Friday, October 31, 2014

A different life to rekindle past interest

Somehow, i find myself to have more time now. I guess its because the compartments in my brain has been unleashed from unnecessary storage. I used to have lots of things in my mind; besides my patients in my daily work, the students, my teaching, projects, future research proposals, hospital committee, the future.. waaaaa... memang banyaklah! And since moving to private...

a different kind of freedom..... peace... 

(except my obsessiveness browsing at my daily charges everyday! hahaha)

And perhaps..  the main reason you see me writing actively again. Not just about what i do or my activities but about what i feel. I've been browsing through my blog and wow.. the blogs in 2006-2009 were really from the heart. A true sharing. I guess being occupied with work and responsibilities, the time in front of your PC is limited. 

Compared to few other doctor's blog, mine may not be as artistic and interesting (mcm Dr Ben punya..) but i don't plan to be him! We are who we are, unique and individual. Its ok to not have fanatic fans and stalkers... hahaha

To my silent readers, thank you for spending a bit of your time here. I do appreciate your presence as how I love to browse and read your blogs :) 

So you wanna be an anaesthetist? Pre Op Assesment Part 2

Ok.. now you are seeing the patient. Why? Obviously the meeting is for rapport but at the same time to discuss the options of anaesthesia available to the patient which is appropriate to the procedure. Sounds like a straight forward job right? Just refer to the guidelines in assessing the patient
Its not that simple. When i was doing this job in my early days, my focus was on the well being of the patient, his suitability, his risks and the consent. It was only about my job and role. Pretty isolated.We were to assess patient's history, medical problems and their compliance to their medication, basic effort tolerance review, airway assessment etc. A review of the investigation was a must and it was a BIG point in HKL then that if the investigations are not ready we will not review the patient.(which has its advantages but that is never the point!!)
What i discovered through the years is its more than that. Anaesthetist are supposed to be the brilliant bunch. Therefore, the depth of knowledge is important and it is not limited to anaesthesia but holisticly. Ie its not enough to know what surgery but the whole process of the surgery itself should be well known from the actual surgery to their recovery in ward. That is why we are perioperative physicians 
Serious! Thats how much an anaesthetist should know. Experience is virtue and should not be compromised for whatever reason. I reckon it should be a pre-requisite for anaesthetist to do compulsory medical and surgical posting before being admitted into the programme. It is a good idea to know whats on the other side and by understanding the whole picture, any miscommunication can be avoided.( i will certainly blog about this in more detail!! haha interesting stories to tell).There was a time during my infancy days that what i care was only when they were in the OT - which is a totally no-no. 
Knowing what surgeon does to the patient is important as there can be times during the surgery that they may request funny things for us to do. EG in PCNL, the urologist may ask us to halt the ventilation when he is puncturing the kidney. THis should be momentary but sometimes it takes more than 5 minutes for them to do so and in due time causing a lot of stress on my side! haha 
I remember when i was a junior MO having an argument with Mr Rohan (Consultant Urologist) in Selayang during his PCNL procedures because i thought it was not right to stop the ventilation for so long! hahaha No wonder he was pissed off when i continued to ventilate. It is through experience that i learn, we can assist the surgeon to make things easier and more convenient for them. eg in off pump CABG while doing the circumflex graft ; sometimes it is necessary for me to intermittently stop the ventilation to ensure my surgeon suture the graft perfectly. This will in fact reduce the possibility of post op graft complication. 
In government hospitals, some surgeons view anaesthetist job is mainly to cancel the cases until proven otherwise.In a way this can be true as any patients not optimized will be cancelled! Unfortunately, the decision to cancel are often  unilateral without a professional colleague to colleague discussion. The word "optimization" can be subjective. The long line of listed patients can be a burden but cancelling and rescheduling is troublesome for the patient. I am glad my training in anaesthesia in multiple centres had taught me how to properly manage a patient. It is not about the anaesthesia so much but more about the quality of care and patient satisfaction.Imagine being the patients themselves, having cases cancelled because the young ASA 1 patient with the pottasium being 3.0 for an I&D case is ridiculous! 
I know a lot of anaesthetist can be really petty about trivial things but by making decisions unilateral does not help the situation. Of course, i have come across surgeons who are interested in just doing their cutting with no regards to the patient's general condition! However i am sure these type of surgeons are a dying breed. 
Anaesthetist i reckon should lead the way to educate teamwork care in a respectable manner. A lot of criterias should be considered before deciding not to proceed with the case. It has to do a lot with communication. How many times have we heard shoutings between a male surgeon and a female anaesthetist arguing about case being cancelled? Haha However, it is not bounded to the gender or place, as when i was abroad these issues are similar! 

