Sunday, 17 November 2013

Paediatric - Rock My Baby

Mother & Baby Department

Actually Paeds is my 5th department, but after completing medical, which is my 2nd, i decided to do peads first. Why? Because after a "tiring & no life" department, i needed some rest to recover physically and mentally. In my hospital, paeds is a chill posting, the head of department, specialists and medical officers are damn nice to you, as long as you don't create trouble and do your job properly (of course!).

My advice is always plan and prepare for whats coming. We're not a fortune-teller....  but we're not a damn gambler either. With better preparation and planning, success is easier to achieve !!

First of all, paeds posting is divided into :-
  1. Nursery : aka special care nursery (SCN) or whatever they wanna call it. Basically you're going to deal with neonates. We all learn how to differentiate neonates and children in medschool don't we?
  2. Ward : From a baby of 1 month old and up to 12 years old, is your future patient here.
You will have to spend 2 months in each of the above. Either you'll start in SCN then ward, or vice versa.  

For example : they gave me ward first, and then nursery. So i did tagging 1 week and spend 2 months in paeds ward... then.... did tagging another 1 week and spend another 2 months in nursery.
So if you realize, the total tagging period is still 2 weeks and the total allocated time in paeds department is still 4 months, like other posting. But i did not have to do tagging for 2 weeks continuously, less tiring !!

*** Disclaimer : Beware of Parents, especially Mother, as they can be very protective, avoid doing procedure like blood taking and branulla (IV line) insertion in front of them.
The next thing you want to avoid is having parents complaint about you, saying you poke their child many times for blood-taking or branulla. Remember that some parents are not as educated as you are, their emotion can easily surpasses their logic thinking. The worst case during my HO time, the so-clever mother, complaint to the Minister using SMS !! Since its near the election, the minister gave a phone call to the Pengarah Hospital !! Then, the whole department is like being shot with a machine gun by the Pengarah.. lol

While some complaints are relevant, some are not !!
This is hospital, happy-health-go-lucky people don't get admitted here !!
Baby = Small Hand = Small Vein = Difficult
Very Sick Baby = Difficult x 99
** remember, sepsis causes peripheral vasoconstriction, causing even harder to get peripheral line access !!!
- if you;re not sure, ask for help, not for trouble

Houseman Job in Ward
  • Usual stuff : Clerking, present cases, blood taking, & set Branulla..
  • Specific stuff : You need to plot the growth chart (google image to see it). If the child is under-weight or over-weight, remember to ask the mother regarding the child's nutrition status (what they eat, how frequent, blaa..blaa..blaa). If the child is under-weight, consider chronic infection? immuno-compromissed? Get the history from the parents. Might need to do screening (Hep B, Hep C, HIV test) for the parents and the child as well. Don't forget to ask the development progress, 6 months old can do what? 1 year old can say what? Start crawling/walking/running/talking??
  • Physical Exam : Always check the throat (main cause of fever/poor oral intake), peripheral circulation (capillary refill time, warm/cold periphery). Always look for the danger sign, as you are the 1st doctor to attend the patient, child can deteriorate super fast, if you sense any danger, straight away inform your Medical Officer.

Houseman Job in Nursery
  • Usual stuff : Clerking, present case, blood taking & set Branulla
  • Specific stuff : Learn how to calculate the feeding. Neonatal jaundice, what level of total bilirubin need phototherapy? Neonatal Resuscitation is a MUST as you will be working closely with your O&G colleague, in a difficult/complicated delivery, they save the mother, you save the child. Also you need to know, the criteria of admission to nursery. APGAR score. (Will write a post of all these separately)

# My experience in Nursery
That day, the weather was nice, there's a rainbow and the birds are singing. I just started my duty, and was informed by O&G team that they are pushing a mother to the operation theater for an Emergency Lower Segment Cesarean Section (LSCS) for suspicious CTG (remember my O&G post?) and suspected chorioamnionitis. So me, a nurse and my MO went there with resuscitation kit and we prepare for the baby.
- The Anesthetic team, gave the mother general anesthesia, because of failed spinal anesthesia.
- Baby was born vigorous, APGAR score full, no resuscitation given. My MO checked the baby and then he said, "ok, discharge to mother lah, baby all ok right, i go out first okay.."
- 1 minute later, when i was writing the discharge ordered by my MO in the mother's file, the baby suddenly stopped crying, became bluish (pale blue in colour) and limp !!
- The nurse started to panic, but thank God, i have my Neonatal Resus Skill like at the back of my hand, when you understand the resus flow and know exactly how to react, you won't panic.
- So i gave the baby Positive Pressure Ventilation (PPV) for 1 minute and ordered the nurse to give a shot of IM naloxone to the baby. The next minute, the baby became pink again and started to cry with good muscle tone, although i was ready to do chest compression, if necessary. Praise to Almighty God !!
- Can you imagine what will happen to the baby if i am not well equipped, knowledge and equipment wise?? My medical officer (MO) already left at that time. Lucky him to have me (hehe).

