2008 Greeting

Did you happen to watch Pak Lah's New Year speech ? I didn't really watch it though but it was the only thing on TV and I wasn't paying attention. However , I do have "sharp" ears and I don't know whether he uttered it by mistake or simply reading the text without thinking..
"Syabas kepada angkasawan kita yang telah menjejakkan kaki di ISS pada bulan FEBRUARI 2007...

HELLO ???? FEBRUARY ??? Hmmm....
Salam Tahun Baru 2008 ...

Hello uncle..

Hepatic encephalopathy patient ; Intubated for airway protection 3 days back because his conscious level decreased markedly. Apparently , according to the medical team , his GCS improved ; and I was asked to review so that he can be extubated ; if possible immediately.

" Uncle apa khabar ? "
He was looking at me.. smiled and nodded with the endotracheal tube still intact.
" Uncle mau tube keluar hari ni... ? "
Still looking at me , smiled and nodded.
" Uncle boleh batuk ? "
still again.. looking at me ; smiled and nodded.Hmmmm...
" Uncle , ini saya pakai baju biru ka ? " I was wearing my red baju melayu.
Again.. the same response... nodded and smiled.
" Uncle , sekarang boleh balik rumah.. ? "
He smiled and nodded. I stopped asking , and moved to the side.

Haks.. he was still looking at the place where I was standing.. pause and smiled and nod !
I guess ; he's not ready yet .... :)

Always about something..

What to do ? do to what ?
Its only you or one of me ,
is it yes or is it not...

Searching for light
Or is it not shining anymore..
Auscultating for heart
or is it not beating irregularly ..
Looking for solace
or is it deep in to stay...

*ICU delirium*

I'm not as young as I thought I am

I am so tired... drained.. exhausted... having being oncall continuously during the raya weekend. I used to be all psyched up physically and mentally while doing my ICU calls but I guess when you have too much of it ; you get jaded and so knackered. Being independent is very prominent as a UM trainee .At the same time to know when to consult your superior as decisions are based on knowledge and experience.
I just wanna sleep for now...

Smile and smile again !

Gambling the fun

We were hoping Dzaeffran's lesion would clear off so that we could attend Azman's ( Edrus's) birthday. It was not so convincing ; and we decided not to attend to avoid spreading chicken pox epidemic ! We all had fun the other day going to the zoo ; spontaneously , we decided to bring both Qaisya and Dzaeff to " Kota Keriangan" Genting !!!!
Of course , this time around it is not about us but about the kids ! Gone were the days i would valiantly thread on my adrenaline and scream my lungs out. Now , its about wait..and wait..and wait... hahahaha.. but I am not complaining ! Seeing both of them enjoying themselves is indeed rewarding ; and watching them adapting to the different ambient temperature was cute to make me smile before I go to sleep ..:)

Sejuk.... intermittently though..

Jumbo trip

It has always been his dream to drive the family

classic Ferris

With the sponsor

One for the album !

Its a zoo day after all

After a lapse of more than 25 years , I returned to Zoo Negara today ; with my offsprings this time. I've always remembered the smell as it is the one thing i really can't stand . It still smells the same though !! hahahahaha It was a fun outing with Dzaeffran running around liberally ; as happy as he can be. To hear him naming the animals as he sees them was a delight ! Now he knows that the characters in his favourite book at home is indeed real ; alive and kicking !

a must standard protocol pic

Trunk call anybody ?

eat me

E = mc2

Don't be sad.. :)

I don't wanna go home...

Though nothing compared to Singapore zoo , it was an enjoyable trip and now i understand why it is so much fun to bring children to the zoo.

Standing still

"Dr.. patient brady... "
" Oh... ok... " I rushed towards bed 13A as I was on the other end of ICU.

His family were reading yasiin around him as how I've instructed them earlier in view of the poor boy's prognosis. Quitely i tapped his father's shoulder.
" Anak pokcik dah nazak sangat sekarang ni.. Pokcik bisik syahadah ye... " I said in the most gentle manner. His heart rate was getting slower by the second and his pulse was very weak.
"Ready for CPR... " I instructed my nurses.

The unfortunate 24 year old man , who collapsed in a nearby Health clinic 13 days back , had almost all his small bowel resected as it was dead - gangrenous upon arrival in our hospital . He then remained septic but it was a bit funny that he never recovered fully - when we woke him up ; almost always restless ; potraying severe pain . He never tolerated his feeds from Day 1 ; and yesterday he went into Septic shock. Through differential of opinions amongst the carers since the first op ; he visited the theatre again yesterday . BY then , he has already developed multi organ failure and needed quadraple inotropic support. The Op findings matched with what we suspected earlier.