Thursday, October 30, 2014

So you wanna be an anaesthetist?: 1.Pre Op assessment Part 1

The most important thing to do as an anaesthetist when a case is posted; is to see the patient. It is essential for anaesthetist to know the patient as a whole before subjecting him the the most appropriate aanesthetic technique for the procedure. Being perioperative physicians therefore the usual history,examination and investigation review are as essential like any other discipline. Based on this, we are to plan our technique so that the surgery can be done in the most successful manner. 
I used to hate doing premed rounds when i first started in HKL. A single person is expected to see other people's list and it can be a lot! What was supposed to be an easy breeze afternoon ends up making me go back after 9pm. The worst was Sunday premeds.. it can take the whole day to settle all the patients! Being thorough meant i had to spend at least half an hour to settle one ASA 3 patient!  What makes it troublesome was when the patient was not worked up ie investigations not completed, no cardiac assessment etc. Having to call different specialists to inform and decide on the management can be daunting as everybody had a different view of how it is supposed to be done. Some may be really contra!! This has been the practice and i am sure it still is in our government hospitals. 
When i was in UM, it was made a point that the team or person doing the list should see their own patients. Initially I felt it was a bit taxing and strange but later i do realize it is important to know your own patient. Who else can tell you about difficult airway unless you assess them yourself ( i can be very OCD on this especially if knowing the patient is obese) or patient's general condition which sometimes can be overrated during phone conversations. 
In CTC, i had my own pre-op CABG clinic. When it is possible, i will schedule my CABG patients to see me so that i know them and the explanation about the whole care process can be given. In Malaysia this will not be a common practice but why be common? CTC was different in the sense of it was more of individual care unlike the mass care basis of IJN, I felt it was essential to describe the whole process especially in ICU as it may alleviate some anxiety later among the family members. 
Now in private practice, i do hope to be able to see the patients as much as possible before OT. We are the consultants therefore it would be entirely on us or our partners. Since we are charging them, i feel it is inappropriate to just see them in OT for the pre op assessment. Despite most patients maybe ASA 1 & 2, it would make a whole lot of difference when we see them in the ward. I am in the process of preparing leaflets and info sheets for my patients so that they have an idea about anaesthesia before meeting me.
The reason why i feel it is important for patients to know more about anaesthesia is becasue of our risks. I will explain this in a more detailed manner in my future postings. Honestly, before Op we hardly spend that much of a time with the patient in taking their consent. Imagine a 5-10 minutes meet. How much can we really make them understand about anaesthesia and its risks? Its not uncommon for anaesthetist to be sued after with the lawyers claiming that we did not explain enough eventhough it was legally consented. It can still be argued which i can see why. There are anaesthetists who would try to make the meeting as short as possible.
I reckon the sample info provided by the Great Britain Anaesthetist is excellent! It is comprehensive and the information is enough to make any lay person understands. I wonder why my local anaesthesia fraternity did not undergo such project which i reckon would be useful for everyone. Perhaps i should initiate this project rather than complaining why others did not.. haha well, in fact, i'm doing something about it with my hospital. 