During my medschool, I never know what Neonatal Resuscitation is, let alone performing it. But I learn it during tagging time in Paeds with all my heart..
If an average medicine student who knows nothing about resuscitation during medschool, can save a baby's life..
You sure can too, medicine is a lifelong learning process !!! 


Monday, 11 November 2013

Medical - the STAT department !!!

When I was a medical student, there are Internal Medicine Dept, Cardiology Dept, Neurology Dept & Respiratory Dept, had to spend one to two months in each department....
Never crossed in my naive mind that in Malaysia, all 4 departments are combined into one, which is MEDICAL !!!

My specialist once said, "All patients presented to Emergency Department (ED) is a medical patient, until proven otherwise".. (in my head, i was like, walao wei !!!)
This explains why in every government hospital in Malaysia, medical has MORE wards compared to other departments !!!
This is why in the beginning, i always say, medical is the busiest department of all !!
So as a houseman, especially if you're given medical as your 1st posting, what should you do??
 I can't teach you everything you need to know in this short post, if its possible, why the heck we spent years in medical school, right?? What i can teach you is, how to become a successful houseman in this department.

Learn How To Do Houseman's Job
With all the knowledge we gained from medical school, it will be useless if you don't know how to use it in real life. When i was tagging in this department, they gave me a list of things i need to master in order to get off-tag (start oncall/shift schedule). So basically, they were telling me, "Aidil, if you know all these stuff, i am confident to let you work night shift alone, because you know what should you do, in case anything happened while the MO is not around"
  • Basic Life Support : Medical Officer (MO) will be busy as well, they can't stay in one ward, ED will always bother them, not to mention, referrals from other department. So if a ill patient suddenly stop breathing, your job as a houseman is try to keep the patient ALIVE while waiting for your MO to arrive !!! Thats it bro..!! Btw, Know the case (read the patient's file briefly), because you need to inform your MO mostly via phone call.
  • Branula : Most of medical patient will need intravenous line, HO need to insert them by hook or by crook.
  • Blood Taking : Medical is a department where they rely on blood too much (sry to say that). There are too many diseases and blood investigation is very vital for diagnosis and treatment evaluation as well. Taking blood from the vein is easy, in medical you need to learn how to take arterial blood, its very common in this department, compared to other.
  • ECG : You need to know how to perform the test and do your own interpretation of the ECG. I will teach you on how to read ECG later. This is expected of you as a HO, as heart attack is the number #1 killer in Malaysia.
  • ABG : Arterial blood gas, yes you need to know how to take them, and do your interpretation as well !! Of course, you need to know weather the blood is artery, vein or mixed. If its not arterial blood, you have to repeat it!! (Poke the patient until you get it right).
  • Glasgow Coma Scale : All HO must know and memorize them. If a patient GCS suddenly drop, your MO will ask about the GCS, because they need to know if the patient need emergency attention (eg:intubation) or not.
  • Basic Treatment : What will you do if the blood (buse/creat) you took, came back as hypokalemia or hyperkalemia? The ABG you took showed poor oxygenation or metabolic acidosis? ECG you perform showed myocardial ischemia? Patient develop hypoglycemia?? Your decision can save a patient life or prevent their condition from worsening. Learn, ask your senior HO, and ask your MO. Better be safe than be sorry. Trust me, you don't want to get extended in this department, its damn tiring dude !!!
  • Learn to prioritize your workload : Nurse will inform you everything, from high blood pressure, low glucose level, patient has shortness of breath, to patient request paracetamol !! Because they don't want to take the responsibility if anything happened.

At times you will wonder, if you had chosen the right path...

Nothing is impossible, the word itself says, “I’m possible!”
–Audrey Hepburn

Believe you can and you’re halfway there. –Theodore Roosevelt

Sunday, 10 November 2013

I Can't Read Your Mind

Dear Visitor,

  • Kindly "like & share" my blog with your facebook or twitter if you find it helpful... Together, we can survive better and help each other out...
  •  Leave a comment, ask me anything, tell me what you want to know, i'll write something in return
  • Like i said, i never learn how to do "mind-reading"...
  • Your interaction will benefit everyone
  • Thanks alot !!!

Saturday, 9 November 2013

O&G - 1 2 3 Push.....!!

Obstetrics and Gynecology

Bear in mind,
O&G is a surgical based department..
what do you have in mind?
as a 1st poster in this department??

These are the things you need to learn before going into this department, especially as a first poster !!
Based on priority, of course !!

