R.I.P Michael Jackson

This is a tribute to Michael Jackson who sadly passed away at the age of 50 years old due to a cardiac arrest. No one can confirm the cause as the autopsy is currently being conducted and also toxicology results take a couple of days; if not days to be released. Despite being accused a sexual molester on two occasions whih both cases ending up in court, was seen by the public dangling his baby on the balcony thus stirring up news instigating him to be a bad parent, suffering years of physical and verbal abuse from his father (or so he claims), building a Neverland park intended for young children to visit and shamelessly saying in a video footage that it was perfectly alright for young boys to sleep in his room, going through astounding physical transformations such as his nose lift and his skin bleached, and his less than 2year marriage to Lisa Marie Presley, he was still an extremely good entertainer and will definitely remain a legend in the history of musicians and in the entertainment industry. In my opinion, his dance moves and singing probably sparked a new era of music videos that not only included the artist singing the lyrics to his song but an actual video/movie. He was seen as an inspiration to many famous artists today including Britney Spears, Madonna, Justin Timberlake, Usher and if you actually watch their videos, some of their moves are an exact imitation of Michael's like the legendary 'Moon walk'. He has apired many artists and dancers who one day dreams of making it big like MJ. For instance, there was this tiny chap called Wade Robson who idolised Michael Jackson so much that he spent endless hours practicing and copying his moves. He was spotted on Star Search in 1990 and impressed and captured the hearts of the judges and people as well MJ himself worldwide as an upcoming protege dancer. (He has also starred in one of Michael Jackson's music videos although I cannot recall which one). Today he is a well known music video choreographer and hosts his own show called the 'Wade Robson Show' on the lookout for similar talented dancers across America. Anyway I'll leave you with one my favourite videos 'Smooth Criminal' by MJ and a video compilation of his live performances and two footages of the Wade Robson one as a child and now as a successful dance choreographer.

Danish pastries and Croissants haven

I've always been rather fond of bread/buns and pastries ever since childhood. I can recall when I was much younger (about 10 years old), eagerly accompanying my parents to the bakery store and picking out (or rather using a pair of plastic tongs) the best looking assorted pastries, buns and sandwiches. I never grew tired of the tuna mayo, ham and cheese sandwiches/buns, barbeque pork/chicken buns/paos, garlic bread toasts and even the sweet ones like the local red bean or lotus buns, pandan sponge cakes, chocolate chip or apple and cinammon muffins and dark chocolate brownies that melt like heaven in your mouth. I was perfectly contented to eat a toasted sandwich slathered with a generous helping of rich butter and pandan kaya that oozed its deliciousness during the afternoon (rather than a boring bowl of noodles) washed down by a steaming cup of hot sweetened green lipton tea that seems to perfectly compliment the meal. Parents these days will be absolutely delighted if their kids devour a healthy and nutritious turkey sandwich stacked with thick slices of cheddar cheese or a smoked salmon and avocado wrap rather than a Mcdonalds french fries or a deep fried McChicken burger. So I guess I was more or less cultivated this good eating habit since I was young as my mum often packed salami, nutella or tuna mayo sandwiches in my lunchbox before heading off to school.

They are extremely convenient to eat, you can eat it on the run while you are waiting to catch a bus, walking down the street or even while your window shopping. They make a fantastic snack when you are too busy to make something like eg: instant noodles (which are brimming with MSG) and can be very nutritious too; such as the ham and cheese croissant which is packed with protein, dairy and your daily essential carbohydrates. And they do leave you feeling quite satisfyingly full afterwards. Back in KL, I always looked forward to the evenings (around 8pm) at shopping malls where they offer discounted prices on the various pastries and everything is up for grabs. Swarms of customers would be queuing up for these delicacies, snatching them off the racks before the next person could even get the chance to catch a glimpse of it. Unfortunately, they do not seem to have the local buns/pastries like the ones I adore in KL (kaya filled buns, red bean polo buns, char siew or dried meat with chicken floss buns etc) and are only available in several stores if you are willing to catch a bus to Chinatown.