Wednesday, October 29, 2014

Farewell party CRIB 26/10/14

I have always wanted to hold a gathering at my place for my staff. Unfortunately, i could never find the time to do so and of course, wifey can be fiesty about it. haha It was one of my hajats and of course, now that i am not with them anymore i did feel i had to settle this once and for all. It was a bit last minute though when my ICU nurse called me to inform the most available date for the staff, i quickly agreed. She even had contacted the caterer and i obliged. Yup.. i know that if i did not proceed, it will be a thousand years before i can do one. 

So it was last Sunday 26th of October that we decided to hold the function. It had been raining in the afternoons during this last week and i was praying that thnigs will be ok. If i am to do it at night, i can confirm that it will be really wet for everybody.
 Wifey had a good idea to rent the inflatable castle for the kids. It was certainly an attraction for the kids so that the adults can catch up and sit down comfortably without having to monitor their kids jumping and about. 
The attendance was fair and in a way i was quite satisfied on what turned out. The canopy was cool with its significant purple UiTM colour, the food was good and tasty and the weather was permitting. I may not have the full attendance of all my staff due to their commitments but I am thankful to those who came. We had a good team, the dream team but all godd things do come to an end. 
Thank you everybody.. may we meet again in our future endevours! 

Saturday, October 25, 2014

Praying for a good start

Alhamdulillah, I have slowly knowing my ways around this new place.It can be confusing but after a week here, things are not as complicated as it used to look like.The hospital is nicely built, certainly designed to entice the public to love the hospital. This is the 25th hospital of its group and the way things are done are standard to maintain their leading ways in the private healthcare sector in Malaysia. 

One of the things that made me interested to join this organization was its work culture. It is certainly engaging as what the GM wants is the sense of belonging amongst its staff.She is very down to earth and listens to the issues brought up. I guess she has more than 20 years of experience in managing a healthcare setup so she would be very wise to know the common issues and reprievals. 
 Yesterday we had a farewell for our founding MOs who will be leaving for greener pastures. It was a gesture i thought was interesting by the management. Of course, there was a surprise when the cake was brought in to celebrate the GM's birthday! I thought that was sweet and i could see the staff were enjoying themselves. 
I see this as a good start, an interesting one as it shows how the creation of a family like unit is being built here. Insha Allah, I pray for the best of the organization and my career here. 

Somewhere over the rainbow

I have started my new job at my new place officially. My last day in UiTM was yesterday on my 38th birthday. Today is 25th October and at the same time, the new Hijrah year.
Insha Allah, my new Hijrah, my new ventures and new environment to learn from. I am humbled by what Allah has given me and may this make me more tawaadu' towards him. 

The passion for football Malaysia Cup 2014

Shah managed to get few tickets forthe Felda JDT semi finals in Selayang. Since its the semi finals, why not as i thought it would be a good game. It had been quite some time since i last had a footie outing with friends. Usually i'll go on my own or lately with my children because i want them to soak the atmosphere of a typical simple Malaysian.
Abe who just returned from London joined us together with Adli and Nik. We met up in Selayang campus and then off to the stadium. It rained in the afternoon heavily so we thought it would be just ok for the night, besides tht it is grandstand. How bad could it be? Adli supports JDT and most of us were certainly not Felda fans but for the love of libe football why not! Stadiums are filled with passion and it would be fun to be amongst the marhaens. 

Hahaha the rain started as the whistle was blown! Initially it was drizzling and the heavy rainpour began! hahaha we were all super wet! There was no place to shelter and the egoisticness of not buying the RM5 plastic raincoat. And there we were..shouting..cheering.. and enjoying ourselves! 
The game itself was not too bad. JDT who paraded most of our national players did not play well unlike the import players from Felda. It was an entertaining game despite the wet and wild pitch though it is not as bad as it could be when rain hits the stadium. I have seen worst!
Felda won 4-3 which is not enough for the second leg in Larkin. The refereeing was foul.. and the crowd was unhappy with his decisions. This was shown at the end with things thrown to the referee by the supporters. We were very near to the incident. What made it worse was the response by the policeman who came rushing at the thugs. There was a commotion but because it was Felda fans, it was not prolonged. And we had our fair share of glamour moment when I got interviewed by TV9! hahaha we were on the news the next day and to my surprise there were quite a few who realized this! I was emotional on it so that made it real! hahaha 
Thank you Shah for the tickets and i do hope there would be more footie outings like this! :) 