1) Clerking O&G cases
- As all department has their template for clerking cases, O&G has several addition to the regular clerking template
- Remember since you're dealing with pregnant lady (obstetric), or women with menstrual problem (gynae),
always remember to add-in (or ask) about their :-
  • Menstrual Cycle : Menarche at what age, how long does the "period" last, the duration of each cycle, does the cycle comes regular or irregular (in terms of duration), any history of dysmenorrhea or any usage of contraception drug/device.
  • Sex life : Married or not (if not married, we call them "Single Parent or Single Mom", if they are not married, ask about their sex partner (do they change sex partner? bangladesh? singapore?)
  • Previous complicated delivery : Any prolonged labour, history of caesarean section, still birth, rhesus positive baby (delivered by rhesus negative mother), multiple pregnancy (twins/triplet)
  • Pregnancy-induced disease : Anemia in pregnancy, Pregnancy-induced hypertension, Gestational Diabetis Mellitus
  • Screening Status : HIV, Hep B, Hep C, VDRL, TPHA (normally done in the  1st trimester at Klinik Kesihatan). If they come without screening (as in single parent, or foreigner), we call them "unscreened". So we have to do the screening for them regardless the age of their pregnancy.
  • 4 Sign & Symptom of Labour : Contraction, Leaking of liquor, Show (blood + mucus) and Fetal Movement
2) Branulla (Intravenous Line) Insertion
- If you never learn how to set an IV line in medical school, its better to learn it before you start working as houseman !!!
- This is the department where 99% of their patients need branulla, even an expected delivery without any complication will need branula

3) Vaginal Examination
- This is very very important !!
- You need to be able to tell, whether the cervix is dilated and the opening is large enough to proceed with delivery or not. Sometimes your MO is too busy, get help from senior HO or staff nurses, as large cervix opening can deliver in the matter of seconds.
- Imagine what will happen, if you fail to identify the large opening of the cervix, the next minute, the baby head is delivered but the body is stuck and you're not in the labour room !!!
- If you're not sure, don't be shy to ask senior HO or staff nurses to reconfirm your findings. Everyone will be busy, but just open your mouth and ask, better save your ass first

4) CTG (Cardio-Tocography)
- Basically this is the monitoring of the baby's heart rate and mother's uterus contraction time
- Normally done at term (> 37 week of pregnancy) lady who shows sign of labour
- You need to identify the pattern of CTG : reactive (good) or non-reactive (bad)
- If its bad, theres a chance the baby is dying inside, this may be an emergency/complicated delivery !!!

 Pregnant lady with ongoing CTG

5) Scrub In
- Surgical based department will always need HO to assist in the operating theater
- Most hospital will arrange 1st poster for a briefing on how to scrub into operation properly
- Watch and learn !!

6) Common cases in O&G
- Urinary tract infection (UTI) : May cause false labour or threatened preterm labour. Check the urine biochemistry (any leukocyte or nitrate found in the patient's urine)
- Placenta Previa (low lying placenta) : Causing bleeding per vagina , check the mother & the baby !!
- Pre-eclampsia : Check the blood pressure, blood workout for Pre-eclampsia, look for protein in urine biochemistry, careful patient may develop seizure !!
- Chorioamnionitis : Mother comes with fever must be taken care immediately as this may be a sign of infection in the amniotic fluid. Check the CTG, any other source of infection, inform your MO as this is an emergency, they will definitely ask for CTG and will proceed with ultrasound scan

7) Common Drug used in O&G department
- T. Cefuroxime (zinnat) 250mg bd : use to treat UTI
- IV Cefuroxime (zinnacef) 750mg tds : use to treat UTI in threatened preterm labour mother
- T. FeSo4 400mg bd : for anemia in pregnancy
- T. Folate 5mg od : supplement to prevent spina bifida / folate insufficiency
- Ural sachet II/II tds or potassium citrate 15mls tds  : use to alkaline the urine, in case of UTI
- T. Papase II/II tds : to reduce swelling at vagina, after delivery / episiotomy done
- IM Pethidine 50mg (or 75mg) stat + IM phenergan 25mg stat : to reduce labour pain
- IM tramal 50mg (or 75mg) stat : to reduce labour pain, if the cervix opening is more than 6cm, do not use pethidine, use tramadol !!!
- T. metoclopromide (maxolon)10mg tds : to reduce nausea / vomitting
- IV metoclopromide (maxolon) 10mg tds : to reduce nausea / vomitting
- T. Amlodipine 10mg stat : to reduce high blood pressure for pregnancy induce hypertension or pre-eclampsia
- IV Magnesium Sulfate 4mg (8ml) stat then IVI Magnesium sulfate 1mg/kgBW/hour  : to treat Pre-eclampsia or eclampsia or prevent fitting. Monitor urine output, respiratory rate and knee jerk reflex during the infusion intravenous injection to look out for mgso4 toxicity

REMEMBER THAT... Generally it took ONE HOUR for the cervix to dilate 1 CENTIMETER...
will be faster in Multipara mother !!!