When I escorted him back from the OT ; I knew the night would be a nightmare. He arrested on the table and a short CPR was done ; luckily his eyes were still reactive then. On arrival to his room ; he just bled from everywhere - and seeing fresh blood coming out from his ETT ;was a sign that his deterioration is irreversible.

" Adrenaline shoot fast..... continue CPR... my saturation... my pulse please... "
Being the standard protocol of CPR ; the ICU nurses were used to the routine and it was good everybody knew their role. But the patient was going nowhere as he was not responding.
I looked around at 130am yesterday , in the tense activity , knowing sakaratul maut and izrael taking their turns . His "roh" taken away , leaving the body lifeless. All that happening in a split second , without any of us in this dimension realizing it.
Lailahaillallah... Lailahaillallah....
Pulse ? none felt..
BP ? no tracing..
SPO2 ? unreadable..
pupils ? both 5mm.. fixed dilated.
Any spontaneous breathing ? No trigger... no chest rise..
ECG ? straight line... asystole....

Time of death ? 142 am.

Dream on..

Something i don't think I will be able to do ( one day... ) tapi macam nak... hahahaha

Dealing with izrael

We had two mortalities ( deaths )last week in our ICU . Both , during my call ! Therefore , being the MO on call on that day , I was to fill in lots of documents ; which if I don't do it fast ; will pile up as days goes by. Paper work is something i'm not keen on and it would be really sad if hospital management revolves around it rather than total patient care.
*****************************************

We had another death today ; and it was in a way a blessing considering she's been in ICU since late October. It will be tough for the parents to accept as she is only 21 but the agonising suffering for the past 2 months was worst. As an intensive care unit , our job is mainly to stabilize , get everything under control ( infection , effusion , renal function etc.. ) and reverse the morbidity .However , it becomes tricky when pre morbid factors are taken into consideration ; and it becomes an ethical dilemna when the patient comes with a known disease with an unlikely good prognosis to start with. It is true , that as carers we have to give our optimal attention and treatment . In our current setting ,it becomes a challenge as resources itself limits one's point of management.

I must say , it is a challenge to make decisions that would decide life or death. A consultant or the person in charge must be brave ; backed by knowledge on every decision. It is the superiority of experience which holds the edge ; but without a firm personality it means nothing. Stamping down one's feet is very crucial because resources are limited and should be aimed for those who will benefit ; not for the sake of academia.

I will hold that responsibility one day , and I am still learning. My decisions will be questioned by god in the hereafter , and will i be able to justify my actions ?

Intensivist dilemna

I am back in ICU , few would dread , few wouldn't mind , few can't wait for the chance. As for me , I am OK lah with the ICU rotation because :
1) you don't have to do pre-med.
2) you are not confined to one theatre for the day
3) If you are not on call , departure from work is predictable.
4) you get to polish your line insertion procedure skills.
5) You get to go to the wards and A&E

Not that i enjoy it so much but it is not that bad. It is one of the subspecialities in Anaesthesia and not many people are fond of it. Few that i knew are really cool and you know they were born to do it. I guess experience would contribute a huge bulk of current decision makings. Its not easy to decide on who should be admitted , who should not. The tough part being to withdraw support ; having to consider patient , family and resources factors. Its a big responsibility.
We are under a different Prof now as the Consultant of ICU. Her management is certainly different from the previous Prof I worked with during my first year. Both have different style of management that are controversial at times ; especially with the doctrine in HKL. I'm here to learn and I guess by being under different heads will ascertain my decision making in the future. These individuals are qualified Intensivists and having Fellowship recognition from overseas anaesthesia body must surely mean something !!

Chicken pox period

During my exams , Qaisya had her chicken pox. Obviously , his elder brother would follow suit and yesterday the pustules were all over his body ..
Kesian tengok dia tergaruk-garuk... hahahahaha

Life goes on

Post exams , I certainly felt a bit loss. For the past 6 months ; my main concern was passing the exams and it was just about physio and pharmaco mugging , again and again without fail. Though at times it became a bore but the show had to go on. I suffered from a bit of "withdrawal" for the past 1 week , coming back home and felt like I did not know what else to do. TV or movie did not interest me . I felt the night was too long !
Work resumed and being on call as the CRASH person on Friday woke me up from my long slumber. I realized that a lot of my judgement on that day was rusty and clouded. ( macam Star Wars la pulak ! ). Being the person to be relied on became a challenge and I was a bit slow to do my usual thing. Felt really really karat - and i realized ..oh no.. i have to buck up as I am going to be in UMMC ICU for the next three months !!
Lessons I learnt from my Friday call :
1) Make your own differential diagnosis. Do not rely on the physician/ surgeon 's opinion.
2) Play it safe ; do not be too confident especially regarding airways.
3) sharpen the setting up of lines skill.
4) Consider A-Z and never take short cuts !