Friday, October 24, 2014

38 today : the magical 24th of October

Alhamdulillah, many thanks to Allah for his grace; today I am 38!!!
Happy Birthday to me i guess haha 
I know it is Sultan Pahang's birthday today and guess what, TMJ just got married today haha 
Its not long before i turn 40. the magic 40.Siapa sangka, dah makin tua dah rupanya hahaha 
Thank you Allah for your blessings. I am indeed grateful for what you have given me and for what you have not let me have. It has been a magnificent journey of life and i will not trade it for any other way. Ups and downs, peaks and troughs.. and i am still learning.

Oh Allah, there is still lots more to learn for I am still not up to par with what is to expect of me as your servant. Insha Allah.

P/S Apparently today's entry is my 84th for this year! the most after 2009 lah.. which means that this blog is still alive and kicking! Last year pun 83 je.. hehe 

Thursday, October 23, 2014

A proud day for SIGRA.. Happy Anaesthesia Day 2014!!

The STAR 19 October 2014

Guardian walkathon 2014

Deeno was the organizer of this run. He offered the Kili group to join in with our family. Of course, it was an interesting idea that I decided to take up! Initially it was just maybe up to Dzareif but then hmm.. why not with budak kecik as well. 
In our store is this jogger's stroller which have never been used. We bought it even before we had any baby so imagine having it for more than 10 years. And there was never a proper time when it was possible to use it with any of the kids. I guess it was the time luxury we never had. 
So after a short notice, yup.. we got all five to be awaken by 7am that morning.We were to take part in the 3km family walk event. 
The walk was organized in Wetlands Putrajaya which is an ideal spot for simple runs. It was our first time there and this is the first ever event attended by all family members. haha It was certainly a handful having all 5 with us but alhamdulillah it was not too bad.
Qayyum and Marissa were certainly not fazed by the distance. In fact, they were too far in front. Laikha was being too manja as usual. Dzareif complained a lot but managed to finish the distance especially when seeing goodie bags were given at the end. Qaisya as usual, despite i reckon she is fit but too dainty despite her tomboyishness. 
And yes.. we completed the walkathon! Truly well organizxed and i will defintely take part next year again. 

Tuesday, October 14, 2014

Its coming.. surely.. #DIAgnosis2

To be brave enough to venture; replacing Dr Aaron.. :)

Quite a number of people asked me, why did i leave UiTM? I have always been known to be a strong staunch supporter of the instituition. Therefore, my move this time had surprised many though it was not something unexpected. To them i looked like i was prepared to end my career with UiTM. I even had a phone call by a colleague of mine in USM Dr Rhendra just before he left for Hajj asking me, am i seriously moving? haha

Honestly, i myself thought i would end my career in UiTM. I was under the pension scheme and that was an early evidence of what i wanted in life. Our plans may change and Allah's will change too. I had a change of heart in the sense of i had to make the step. It was now or never because this is just about the time for me to make my decision.
Some might argue my future in UiTM was bright as i was seen to be one of those who was assumed to be interested in taking over the faculty leadership in the future. I can say this maybe true but we do have our priorities in life. What we would want to achieve can be different and the satisfaction factor differs from one to another. I could have persevered to be a professor or even the dean, but i know somehow that was never my goal. I do love to teach as it is in my blood. However, going private does not mean  i have to stop teaching as there are numerous available pathways of part time teaching.
Private practice is hard work as the wagers earned depends on how many patients we see everyday, in my case how many case I do. I did cover for locums now and then during my tenure in UiTM and it was an introduction of what private practice is about. It was not easy as most of the time we are alone in making our decisions. We have to be really sure what we do is the best of practice because suing a doctor or another is not uncommon. Sure it can be lucrative as charges per day can reach up to RM10K if we do the right type of cases. (on a good day provided no complicated cases during the day).The stress is different, public and private practice.
In private practice, independence is the word.Especially in Anaesthesia. You do things all by yourself and your skills will do the rest.Honestly it is all MOs daily work in the government setting. The cases that you see and do. Nothing to shout about in terms of complexity mostly.  I guess that's the reason why certain institution would want at least 5 years experience as a specialist before being allowed to join private hospitals. 
Insha Allah, from time to time perhaps i can reflect on private vs public practice in my coming entries. It would certainly be interesting to note the differences of attitude and work ethics being on the "dark" side. Being a doctor is noble to many and some may doubt of private practice doctors role in the medical world. I am sure we have our part in ensuring the best of care to patients but in a different viewpoint. 

