Friday, September 11, 2015

Perjuangan Ultras Malaya #ultrasmalaya

 The mass media is playing the blame game on the Ultras for their brave act in Stadium Shah Alam the other night. I would have been in the stadium if not for an emergency case that came up last minute despite planning to attend the calling by Ultras for true fans to show their strut. I am disappointed with the media who are trying their best to show the so called EVIL amongst this batch of Malaysia supporters. I am sure the ultras bashing is being orchestrated by the powers up there: obviously the one funding them .. periuk nasi maah..
All Malaysia football fans were angry, dismayed by the poor performance of the team in the last few games. Of course the pinnacle was the 10-0 drubbing by UAE. Everybody knows the root of the problem which have been breeding for years; and being let to rut. It is unfortunate for Dollah Salleh to inherit the title of the WORST MALAYSIAN COACH ever with our heavy defeats to Oman, Palestin with 6-0 each and the UAE tragedy.
ULTRAS did what they had to do. There was no other way or SALURAN to use as it has been exhausted and not being taken seriously by the authorities.
Perhaps it was over the top, but HOW ELSE BRO? How else to make the whole nation realize how bad the situation is at the moment.
The media is trying to brainwash the public of how embarrassing to have the ULTRAS around.. but HONESTLY, I AM MORE EMBARRASSED with our LOST to PALESTIN.. C/mon.. PALESTIN? A turmoiled country and we lost to them. 10-0? WAAAHH.. Memang standard SAN-MARINO..ANDORRA.
I am a keen Malaysia football fan and as much as possible will try to be at our team games despite their mediocrity at times, even though the games were played with only a scarce number of fans. You can check out my previous entries about Malaysia team and i will continue to support despite us being in the lowest pit of quality at the moment. 
Ultras Malaya has brought a new dimension to the supporting crowd of the national team. It used to be very boring and only full of swearing by the crowd. At times everybody would cheer and sing to the tune of Inilah Barisan kita. But since it has the word Barisan, few are not too happy to sing and clap with it anymore... haha
Ultras would chant.. and sing..and dance for the whole game. Before and especially after the game. They will continue giving their support and I've NEVER seen them jeered the National team players during the game. The crowd used to boo certain players from the likes of Zainal Abidin Hassan to Khalid Jamlus. The worst was when KJ brought MYTEAM to play Malaysia. That was a purely CIRCUS game! Perhaps KJ had the same sentiment against the FAM admins as he was the Deputy President then. He must have realized something had to be changed and organized the circus. That was the saddest moment when our players in the traditional national colours were booed by the crowd and only a handful of us cheered the National team. Imagine if ultras were around then..
Ultras best moment? The electrifying legendary moment of AFF 2014 finals in Bukit Jalil. They did the parade and made the whole stadium in awe with their support and chants. Whoever was present in the SSBJ would witness to the best of support in our lifetime. It certainly made the players fired up for the game and despite losing, NEVER did the ultras bowed away from supporting till the very end. 
KAMONLAH MEDIA.. Jangan makan suap!! Where is your integrity? 

To the ULTRAS, Please continue to show your support to Harimau Malaya. You've made the difference to all national team suppporters out there. Sapa yang banyak komen tu confirm not those who goes to the stadium..Wannabees who only support the national team when we are winning which defines them as not true supporter.


Wednesday, September 09, 2015

Its coming soon

Its getting nearer, my flight to Makkah. It is coming soon. Every night i get palpitations, don't really know why. Its the journey. The journey of my lifetime. Am i ready for it? I don't know. I can only pray that things are made easy for my ibadah. 
Its the 5th pillar of Islam, and every muslim who have fulfilled the earlier four is summoned to complete the five. Ideally, all four should be at its maximum before one submits oneself to realize one's iqrar of Islam. However, i guess the calling, the calling to his holy land. 
Reciting the talbiyah, can be very emotional when one recites it..Somehow..

Labbayka Allāhumma Labbayk. Labbayk Lā Sharīka Laka Labbayk. Inna l-Ḥamda, Wa n-Niʻmata, Laka wal Mulk, Lā Sharīka Lak.
In Arabic: لَبَّيْكَ اللَّهُمَّ لَبَّيْكَ، لَبَّيْكَ لاَ شَرِيْكَ لَكَ لَبَّيْكَ، إِنَّ الْحَمْدَ وَالنِّعْمَةَ لَكَ وَالْمُلْكَ لاَشَرِيْكَ لَكَ

Here I am at Thy service O Lord, here I am. Here I am at Thy service and Thou hast no partners. Thine alone is All Praise and All Bounty, and Thine alone is The Sovereignty. Thou hast no partners."

