My 1st Time

Imagine you are touching a beating heart, pulsating aorta, and all other organs in thorax and abdomen, how would you feel? Few days back,while i was having my oncology cycle, my teacher brought us to observe an operation by the head of department. In the OT, there was a patient with a large stomach cancer, and the surgeons were going to perform total gastrectomy and lower oesophageal resection due to malignant infiltration ,and then oesophagojejunal anastomosis. In the midst of operation, the head surgeon suddenly asked if anyone is interested in palpating the tumour. Spontaneously i raised my hand ,followed by another friend. After changing and waiting anxiously, finally the moment arrived. The head surgeon was so nice by showing us every organ in the thorax and abdomen, heart, lung, stoamch, liver, spleen.... Adrenaline rush , that's what i could use to explain how i felt that time. Felt the rhythm of a beating heart, pulsating aorta, a stomach tumour... Guess what, after that, my teacher jokingly asked me if i changed my mind to pursue my career in surgical field , as i told him during our 1st class that i m interested in internal medicine. Well, after this experience, i guess i have another option in my mind :-D.

When you call for emergency service

Imagine a scenario, while you walking on the street, you encounter an accident, involving multiple vehicles, and the scene is bloody. And you call the 999 service in M'sia, what is the 1st thing you gonna say? What happen? How many people involved? Dr. Chew has posted a useful mnemonics in his blog. When you call next time, just remember use the mnemonic ETHANE.
What' does ETHANE stand for?

E = Exact Location - The precise location of the incident

T = Type - The nature of the incident (trauma, non-trauma, heart atack, motor-vehicle accident), including how many vehicles, buildings etc. are involved

H = Hazards - Both present and potential (e.g., explosion, spillage of combustible materials, highly volatile hydrocarbons, chemicals, etc)

A = Access - Best route for emergency services to access the site, or obstructions and bottlenecks to avoid

N = Numbers - Numbers of Casualties, Dead and Uninjured on scene

E = Existing Emergency Services - Which services are already on scene, and which others are required - s0 as not to duplicate services, and for better utilization of services in other concurrently emergency happenings.

Remember this mnemonic and make a proper call to the ambulance service in case you need to in the future. You will never know that by providing accurate and necessary information, you might save a life/lives !By the way, don't make prank calls!

Are you prepared to be a doctor?

Came across this post ' Are you prepared to be a doctor' by Dr.Hsu. A big thank goes to Doracrates for telling. Seriously, i have never thought of some of the questions posted by Dr.Hsu. How about you? Below are the questions :

For those who are going into medicine, ask yourself:

Is it for money you are entering the field of medicine , or is it really for the love of helping people and alleviate sufferings?

Can you be patient enough to sit there for 60 minutes listening to an old lady telling the woes of her family ? Can you be human enough to comfort her,holding her, even when she smells and stinks ?

Can you stand the chores of standing there for over 10 to 20 hours to do or assist in an operation without asking to be relieved, since chances are there would be no one to relieve you?

Can you stand working from 8am in the morning on a Saturday and finish work at 4.30pm the next Monday (that was the weekend call I personally went through)?

Are you prepared to be on call for 24/7/365 a year , if you are the only doctor in town in some of the rural areas?

Are you prepared to face SARs or Ebola patients coming to your clinic to consult you without you scooting off from the back door? (During the SARS scare, doctors carried on seeing patients like normal, even though anyone with fever could be a SARS patient and you would definitely be infected in the small confine of your consultation room if the patient that walked into your room was a SARS case)…

Are you prepared to handle excretions of patients such as stools, urine and vomitus, or physically handle a foul-smelling and maggot-infested wounds?Even if they cannot pay you?

Are you prepared to face a lifetime of learning since medical knowledge needs to be kept up to date ?

As a hypothetical question just to illustrate a point, are you prepared to treat someone who might have killed your loved ones? Medical ethics demand that you do..