Kilimanjaro Part 5: Summit attack.. Stella point-Uhuru peak MERDEKA DE KILIMANJARO!!

During dinner time, everybody was not in the best mood. It was drizzling and that made the temperature drop. It was cold. We were all tired. The dinner was not very encouraging as the soup and potato was not to everybody's liking. Enock and Deeno lead the briefing, telling us about the 17 hours journey we were about to embark in the next few hours. 4800m to 5900m!! That is a very demanding height for our condition. The AMS symptoms were beginning to bug few of the team members. The initial plan was to have our 4 hours rest, and the team to start moving up at midnight. When Seri suddenly puked everything out of her guide, 
Deeno then said,"OK Enock.. since I am the team leader, we move at 4am!"
 At 3am we were all up. To say that everybody was enthusiastic is an understatement hahaha People were sick but very determined to reach the peak. Everybody knew it was the beginning of the dream. Going against nature is the toughest to cope as i know most of us do have the basic fitness requirement. What was with us was the snow and rain, despite being too cold to sleep, it made the path to be less dusty and slippery. Off we went at the early hours of the morning. 
 We were moving slowly.. too slow but necessary. The cold weather increases our oxygen demand and at 4800m above sea level, there ain't much of it. We had to mentally reduce our oxygen cell requirement and continue. Failing this is not the answer but at the same time, we were reminded to throw our ego away if we are too tired to think. AMS was evident in the sense of it made us very sleepy. Most of us keep asking if it was possible to take a short nap before moving. 
 The sun rise view was majestic and subhanallah. Despite huffing and puffing we were reminded of how great Allah's creation can be. To really saviour the view was not possible as we were physiologically challenged. We kept on moving and by 8 am our groups were divided into 2. I was with the front pack and we moved on. Not that we were any faster but we stopped for rest less. 
Abang Ayob made his legendary move when we passed us and stormed away with his walking stick! I was dead worried at that time because i knew what happened the last time around. I was concerned if he had HACE which would make his judgement unreliable. Unfortunately i myself was too tired to follow his step and i prayed that he will be OK. 
 We did pass Abang Ayob on his way down. He arrived at Stella Point quite early but unfortunately was without any food or water. He decided to descend as he was not sure whether he could survive the trip alone to Uhuru. What made my heart sunk was when he said we were 2 hours away from Stella point! Hahaha and i thought at 10 am we were near our destination. We persevered though.. 
 Alhamdulillah, at 1pm we were on Stella Point and it wa such a relief! I was tired myself as i was unable to follow the steps of Joshua and the gang. However i was not left too far behind. I knew i can reach the peak but not at the pace they were going. Kicok then motivated us to keep moving as we have to reach Uhuru. Joshua (our guide) intially was not encouraging but after seeing how we springed to life while taking pictures, he changed his mind. We could see Uhuru peak and its wall which looked quite far away. With some amount of sneakers and kurma, I then slowly walked to reach my destination. Memang nak muntah dah dengan sneakers.. hahaha 
 THe journey to Uhuru peak took longer than what i thought it would be. My legs were tired , i was breathless with every step that i take. Having the thought that the trek was flat was bullshit haha it was ascending.. and ascending.. and still the peak was nowhere to be seen.. hahaha I saw Tokki sitting down and having his rest and urged me to go on first.. The view was however damn cool. It was amazing though as i could witness the enormous glasier on one side of Kilimanjaro. Simply superb. Subhanallah.. about 130pm 31 August 2014, I have summited Kilimanjaro! The highest peak in Africa!! I felt amazing and thankful that we managed to summit. The team was exhausted but alhamdulillah we did it together. Deeno and the rest of the team came after and we passed them on our way down. Everybody looked superbly exhausted with few appearing like hallucinating all the way. The guides were certainly inspirational as they urged my colleagues for them to continue as it was just a bit more of a distance. 
Guvu Kama Simba.. Strong like a lion.. 