Semoga dipermudahkan.

Thursday, September 03, 2015

When a fellow colleague reflects.. All reflexes maintained constantly :)

Reading this entry from an anaesthesiologist in Canada made me smile. If it was a facebook entry i would have just clicked the button SHARE. I am relatively new to anaesthesia as compared to him but i could relate to what he had written. The practice may change with technology and time but the sharpness of mind and practice of an anaesthesiologist is maintained through generations. 
Its true that with technology, the fundamentals of anaesthesia care may not well be emphasized - more so to consider giving anaesthesia when there is no electricity remains foreign to the young. In my earliest training, I was mentored by few really senior ( as in now RIP..) anaesthetist. I can still remember how they emphasized on ME as being THE BEST PATIENT MONITOR at all times. This remain as my mantra to my trainees.. 

Credit to bleeding heart. Excellent entry! 

Reflections on a quarter century

25 years ago today or maybe it was yesterday I gave my first anaesthetic as a specialist.  I remember it was an oral surgery list.  I also remember my first patient was a Pediatric patient and I remember thinking how it was a good thing I hadn't looked carefully at the list the night before because I might not have slept well knowing I was doing a kid first.  Fortunately that child and the two other patients I did that day did well.

The child I would have induced with Halothane before starting an IV, giving a muscle relaxant (probably vecuronium) and intubating after which I would have maintained him with N2O, oxygen and halothane.
The two adults I would have used Alfentanyl, thiopental to induce and either succinylcholine or vecuronium to intimate.  I would have maintained with nitrous and oxygen and either isoflurane or enflurane.  Because the surgeon may have wanted induced hypotension, I may have used curare as my muscle relaxant.  Morphine would have been given for analgesia and I probably gave droperidol as an antiemetic.  Interesting how many of the drugs I used then are either no longer available or have fallen out of favour.
My machine would have been a Boyle machine.  No electronics, no software, driven by compressed gas and just as safe or safer than the $100K behemoth I use today.  To switch fron the bag to the ventilator, you manually disconnected the bag and connected the ventilator hose, remembering to close the APL valve.
The anesthetic circuit was the Bain circuit, with its necessary high gas flows which meant you went thru at least 1 bottle of isoflurane a day.  The circle circuit which had fallen out of fashion was just coming back into fashion.  Circuits were changed every case but there was no filtering.
Monitoring was with EKG, NIBP, pulse oximetry, and  ETCO2.  The latter two had only recently been mandated as standard.  There was no expired gas monitors.  Most of us figured that by dialling in a certain percent, we got a certain end tidal gas concentration.  Pulse oximetry had not been mandated in recovery yet.  Our recovery had one or two pulse oximeters which they put on whoever they figured needed it the most.
A significant number of patients were admitted the night before surgery which meant seeing them the night before after your list  and coming in Sunday evening.  At our hospital then, the person on call saw all the pre-ops which meant 10-20 patients on Sunday evening on top of doing emergency cases and I remember rounding at 2300 some nights. (When people complain about the pre  assessment clinic I remind them of this, but so few people remember having to do this that it doesn't work any more.)
Cholecystectomies, appendectomies, and hernias were still done open.  The laparoscopic cholie appeared early in my career ( initially three hours of farting around followed by an open cholie), the others later.
Over time things changed.  Propofol was introduced early on.  At first pharmacy refused to supply, then rationed it; I got into the habit of mixing it with Pentothal, I called this mixture President's Choice propofol.
Muscle relaxants came and went, rocuronium came and stayed, less so cisatracurium and pipicuronium. Curare disappeared soon after I started.  Pancuronium hung on until recently.  Atracurium and vecuronium, introduced while I was a resident are gone.
Sevoflurane and desflurane appeared in the mid to late 1990s.  I still don't think they are much better than halothane and isoflurane which have also disappeared from use.  So has enflurane.
The laryngeal mask airway was introduced early in my career.  Who remembers mask anaesthesia?  That was how we did short cases like D+C s and cystoscopies, holding the mask with one hand, and writing up the chart with the other.  Some of our older colleagues even did longer cases and had elaborate set ups with the black mask strap and tongue depressors to free up their hands.  (Periodically a resident comes across the mask holder and asks me what it was for).  The LMA has mostly supplanted the ETT in many of the cases I used to intubate although I am still a lot more conservative that some.
When I started well over half of Caesarian Sections were done under general.  Now GA is reserved for special exceptions and dire emergencies.  Some commentators are now saying we don't do enough GAs. Unfortunately in my time the section rate has increased from 15-20% to 30%.