If any of the answer is no, then medicine is not for you.

For full post, please read in Dr.Hsu's Forum.

POTS effect

Recently 2 posts about Ukrainian and Russian medical graduates by POTS generated alot of responses from his readers, and became a hot topic among the students studying in Russian Medical Schools, as well as doctors in Malaysia. And today Palmdoc posted the same thing on MMR.
By talking to few friends, some responded with anger and curses ( like 'Anonymous' who commented in POTS's post). Some were saddened, couldn't accept the fact. Well, there are students who accepted the criticisim. At this point, while scolding and cursing at POTS, don't the students think it's time to think on what can they do, and what should they do to improve themselves? Only by accepting criticism and willing to learn , then only we can improve. Afterall, i believe POTS just voiced out his experience and opinions. Just wanna end this post with few words by a senior who graduated last year:
- 'Be humble and willing to learn' - by Dr. E.N

p/s: Before you guys bombard me, just wanna clarify that i am not related to POTS + i am also a Russian medical student,and have no intention to degrade anyone.

18th edition = 17th edition? At least for Dr.M

We met Dr. M, our gynae teacher on Mon. During the class, she saw my ' gynecology by 10 teachers 18th edition' textbook and wanted to borrow it to make photocopy and would return to me on Sat. Without hesitation, i said ok. Guess what. Today she came in , bringing an older edition(17th edition) and started showing and telling me both books are the same actually, just that the publisher wanted to make money by changing some words and colour and then republished the book as newer edition.And she wanted to exchange for a newer edtion with an older edition. What the heck! Just for your info, 17th edition and 18th edition of that book were printed in year 2000 and 2008 respectively. Though i never compared both books before, i personally feel there should be changes, e.g the way of managing and treating a particular disorder. And she kept on insisting that such small changes aren't needed by students, only needed by teachers. And she kept on asking whose book is that,as i previously told her that book belongs to my friend. And she demanded me to tell her who's that.Haih..Seems that i have to create a good story to /not to exchange the book. You will never know what will happen if you don't. Anyway, an advice to all students, don't bring your English Gynae textbook to class in case you have Dr.M as your teacher!

Sleeping Less Than 7 Hours Per Night Increases Common Cold Risk (Interview with Dr. Sheldon Cohen, PhD, Carnegie Mellon University)

(January 12, 2009 - Insidermedicine) Getting at least 8 hours of sleep may help stave off the common cold, according to research published in the Archives of Internal Medicine.

Here are some tips to help you sleep well:

• Go to bed only when you are tired.

• Avoid taking naps. If you can't get through the day without one, limit them to less than one hour, before 3 PM.

• Get up and go to sleep at the same time every day.

Researchers from Carnegie Mellon University interviewed over 150 healthy adults about their sleep habits. They then quarantined each person and gave them nasal drops containing the cold virus.

Those who slept less than 7 hours a night were nearly three times as likely to develop cold symptoms as those who slept 8 hours or more. Those who spent less than 92% of their time in bed asleep were over five times as likely to develop cold symptoms than those who spent 98% or more of this time asleep.

In the following podcast, Dr. Sheldon Cohen, the principal investigator of this study, offered some further insight.

Today's research adds to the mounting evidence that a good night's sleep is important for optimum health. It is possible that sleep helps regulate the changes that occur in the body that cause symptoms of illness.

A good news for Malaysian Housemen

Read about this good news on TheStar Online,

Day off after 24-hour duty for trainee doctors

KUALA TERENGGANU: Trainee doctors will now get a day off after carrying out their 24-hour on-call duty.

Health Minister Datuk Liow Tiong Lai said the directive will take effect immediately.

He said it applies only to housemen on active call and at the hospital the entire time.

“We will not let these trainee doctors be overworked. We will look into their welfare,” he told reporters yesterday after visiting the Sultanah Nur Zahirah Hospital.