And even right now, POW hospitals offer free food during clinical meetings or presentations which largely comprises of delicious meat wraps, muffins, finger sandwiches and assorted pastries. So I was attending one of those meetings and spotted a few scrumptious looking Danish pastries and decided to try one. After I took my first bite out of a strawberry jam filled Danish pastry, I could taste the loveliness of the bread that was crisped to perfection and didn't even bother that the jam was probably spurting out the corners of my mouth. I did not regret choosing this over the finger sandwiches. From that day onwards, I took a complete infatuation with danish pastries and lattices and similar looking savoury croissants (like ham and cheese). Luckily they are available near my apartment and are often sold at bakeries such as Bakers delight or even Coles supermarket where they pack different sorts of Danish pastries at a reasonably affordable price. (I HAVE TRIED ALL THE DANISH PASTRIES AT COLES SUPERMARKET). All I have to do is pop it into my electric toaster. I must admit that my electric toaster/oven has become a very valuable kitchen appliance (like my new best friend) as it is being fully utilised. So much, that one day my toast actually caught fire due to my carelessness of leaving the bread too long in the oven. It's actually more convenient for me to buy the pastries from Coles supermarket as they expire in a couple of days which gives me ample time to eat it, are actually cheaper if you divide the total cost and are stored in air tight sealed plastic containers which conceals the freshness and flavour. I normally buy several packets to keep during the week which saves me the trouble of making trips back and forth. Yeah, so there have you have it, my new found love and staple diet: Danish pastries and croissants.

Exam Stress

I have barely 3 months left till my dreaded final exams. I need to utilise these precious 3 months to the maximum in order to drill as much information as possible into my head(pray that it doesn't disintegrate) and patch up weak areas eg: neurology, ECG intepretation and other diagnostic imaging such as CT scan and MRI scan. I am currently in a study group comprising of two other fellow students and we have had several VIVA sessions together (which have proven to be useful) where we tackle the problems and present it to one another under examination conditions. We've also had a few practical clinical examinations supervised by an intern/resident/registrar where we see patients and are given approximately 15 minutes to take a history, perform a physical examination and present our findings. Plus come up with a possible diagnosis. This area is probably a lot more difficult than VIVA as it involves practical skills, possessing a sharp eye in detecting abnormalities and trying to figure out the probable illnesses. It is more likely for students to fail this examination due to improper technique thus not eliciting the correct signs, poor communication skills with the patient and poor summary of our findings.

Apart from having a mini study group (it is best to not have a group that big otherwise it will prove ineffective as not everyone will be able to have the opportunity to practice)there have been organised tutorials at POW hospital by enthusiastic registrars/interns and consultants willing to lend a helping hand to the 6th years in preparation for the exams. Like there is a surgical viva tutorial every friday which just commenced recently conducted by Dr Shing Wong who is a lower gastrointestinal surgeon as well as the examination head and coordinator of the POW clinical school. I have been under him during my lower gastrointestinal surgical term and I must say that this guy has very high standards. He expects students to be dilligent, have a good background and knowledge of the common surgical diseases and to be precise and confident during the exams. If he is your examiner at POW, the chances of you failing is as high as 60%. So even if you manage to scrape through his station, it probably means that you will get a distinction in the other stations.

Anyway, he conducts his viva session by randomly picking students and throwing a VIVA question at them in which they have to basically rattle on for about 5 minutes on their approach to assessment and management of a patient in a particular clinical setting. Furthermore, the student has to present his case in front of all his other colleagues which further adds more tension. I was lucky today in that I didn't get picked but I can be assured that my turn will surely come if I continue attending his VIVA sessions. The students he picked were all good in my opinion, they demonstrated good knowledge and a focused sequential approach. The examiner can choose to ask you questions during the VIVA to test whether or not you do understand what you are saying and not literally regurgitating everything you've memorised from the textbook or divert the scenario to another clinical problem. But Dr Shing Wong told us that due to lack of time most examiners will allow students to talk non-stop for about 5 minutes before asking the vital questions. He advised us that it is best to display AS MUCH KNOWLEDGE AS POSSIBLE and not hesitate or keep information that may actually prove useful and show that you have superior knowledge in that area. The whole idea is to IMPRESS the examiner and demonstrate that you are capable of handling the situation as if it were in real life. I thought that the students today did really well and would probably have done even better if given more time.

Apart from preparing for exams, I am currently in my endocrinology term where it is mainly outpatient based with the majority of the cases being diabetic. I am lucky in the sense that my next two terms are all selective postings (respiratory and gastrointestinal) with no formal assessments or presentations. I'm always contemplating on ways to spend as minimal time as possible at my attachment (except for important tutorials, lectures and teaching sessions) to stay at home and study (due to the scarce amount of time left) and even if i go to the hospital it would be to search for patients in other wards (cardiology, neurology, rheumatology) to practice my examination skills and to recognise the physical signs present in them. Not that I am being a bad student, in fact a lot of my colleagues are doing the same thing as you are now given a choice: Either go to hospital and be a pro-active student in the posting you are allocated to OR spend your time wisely in preparing for exams. Of course, I choose the latter...I mean which student wouldn't when you are already so close to the end of your course?