Kilimanjaro Part 4 : Shira camp-baranco camp - baranco wall - Barafu camp

The departure from Shira camp was memorable. After the morning briefing before we were about to leave, Joshua and his crew sang the magic "Jambo Bwana" song. It was lively as everybody participated and danced to the rhythm of the song. We were not fully fit but we were jumping around with the guides and porters! The sun was shining bright and the weather was cold and crisp but we did not bother that! And began was the journey to Baranco camp. The journey from Shira (3766m) was to Barranco (3983m) but we will go above 4000m before descending as this was appropriate for our acclimatization. 
The journey was tough as again it was high and low with the sun shining bright without any cloud filter. I was walking with Azad and Mtey the guide. Of course, the scenery was legendary but knowing that we were still far away was not a sounding factor. Azad was dehydrated from yeterday's travel and to control his AMS symptoms, we needed to really move Pole Pole. 
We were supposed to climb up to Laya Tower (4600m) but because the pace was not as how we wanted it to be, we bypassed it to go to Baranco camp. The junction was already above 4000m so Deeno as the team leader decided that the team was good enough to acclimatize without going to Lava. The walk to Baranco camp was never ending as Mtey keep saying," Yes Azad.. another hour to go... the camp is just there.." And for hours we walked without the slightest sight of the camp! It startedto snow as well and made the journey cold and wet! Something you would rather not have during this period of fatigue.
We reached the camp at 6pm and it was such a relief! What i was keen on was the scenery as this camp was hidden in between the valleys at near 4000m above sea level. Simply breath taking. Kilimanjaro peak was certainly our background. Looking at the majestic peak of Africa, some of us were doubting whether we can achieve it in the next few days. 

The trek to Barafu camp the next morning had its unique challenges. The first was to climb the vertical Barranco wall. It was not technical but we did not have that much room to walk. the pathway was small and we were lucky that it did not rain the night before. The view was amazing and i wouldn/t know if i want to repeat it again as we ascend to 4800m above sea level. Barafu camp would be the base camp before we summit. Few of the team members were superly exhausted. I had to give Abie his daily Arcoxia dose for him to survive everyday. It is amazing to see how he recovers overnight and fit and well to begin the next day's climb. 
 Midway climb, we arrived at Karanga Hut which where we planned to have our lunch. Everything was set when suddenly the rain hit us hard. It was heavy that the ground was flooded! Imagine flood at 4000m above sea level! hahaha And of course, there would be snow and that was what greeted us till we arrived in Barafu. It was becoming colder as we went.At this point, I have moved with the front group.. namely Kicok, Mawi, Azman, Kak K and Tokki who i guess were the fittest amongst us. 
 We arrived in Barafu at about 4pm. It was cold.. so cold that i was shivering like mad eventhough i was wrapped in Azad's sleeping bag.(my bag has yet to arrive). I did not have a carry mat with me and i guess.. NOW I KNOW.. why you bloody need the carry mat! The ground especially the hard stone surfaces were really cold up to one's shivering spine! Down jacket is definitely the best to be used! Most of the team members arrive quite late in the evening and i can see how exhausted they were. And imagine.. we were supposed to start our summit at midnight with some rest in between...