My malpractice premiums were $9000 (14,600 in 2015 dollars) that first year.  I currently paid $8600.  I would like to think that this is because we are all better anaesthesiologists but I credit the pulse oximeter for most of this.
One constant in my career has been the drive to cut costs.  For the past 25 years, the mantra has been that health care costs are spiralling out of control.  With that logic they should now be consuming 200-300% of the total provincial budget or GDP however you want to express it.

One major change in anaesthesia and in medicine in general has been the increase in obesity.  On my fellowship oral exam, I remember being given a case of a morbidly obese lady presenting for a D+C.  I see at least one such lady every time I do the Gyne list.
Two things I thought were inevitable when I started have not come to pass.  Today as I have for the past 25 years, I charted on a paper chart.  Lots of places have an EMR; in my chronic pain practices I use an EMR at some but not all sites, but if you offer me good odds that I will not be exclusively charting electronically before I retire I will take them.  Secondly I am still billing exclusively fee for service.  I gave this 5 years maybe, when I started.  I will take the same odds that I will be billing fee for service until I retire.
Since my first day I have moved cities once and lived in 3 very different neighbourhoods in my current city.  I have fathered a second child, and watched 2 boys grow up.  I have gone thru 4 dogs.  I became an accidental chronic pain specialist.  After working unhappily at the C of E I now enjoy my life at my medium size Catholic Hospital.  I have gone into and survived administration.

When my wife learned I was blogging on this, she asked if I was nostalgic or whether I was happy with the way things had changed.

I am nostalgia for the way I felt during the first few weeks in practice when everything was a novelty, and you realized that after 4 years of training, you had made the right decision and you were competent at it.  You never get that feeling back.  I feel nostalgic for some of the people I first worked with who helped me out.  I also feel nostalgic for the little town in Atlantic Canada where I first worked for 2 years before I went to the Centre of Excellence.  I don't know how many times in the first few months, I wanted to call them and ask for my job back.  All in all I still think that the move was for the better.

Have things gotten better?

I do like the short acting drugs we have now although they are not always a short acting as we would like them to be and sometimes because we don't respect them we get into trouble.  Like the recent article in Anesthesiology suggesting that a significant number of patients still get discharged incompletely reversed from their intermediate muscle relaxant.  Pancuronium and curare we knew lasted a long time, so we used them sparingly.  If the surgeon complained about bucking while he was closing, we didn't give another dose.  It may be a good thing that patients are more awake post-op, however I wonder how whether the recovery room nurses appreciate the awake, anxious, painful patients we now drop off as opposed to the sleepy ones we used to.  No matter what anaesthetic you use, discharge is driven by things like policy, availability of porters and when the patient's ride shows up on time.  When I recently had a colonoscopy with sedation, I liked being able to walk out 15 minutes after the end of the procedure (I told my wife, "I've driven in worse shape then this.")

The greatest advance in anaesthesia is the pulse oximeter.  The ETCO2 is also a useful monitor and one I am glad to have.

With the medical system in constant crisis, I often wonder whether we are worse off.  I sometimes think that we are like the frog in the pot of water that is slowly being heated, and don't realize that we are being boiled alive because it is so gradual.

I like history and one of the advantages of growing old is to look back on how things have changed (and how things have not changed) ; how dogma becomes heresy and how heresy becomes dogma.

Looking forward to the next 25 years.

Thursday, August 27, 2015

RA Workshop UMMC 2015

It was a hectic schedule leaving work. I would have stayed in BAngkok for the weekend if not for a workshop that i have committed to facilitating in UM that Sunday. It was jointly organized by SIGRA and it had been some time since we all last met and do a workshop together. Pak Dan came down from SIngapore while the rest are local anyway. It was good to be back together teaching. I do miss regular teaching I must say! And i guess the reason why i totally went overtime during my talk! Hahaha 
It was the regular RA knowledge to be imparted. The hands on station that afternoon was really taxing as we had to do it for 8 times! Hahaha Penat gile! Alhamdulillah, everything went smoothly and we had a casual dinner in Serai catching up and planning for our next big project! 