Oh, I found this rather cute picture on google which typically represents the detrimental effects of exam stress physically and psychologically. Click on the picture to enlarge.

Social gathering

Tonight, my friend Sarah invited me over to her place for steamboat with a couple of friends from church. She supplied most of the ingredients (although we split up the total cost among ourselves) as well as boiling a wonderful mix of chicken and pork stock/soup and a huge plate of stir fried meehoon. Since its the beginning of Winter, I think that everyone was very grateful that we had something warm, nourishing and delicious in our bellies. (Although the guys were complaining that they didn't feel 100% full afterwards). This was then followed by a short CG session mainly aiming towards those that were sitting for their end of semester exams next week. Afterwards, we spent an hour or so of leisurely chat about studies and life. It's always inspirational and stimulating whenever friends engage in conversations about life and exchange ideas and opinions. You can learn a lot from listening to others (especially those that are heading down a similar path as yours) and it enables you to reanalyse or re-evaluate your own thoughts and opinions. The act of bonding is essential to any human being; we are not created to be solitary beings. Friends can give you support, encouragement and advice that greatly differs from your own family members. Most of all they make you feel less alone in the world; after all life is full of so many trials and tribulations, ups and downs, so it always helps to have someone to lean on for comfort and reassurance.

Being a final year medical student in the midst of preparation for finals and going to hospital on daily basis, we are left with very limited time for social interaction. Not that we don't converse with one another but I am referring to gatherings or functions not related to medicine. I guess when we are interns, residents or registrars we will be left with even less time which even includes caring for our ownselves. I heard that interns back in Malaysia work like 'donkeys' and their overnight shift is 36 hours long that they do not even have time to take a shower so they develop a rather dishevelled appearance. Not to mention eye bags, dark circles around the eyes, wrinkles, oily hair and bad complexion. Sometimes I wonder why medicine involves so much sacrifice. We kill ourselves trying to soak up everything that is taught to us like a sponge, fret about the things that were not taught so we turn to a torturous hours of self-study, endure the daily drilling and questions fired by our consultants, face exams/assessments, sleepless nights worrying about the next day where the entire vicious cycle starts all over again. And when we are finally graduate as doctors, the happiness lasts temporarily and we are worked to the point to exhaustion where we live by the motto that 'the patient always comes first'. We have to work a minimum of 5 days a week, endure night shifts that can seem to last for an eternity and perform procedures that we have not done in our entire life (I have heard horrendous stories from interns and residents claiming that they were forced to do minor surgeries/ clinical procedures that they have only witnessed once or read about from textbooks but never have actually done it in real life). It is no wonder interns dread days when they are 'on call' as they are basically unqualified doctors clearly lacking in clinical experience. If you are posted to somewhere rural, it is highly unlikely that many of your colleagues or consultants will be available during the wee hours of the morning and if you are the only registered doctor around, any patient that comes in is under your 'duty of care'. This can mean any sort of patient (especially in the ED where all sorts of patients can present to you) and you are in charge of managing the patient regardless of whether its a psychiatric, obstetric, paedetric or surgical case. Most of the interns at POW walk around with a 'stressed look' on their face. That's probably going to be me in the future. Its kind of like a scene from a superhero movie; you come when you are called irrespective of whether you are in the midst of something (sleeping, eating, etc) and you try your very best to save the victim (in this case its the patient) even if it involves your life (in this case sacrificing your physical and mental health).

End of E.D.

Today is the last day of my ED term and next week I will be starting my selective term at the respiratory ward. So what has been the benefits and downfalls I have experienced during this ED term? Well for starters the ED term is a fantastic place to gain clinical experience as you will be the first or one of the first to examine the patients when they symptomatic as opposed to the patients in the ward who are mostly stable and undergoing treatment(thus may not have the signs and symptoms they orginally presented with). The cases you do see at the ED are mostly chest pain, dyspnoea and respiratory distress, acute abdominal pain, sudden collapse and syncope (loss of consciousness), trauma and other accidents, and sometimes patients presenting with an acute psychotic episode (suicide, mania attributed to drugs/alcohol/halliconogens). These cases are commonly encountered by primary care physicians and you will DEFINITELY be expected to know how to diagnose and manage them as a final year medical student. Also, you get to see the consultants, registrars, residents and interns perform resuscitative measures (which you don't see much of at the wards) such as CPR, electronic cardioversion (note that the patient does not literally jump off the bed as depicted by movies; at the most their entire body just jerks momentarily), insertion of chest drains for pneumothroax etc. And if the patient requires emergency surgery, you can be sure that the surgical team will be around and you are welcome to follow them and witness the surgery provided you have obtained the patient's consent and permission. Once the patients are haemodynamically stable they are either discharged or sent up to wards for further monitoring and maintanence of treatment and students are welcome to follow up these patients.