Liow was asked to comment on grouses from trainee doctors that they sometimes had to work almost 24 hours and then report to their superiors the next day.

Some trainee doctors complained that they had to work seven days a week without a single rest day during their two-year stint in government hospitals as housemen.

Liow said trainee doctors should also be allowed to concentrate on getting the right exposure and medical proficiency by giving them off-days.

A trainee doctor at Sultanah Nur Zahirah Hospital, who only wanted to be known as Sally, said she was relieved to hear that the ministry would look into their welfare.

“Frankly, we are very exhausted as we have to focus on our training and also carry out clinical rounds frequently,” she said. “It is stressful.”

Sally said she and her colleagues were unable to pay attention during their stints due to fatigue and time constraints.

Some thoughts to share after reading ?Mine is just simple : Same pay, more time to study, less time getting scolded. Haha....Anyway, i was joking about the 'less time getting scolded' part.. I am sure the senior doctors scold the trainee for their own good rite. :-)

How to perform a perimortem cesarean section (c-section)?

Read about this in a newly located site : My EmergencyMedicine Blog.

Indications:

• pregnant patient in cardiac arrest who has not responded to resuscitation efforts within 4 minutes of onset
• viable fetus, generally > 24 weeks (but somewhat institution dependent)

Procedure

• vertical incision from 2-3 cm above pubic symphysis to 1 cm below the umbilicus
• extend incision through subcutaneous fat to rectus sheath
• grasp rectus sheath with forceps and carefully make incision through it with scalpel/Mayo scissors
• expose the uterus
• make midline vertical incision through uterus with scalpel/scissors
• deliver fetus

Sources

Reichman, E MD and Simon, R MD. “Perimortem Cesarean Section” Emergency Medicine Procedures. McGraw Hill. 2004.

Roberts, J MD. et al. “Perimortem Cesarean Section” Roberts: Clinical Procedures in Emergency Medicine 4th ed. Elsevier. 2004.

Simple Quiz 1

What's shown on the picture?


















How are these 2 signs called?

Osler's or Janeway?

Q : How to differentiate Osler's nodes and Janeway lesions in SBE patients?
A : Osler's nodes are tender and nodular (swollen), while Janeway lesions aren't

Spotted this in a Taiwanese blog
It has been slightly modified as part of the post was in English.To read more, pls visit the link.

Histoplasmosis

I was asked by my dear what's the other name of histoplasmosis. Ok..i admit i am dumb, and before this, i jz knew histoplasmosis is a fungal infection which mostly affects the lungs,that's all. So i decided to find out more about it...(though i am having summer holidays now, my 'CME' still goes on ok.Haha!)

Histoplasmosis (Darling's disease)
Etiology : Histoplasma capsulatum

Epidemiology : throughout the world, and endemic in certain areas in the USA.

Transmission : It's contracted by inhalation of the spores from soil or guana. It isn't contagious!

Clinical picture : After exposure, the symptoms will appear in 3-17 days (average 12-14days).
Most patients show no apparent illnesses. The acute phase of histoplasmosis is
characterized by non-specific respiratory symptoms. Chronic histoplasmosis cases can resemble tuberculosis; disseminated histoplasmosis affects multiple organ systems and is fatal unless treated.
Severe infections can cause hepatosplenomegaly, lymphomegaly and adrenal
enlargement. These lesions tend to calcify as they heal.
Ocular histoplasmosis can result in loss of vision.

Diagnosis : Look for the fungus in the blood, sputum or infected organs. ELISA or PCR. It can also be diagnosed by a test for antibodies against Histoplasma in the blood. Histoplasma skin tests indicate whether a person has been exposed, but do not indicate whether they have the disea

Treatment : Antifungal medications are used to treat severe cases of acute histoplasmosis and all cases of chronic and disseminated disease. Typical treatment of severe disease first involves treatment with amphotericin B, followed by oral itraconazole.^[3] In many milder cases, simply itraconazole is sufficient. Asymptomatic disease is typically not treated. Past infection results in partial protection against ill effects if reinfected.

