teenage patients admitted for diabetic related problems. Fortunately, my job in Paeds allow me enough time to be able to sit down, listen and let them vent. It feels like it is the first time I am putting those 'communication skills' learnt in medical school to good use. Maybe because I have younger sisters about their age, I understand and can relate to their life more easily.

There was a teenage boy, clever, but had unfavourable social circumstance which contributed to his extremely lousy diabetic control. I brought him to chat to a kind Indian lady on haemodialysis, let him feel the fistula, see the blood spinning through the machine, and now he realised one good reason to keep his diabetes well controlled. How I wish everyone in this world can do whatever they aspire to do. This boy was interested to study medicine. He had been a diabetic since one year old and being in and out of hospital so many times had stirred up his curiosity and made him very interested in finding out more. But he can't now, because he did not believe it was possible and had taken the arts stream for SPM. There was another boy, whose diabetic control is so good that he is often overworrying and recently complained of dizzy spells. We simply did not know why is he having such symptom as examination and bloods showed that he is perfectly healthy. We built strong rapport and he finally broke down about breaking up with his girlfriend two weeks ago, which was when the symptom started. He told me why the couple broke up and a few thoughts troubling him regarding having to live with no meaning in life (which I believe is temporary as he is not doing anything at home waiting for college to begin), which sounded so familiar that I was able to give him advice him like a big sister. After the outburst, his symptom improved.

It felt good that I did not have to give any antibiotic or perform big operations to help them. I am learning from my boss. She cares for her patients. She expects her patients to call her up personally if they have any problem at all. She knows the social background of her patients well. She gives practical dietary advice and teaches insulin injection herself. She draws up many insulin action diagram in every ward round to teach us on management of diabetic in different patients. She created the insulin sliding scale many years ago but tells us now it's outdated and ought to use another approach to manage DKA. I enjoyed learning everyday. I wish I am staying longer so I can continue to see these patients, continue to help them.

.

Maturity

As a doctor, I feel I have matured compared to the time when I was a baby last year. Gosh, I complained too much before because I didn't know why things were done. Now, I review patients in the morning, evening and night if I am oncall, and more frequently if they are ill, without needing any prompting, because I want to know how they are and if there has been any problem. I have developed a few the spinal reflexes when dealing with emergencies. I spend time with my patients explaining about their illness and treatment, and make them feel they can approach me any time to ask me any questions. I volunteer to help at clinic if the MOs are short in numbers. I clerk cases as thoroughly as I could as if I am ready to present each and every of my patients with my bosses. I do not blindly copy management plans from the MOs. I am considerate to my colleagues. I pass over ill patients and never leave behind unsettled business to the oncall person. We support each other mainly by regular verbal outburst during lunch time. I feel more like a doctor now.

I am starting my fourth week in paediatrics. I work in an awesome team with super nice bosses who teach all the time. I am the only house officer in the team but patient load is manageable. It's a very rewarding experience working with kids and their parents. I am spending so much time praising and motivating the kids and teenagers that I am feeling so positive myself nowadays. Is paeds the way forward then? Haha... we shall see...

.

Emergency department - Checked.

Extremely infrequent blog update now. Life has been mundane, nothing really exciting to write about. I have finished yet another rotation, this time in the accident and emergency department. The doctoring part was enjoyable. But I dread patients who wouldn't stop coming through the door - all were ours to see. Trauma, hysterical school girls who fainted, old lady who has been having 3 months of dizziness, cough and cold etc. We get odd patients once in a while interesting enough to kick my passion back on, but I must say that was rare. The good thing was that But pressure is immense. Patients waiting. Patients with questions and more questions. Patients who want to cut queue. Patients who wouldn't stop coming.


Actually I have lost the meaning of life along the way. There was no motivation to go to work. Seemed to me, at home and at work, everyone feels the same way. Maybe have saved a few lives, maybe have had a few satisfied customers, but honestly, they do not make me feel like coming to work the next day with a renewed spirit.


I have to find the meaning of life. Soon. Quarter life crisis.


.