The main pitfall of the ED term is that we have not been allocated a specific supervisor so we just have to latch ourselves on whoever is on call that day. And since most of the consultants and junior medical officers are all SO BUSY, they might not have the time to actually teach you properly and might get irratated if you ask too many questions. However, most of them do appreciate the final year medical students as we are able to lighten their workload quite substantially by taking a history and examination beforehand and writing in the clinical notes(all they have to do is just reconfirm the findings and history), perform simple clinical procedures such as cannulation and filling in the laboratory forms for the tests being ordered.

I was fortunate to find an intern and resident (both their names are Grace) who are keen to teach enthusiastic medical students and are willing to share their knowledge. Today I had a bedside tutorial with Grace Aw (the resident) and two other medical students in a very formal examination style. We went up to the wards to hunt for patients and each of us had to examine a patient (i.e. take a history, physical examination, summarise our findings, come up with a provisional diagnosis and answer Grace's questions regarding the patient). It was very generous of her to actually spend three hours today teaching the three of us and giving us feedback on our strengths and weaknesses. So the three cases encountered today were biliary colic (probably attributed to gallstones), a post-stroke patient and a patient with myasthenia gravis.

I was the unlucky one to get the myasthenia gravis patient which is a rare neuromuscular condition that causes muscle weakness and fatiguability. These patients are unique as their muscle weakness progressively worsens on bried periods of activity (eg: one of the tests involves you asking them to stretch out their hands for 60s and you will notice that their arms will slowly move downwards to rest position or get them to count to 50 and you will slowly notice slurring of the speech). Often, their presenting complaint is difficutly in swallowing foods and inability to keep liquids in their mouth, slurred speech or weakness of the eye muscles. This patient came in with difficulty swallowing food and inability to drink liquids as they would dribble down her chin. If the patient didn't tell me she was diagnosed with myasthenia gravis I would be thinking more of an extrinsic or intrinsic esophageal cause due to her difficulty in swallowing foods such as esophagitis or a tumour or enlarged thyroid gland compressing the esophagus which are more likely. Furthermore, I didn't really know much about the condition so I couldn't really ask all the appropiate questions to confirm her diagnosis. After the examination, Grace told me that this was in fact the first time she has encountered a patient with myasthenia gravis and that it was not in her area of expertise. If we get this sort of case in the exam it will be very difficult to diagnose her condition and we will probably be leaning towards asking questions that are of gastrointestinal origin such as gastroesophageal reflux disease, esophageal conditions etc. Grace said that it will be very unfair if we were given this case and expected to diagnose it right on the spot. So why did we choose this patient in the first place? Well, this patient was recommended by her boyfriend who is a neurology resident and he claimed that she was one of the few patients on the ward who could actually give a coherant history and examination (most of the patients are stroke patients or patients with cerebellar or frontal lobe problems so are not able to speak properly or understand the instructions you give to them during the physical examination). Nevertheless, my neurology is one of my WEAKEST AREAS and it definitely needs much improvement. I kind of wish I could swap my respiratory term to a neurology one. Neurology is extremely wide and variable and even the entire neurological examination takes about an hour to perform. I desperately need to work on this area before the exams as I am clearly lacking in knowledge and clinical experience. I guess it will be a bit of a struggle as I don't really like studying about the brain as it is just too complex.

Overall, I believe that my experience at the ED has been a beneficial one. One of the highlights is that since the ED is open 24/7, we can can basically come and go as we please (however you must at least attend the ward rounds either at 8:00am or 4:00pm). I actually wouldn't mind redoing the ED term instead of my selective as I will be able to see a variety of patients instead of just patients with respiratory illnesses. I just hope that for my next term, I am not assigned a supervisor that it strict and demanding as after all, the selective posting is supposedly one of the easier and more relaxed terms which gives time for students to revise for finals.