CVC Arrows in Bangkok

This was the training for trainers course where Arrows spefically chose us to be the bulk of trainers according to their Vascular access team in the US. The faculty was specially brought from US and we were exposed to their methods and standards. It was a good refreshers course for me as it was quite sometime back since i updated my knowledge in this. 
 We had participants from most ASEAN countries. Vietnam and Myanmar pulled out at the very last minute because of the bombing inicident. Singapore apparently had issues regarding the contract that they were supposed to sign. It was much fun having counterparts from ASEAN and we did exchange a lot of our experiences in this course.
 The highlight of this course was our visit to Siriraj hospital, perhaps the biggest hospital in BAngkok.We were priviledged to watch live cases inserted by their expert, Dr Praterp who i have met in a cardiac conference in Singapore back in 2013. He is a definitely the top guy in Bangkok and i am impressed with all his achievements. He was a good teacher as well. It would have been fun if i have had a stinit in this hospital during my training. 

The unfortunate Bangkok incident

It had been quite sometime since i took time off to attend courses or conference. This particular training in Bangkok was something not to be missed. However, i was due to fly on Tueday but on Monday evening the breaking news on CNN showed a public bombing done! It was at the Erawan shrine during peak hours. When i was watching the news, i thought.. eh.. my hotel is nearby! Ratchaprasong area along Ploenchit Road! Quickly i called Steven and he later replied that the programme was to proceed as planned. 
 It was nerve wrecking as upon arrival to Bangkok, there was news about the 2nd bomb on that day. Obviously it can be worrying to roam around in Bangkok during this period. However, we were reassured that the 2nd attack was at a very small scale and nobody was injured.
 We passed the bombed area before arriving at our hotel. It was still sealed but the road was open to public. Unfortunately 21 people died and they were really blown as according to the locals , body parts was all over the area.
Steven and I visited the area that night. It was the start of their vigil respect. The mood was sombre. It was sad as how innocent people were killed because of this act. Until today however, nobody has claimed responsible and the suspect is still at large.

Friday, August 14, 2015

Costochondritis la pulak

I had a bad knock on my chest during Futsal last week.I was floored and had difficulty to take in deep breathes then. Thus resulting me having intermittent chest pain til now.. haha no worries! bukan MI ek.. but this thingy called costochondritis.
I can tell you that the pain is significant! U'd feel pain upon taking deep breaths. What makes it limiting is when you want to laugh hard and sneeze! Maak ai..sakt woo.. 

Costochondritis (kos-toe-kon-DRY-tis) is an inflammation of the cartilage that connects a rib to the breastbone (sternum). Pain caused by costochondritis might mimic that of a heart attack or other heart conditions.
Costochondritis is sometimes known as chest wall pain, costosternal syndrome or costosternal chondrodynia. Sometimes, swelling accompanies the pain (Tietze syndrome).
Costochondritis usually has no apparent cause. Treatment focuses on easing your pain while you wait for the condition to improve on its own, which can take several weeks or longer.
Costochondritis usually goes away on its own, although it might last for several weeks or longer. Treatment focuses on pain relief.

I used to get patients during my medical days patient whose results were all negative for heart issues and we would spell out to them the diagnosis as costochondritis. Some came without any precipitating factor as compared to mine which was a trauma blow. Apparently it can take up to 6 weeks for it to really heal and not feel the pain. 
Waahh... 6 weeks! haha Apparently it did not stop me to play futsal again yesterday. Reaffirming myself that it is not ischaemic heart disease as I managed to exert myself without having obvious chest pain.
However, during the night.. waah, of course i made it recur and it was more painful than before! Hahaha Sendiri cari pasal, sendiri mau ingat.

Malaysia current issues : to just worry or to do something about it

Malaysia is dwelled into a crisis upon another. SInce the disappearance of MH370, it was catastrophy all the way. We may not have an outright natural disaster hitting us, but a collective exponential disasters is faced by the country. The worrying economic state and the moral turmoil of leadership would be the main topic which is being discussed by every Malaysian. 
If one noticed, I've not really commented on any of these issues. Too many keyboard warriors around and making unsubstantial claims and accusations. Some maybe too good to NOT be true, some scandalous and with conspiracy shadows behind every move and action. The demise of the DPM became a bit of dejavu to the 1998 debacle.
Neither side is winning this time, Its not a win-win or win-lose situation. Its totally lose-lose at the moment. We are all flabbergasted with the situation and perhaps wishing that we all wake up from our sleep and consider this just as a dream or nightmare. 
Unfortunately it is not. Unfortunately we are all involved. Unfortunately it will be our children and future generation who will suffer if we let all this nonsense to continue. It is easy to blurt it out but unfortunately, the power is not within our means. We have all forgotten what people power mean, we have all neglected the need to stand up for our rights. We are too comfortable in our deskjob middle class society that was strongly rooted in the past few generations.
What can we do about it? Start somewhere.. just start.. 