(Source : Wikipedia)

p/s : For those who laughing at my dumbness. Pls do it in private ok...Feel so bad now..Certainly have to study harder now...As my hsmate and i always say, 'have to turn into new leaves' next semester...But, after few semesters...i am still the same old leaf..Perhaps next sem?..Haha..

Pleural effusion : transudate vs exudate

Learnt about differentiating transudate and exudate based on Light's criteria.

Light's criteria :
1. Protein - pleural fluid : serum >0.5
2. LDH - plueral fluid: serum >0.6
3. LDH is more than 2/3 normal upper limit for serum

Twenty-five percent of patients with transudative pleural effusions are mistakenly identified as having exudative pleural effusions by Light's criteria. Therefore, additional testing is needed if a patient identified as having an exudative pleural effusion appears clinically to have a condition that produces a transudative effusion. In such cases albumin levels in blood and pleural fluid are measured. If the difference between the albumin levels in the blood and the pleural fluid is greater than 1.2 g/dL (12 g/L), it can be assumed that the patient has a transudative pleural effusion.

If the fluid is definitively identified as exudative, additional testing is necessary to determine the local factors causing the exudate.

According to a meta-analysis, exudative pleural effusions must meet at least one of the following criterias.
1. Pleural fluid protein >2.9g/dl
2. Pleural fuild cholesterol . 1.16mmol/l
3. Pleural ADH more than 60% of upper limit for serum

(Source : Wikipedia- pleural effusion)

New site for medical students

Spotted this new site : Medicine for medical students. For those who like quizzes and questions, certainly this is a site not to be missed. :-)

Modified version of 4Ts

Modified version of 4Ts as suggeted by Darren :

1. Tone (75% of cases)
2. Tissue (15%)
3. Trauma (5-10%)
4. Takes too long to clot / coagulopathy.

Modifications include :
1. Causes are arranged from the commonest to the least.
2. Thrombosis is changed to Takes too long to clot / coagulopathy.

Thanks Darren for his suggestion :-)

4 Ts - for postpartum hemorrhage (PPH)

To remember causes of PPH, just gotta remember 4 Ts

1. T - trauma - e.g laceration of cervix, uterus
   
2. T - tissue - e.g retained placental tissue, placenta accreta
   
3. T - tone - e.g atonia / hypotonia of uterus
4. T - thrombosis - e.g coagulopathy

Any1 wish to add, jz leave a comment.
Any mistakes, jz correct me.

Thermal burns - by Dr.Chew

A post on Thermal Burns , by Dr.Chew...Managed to revise how to estimate TBSA (Total Body Surface Area ) , on adults and children. Below are a few Q&A from that post which i would like to share with you :

Is there any other formula to use to calculate fluid requirement besides Parkland formula?
You can use the Galveston formula, which is based on BSA rather than body weight. Although many pediatric burn centers believe it is more accurate than the Parkland formula, it is more time-consuming to calculate.
URL: http://www.emedicine.com/emerg/TOPIC72.HTM

How about the use of Silver Sulphadiazine (SSD)?
When I was a house officer (HO), SSD was recommended for all types of burns especially for first aid measure in A&E and for daily dressing, as long as it was a burn case, the HO would order for SSD dressing daily and the staff nurse would apply the SSD every time a burn dressing was changed.

But increasingly there are published papers to say comparing SSD with other methods like using hydrocolloid dressing (Duoderm), and even honey and found that SSD has not been found to be superior; in fact, worse in terms of healing rate, repigmentation, etc. Click here to read a good review article comparing SSD with other agents.

Evidence exists that the use of SSD may place patients at increased a risk of
1. developing neutropenia
2. erythema multiforme
3. crystalluria, and
4. methemoglobinemia


For the complete post on Thermal Burns, please visit the following link.