Sunday, 3 November 2013

1st Posting

Aren't We All Curious About "The FIRST"

First Love...
First Salary...
First Child.....
First Home.......

"The FIRST time I stepped on the NBA court, I became a businessman"
         - LeBron James

So you should be (if you're still not) curious about your first posting !!!
What to expect??
Will i screw up things??
Is the senior houseman helpful??


Here is an interesting fact about FIRST POSTING
- 99% of those who quit housemanship are in their FIRST posting !!!
- Most of them can't even endure the FIRST month of housemanship !!!

Erk.... !!

Okay, the key @. the vital part @ the X-factor thing... that you need know in order to become a successful first poster is.....
To be prepare of whats coming !!!

What you need to prepare may vary according to the department you're going to be assigned to..
I'll explain this in a different post, to make it easier for your future reference..
Cheers ! 

Is Family Important During Housemanship??

"My kids give me the balance to live RIGHT"
                                                                                - Celine Dion

So straight to the point...
Is family important during housemanship?
Absolutely !!!

And why is that?
You're going to need your family to be by your side at some point of your life..
Most people tend to look for family when they're in trouble..
Housemanship can be troublesome !!!

Does it apply to everyone?
Of course NOT.. !!
It depends on your character & personality..
We often watch on TVs, the main character try so hard to avoid his/her family know that he/she is having difficulty in life..
As for me, i am blessed to have my brother & sister-in-law by my side in the beginning of my housemanship life...

I don't know what will happen to me, if they weren't there in the 1st place...
They helped me alot (they might not realize it) in terms of mentally !!
I might quit housemanship due to the overwhelming stress, workload & workplace culture shock in the first few months !!
But thanks to them, although the 1st posting was hard for me, i manage to buck up & keep on fighting till the very end..

Some people don't express the same concern like me..
With or without their family, they can go through the hard life of houseman themselves..
Trust me, there are some people like that..
They just don't feel anything when being scolded or shouted at..
These kind of people, i labelled them as "takde perasaan"
Kinda nice ability to have, especially during housemanship !!! haha..

I've Made It...
What About You.. ???

Friday, 1 November 2013

Should I Stay in Klang Valley or Not ??

The Klang Valley Dilemma For Houseman

If you have no idea what this post is all about, its either you're too junior in the medical field (1st year student) or you're unaware of the typical new housemanship dilemma.
You can't be both !!!

Prior to housemanship, you will be given a chance to choose 3 hospitals which you are willing to work at.
One of the condition is, if you choose hospital within klang valley (kl/selangor) for your housemanship, then upon finishing housemanship, you will be transfer OUT of kl/selangor within 6 months after becoming Medical Officer (MO aka pegawai perubatan UD44).

Situation :-
Alex Ferguson chose to do HO in Hospital Kuala Lumpur (HKL) because his parents live in Kg Baru, so that he can stay with his family during housemanship.
After 2 years of housemanship, he received a letter from the ministry saying that he will be transferred to Sabah, to work in Hospital in Kota Kinabalu. His appeal was rejected and was told that he needs to work there (KK) at least 2 years, then only he can apply for transfer to hospital in semenanjung, let alone KL !!

It is almost certain that you will be transferred out of kl/selangor once you become MO, if you choose to do your HO there. You CAN NEVER stay there.

Looking from a different angle...
If you choose to do HO outside of kl/selangor, say Melaka or Johor...
Once you become MO there, you can apply for transfer to hospital within KL/Selangor...
Or you CAN stay there... !!

Choose KL / Selangor :-
1) If your parent stay in KL/Selangor, they will be by your side, encouraging you to go through hard HO life
2) You can stay in your parent house & save money. Bfast / lunch / dinner served direct from the kitchen
3) Sometimes parents can help you send your car for service, wash & iron your clothes, ect
4) You get to see your parents everyday !!!
5) Family looking after you if you fall sick

Outside KL / Selangor :-
1) You're far away from your parents (if they live in KL / Selangor laa). Busy & tiring HO life, make it harder to see them as frequent as you wish
2)  You'll spend some (or more) money, to buy bfast / lunch / dinner
3) You need to wash & iron your own clothes. But you can send it to the laundry shop nearby
4) More freedom & control of your life (which can be "pisau bermata dua") !!
5) More subject to stress / boring life (subject to personality)
6) Most IMPORTANT is, you can apply to work in KL / Selangor once you've finished HO !!!!

So should i choose my workplace according to where does my parents live???

* If they're staying in KL/Selangor, you have to think & choose....

* If they're staying outside of KL/Selangor, no dilemma laa, just choose, later when become MO, 80% can stay there also !!!!!!!