Wednesday, August 12, 2015

The journey getting closer

After attending the Kursus Asas and intensive, it was time for Kursus Perdana. The state level course was held in Shah Alam Mosque early August. TH organizes such courses every year and it gives a realistic simulation of what to expect during Hajj in Makkah. There were about 2000 jamaah who came and I thought that was already a lot. I cannot imagine the overwhelming crowd of hundred thousands during the peak time in Makkah at that time. Subhanallah :)
                                                      mini kaabah
                                                    Safa to Marwah
We were simulating the Tamattu way of hajj. We started of with umrah in our ihrams and then proceeded to the hajj rituals.I thought it was cool for TH to have a mini Kaabah and area of saie for us to do the routine. It felt real and i guess when we are there, there is no time to think but just do it! 
 I felt humbled being present in the thousands, all equal wearng white cloth wrapping our bodies. I cannot imagine later being there in the spirit of submission. Subhanallah. May Allah ease my journey.
Doing the jamratul at night was equally cool. This is the usal time TH would encourage their jamaah to proceed with the rituals. I had my go at throwing haha 
Met Lanud and Johan. Lanud - who will be one of the medical officers in charge of us in Makkah and Johan, my colleague in UiTM who will be joining the Muassasah. Masha Allah. 
Insha Allah, may Allah easen my journey which should begin soon in mid September as Wukuf would be the last 1/3 of September.

BUX adhoc reunion 2015

It was a totally last minute thingy. We were in the midst of kursus haji perdana but the idea of our get together was too good to be missed. Ady was coming down from Qatar and asked if we could all meet up. Doner picked up the idea and organized a whatsapp group and within hours , we had our definitive plan! BUX to meet up again.. and some of us who had not seen each other for at leaat 20 years? Wow...
                                          the early birds
                                         the early mums
 It was just within 24 hours that we decided to do our simple reunion at our place in Bukit Jelutong. We reckoned it was convenient for everybody as we had ample of space for everyone. It was hardwork to arrange the food and the bouncy castle within 24 hours! Alhamdulillah, it was made easy.
                                         Happy burst
                                          catching up

                                         night crowd
The event started at 4pm and it was good to see the once familiar faces again. We may not have the whole group but whoever was around did made an effort to be with the group. It was totally last minute so only those who can accommodate were present. haha 
Some of us did not change a bit, some changed a degree that we did not expect! Having bouncy castle was the greatest idea as it gave the kids the space to let out and for them to play amongst themselves whilst the parents catching up on the 20 years throwbacks :) I reckon it is better than keeping the child on the touchpads or gadgets.. Let some steam out!! 
Farid and Fahja actually drove all the way from Batu Pahat to be with us despite just travelled from KL the day before. And they were due to go back to UK the next day! Haha i guess the longing to meet up with your teen friends is an urge not to be missed. I would have done the same if I was in their shoes. 
Thank you BUX who made it! It was worth the last minute effort and Insha Allah, perhaps we should do this a yearly affair.

Thursday, July 30, 2015

Melaka-Muar Raya 2015

I was oncall during the raya weekend but not the one after. I took the opportunity to go back to Muar for raya. Better late than never. Somehow this raya starting from the first day, I was reminded how fragile life can be. How we will grow old and die one day.Qada' n qadar.. the cycle of life.
It had been 4 years since i last went back. It is timely to bring the MDQs back and they certainly enjoyed it to the max. The advantage about the latest tech : tongkat wefie is that i don't depend on any unknown individuals for our group photo! And i am in the photo with everybody! haha
                                         En's place in Ayer Keroh
                                         Pak Nal in Alai
                                          Mak Long in Tengkera
                                          Mak Tok and Pak man special
                                          Tok Cik Amah
                                         Tok Tam
                                         Uncle Malik
                                          Rambutan happiness in mak azad's
                                          Uncle Malik's MG joyrida
                                          Mymunna the brave

P/S As much as i want to write about the latest happening in our country - i would rather not.. haha The best ever drama series of the Malaysian politics!