Simply me....

Hi everyone, I m sorry, quite some time I never update my blog ledi. I m currently back in Malaysia for about 1 and a half month already. Ya, I finally finished my 6 years of medical studies, graduated and had my convocation.

I was very busy ever since I came back from Ukraine as I had to go to Putrajaya several times to settle some of the registrations  and documents and also attended an interview.  In between I went to Terengganu. I went n did elective posting several days at KT hospital and also went for a 3 days 2 nites trip to Pulau Redang. Then, I got letter for my induction in port Dickson.

 I am currently doing my induction in Port Dickson from 16^th to 21 August.  Is a 6 days kursus  and we all got to know where we got posted on the first day. I got posted to Hospital Tengku Ampuan Rahimah, Klang. It was my 3^rd choice. Let me tell u some tips here. As from my survey and what my friends told me, usually people will get their 2^nd or 3^rd choice of hospital and very rarely people will get their first choice. So, I put the hosp I wanted  in the 2^nd n 3^rd choice and the least I wanted as my 1st choice. However, this doesn’t apply to those who put Sarawak or Sabah hosp as their first choice as KKM usually encourage or so called ‘like’ people from Semenanjung to work there. Here’s also some information, as from the KKM pegawai told us, for those who got Hospital Universities and GHKL for their HO training for 2 years, after the completion of 2 years HOs, they must or will be transferred out to other hospital out of Klang valley . They might b transferred to Sabah and Sarawak to do their MO as well.  So, think wisely if u plan to  apply hospital universities to do your housemanship.

Well, things juz go so fast, from a medical student and now I am going to step into my medical career  soon.  I am starting my work on Monday. My friend asked me whether I m excited or nervous over my work soon in the hospital. Of course I do worry whether  I can perform or cope with my work, but one thing I am sure God has prepared the best for me. So, I just hope everything goes smoothly and I alwaz walk tightly with God.

Actually I did my elective posting in Klang Hospital last year, so at least I m a bit familiar with the hospital. On the other hand, I also know that Klang hospital is a very very busy hospital, not going to have an easy HO life over there  from my own experience seeing the HOs when I did my elective posting there. My friends keep on telling me how nice and easy their hospital is in Sarawak. Well, I guess they wont understand whenever I told them how strict the specialists are in hospitals of Klang Valley. Whatever it is, I just hope that I can do well in my job, try to get less scoldings. Dunno how It will be in future…………………..

 

 

Cant really sleep these few days. Something and someone is running in my mind. I dunno wat had happened between us and I dunno why I am like tat. I am confused…….. 

As usual i went to library to study today but too bad it wasn't a very productive day today. i spent a whole day in the library but yet at the end of the day, i felt myself was just reading some story books, without remembering any facts in my brain. i hate myself being unproductive and at the same time, i start to feel the stress in myself ..... Perhaps is because i know the coming up 3 subjects (O&G , therapy and surgery) are not as easy as the previous exam and the material to study maybe is 2 or 3 times more. Well, what can i do? Just hoping for a productive day tomorrow. Maybe i should concerntrate more and less talking ......

I got a surprise gift from one of  my friend 2 days ago. It was a card congratulating me for graduating soon. A never expected gift though it was a little bit early, but the thought that counts. Thank you very much and love it.

 

Well, without knowing, I spent about quarter of my life here in Ukraine. I still remember I used to say last time that I hope I can leave this place as soon as possible and I will never look back or miss anything here. But right now at this moment, I know actually there are lots of things I gonna miss here. A lot of memories throughout the 6 years here especially these few months. I cherish all the memorable moments here. I know I gonna miss a lot of my friends here, those who walk through my ups and downs, some amazing friends of mine here.

 

Going back to Malaysia I guess it means we are entering another stage of our life, stepping in to the working society. I m not sure what is gonna happen but I do hope that I can keep in touch with some of my friends here. Well, I know I am rather lazy in contacting friends in distant and this reminds me that I lost contact with a lot of my close friends in Malaysia once I came to Ukraine due to my laziness. I hate the feelings when meeting friends who once upon a time that were so close, having endless chatting and then becoming stranger to each other due to lack in contacting each other. I guess this is life as things always change and we cant do anything but just try to adapt to the new environment.

 

Well, nothing much, just some random thoughts. I am in the midst of preparing my finals, hopefully everything goes smoothly as i guess is gonna be my last exams in Ukraine. Good luck to all my fellows friends who are preparing for their coming exams too and all the best.

 

因你与我同行 我就不会孤寂

欢笑时你同喜 忧伤时你共泣

因你是我力量 我就不会绝望

困乏软弱中 有你赐恩  我就得刚强

经风暴 过黑夜 度阡陌 越洋海

有你手牵引我  我就永往向前

愿我所行路径  愿我所历际遇

处处留下 有你同在 的恩典痕迹

 

因你与我同行  我就不会孤寂

欢笑时你同喜  忧伤时你共泣

因你是我力量  我就不会绝望

困乏软弱中 有你赐恩  我就得刚强

经风暴  过黑夜  度阡陌  越洋海

有你手牵引我  我就永往向前

愿我所行路径  愿我所历际遇

处处留下 有你同在 的恩典痕迹

 

经风暴  过黑夜  度阡陌  越洋海

有你手牵引我  我就永往向前

愿我所行路径  愿我所历际遇

处处留下 有你同在 的恩典痕迹

 

 

4 Fridays ago…..

I went for a short trip (17/4-21/4), to Oslo and Stockholm with 1 of my close friend. We went from simferopol to Kiev to Oslo, from there we spent half day and took a night bus to Stockholm. Spent 2 days there n again took a night bus back to Oslo. We spent another day in Oslo and there we took a flight back to Kiev. In Kiev, we had to spend a night in the airport and took the morning flight next day back to Simferopol. Well, this is roughly how the route was.

 

Well for this trip I would definitely say it was a great trip, and probably 1 of my best trip. Perhaps it was because it was a short trip and  my last trip from Ukraine.  

 

As a whole, the trip was rather smooth. Weather in Oslo was nice, as compared to Stockholm which was quite cold, but still bearable. Traveling this time was not so rush and tiring as compared to my previous trips. I personally would say Stockholm is a very beautiful place. I enjoyed the scenery and the weather a lot. We also managed to visit a few places and did some shoppings and tried the local food (Swedish meatball). Not only that, Stockholm made me felt very homely and a safe place to visit.

 

Other than that, finding the right travel mate is very important. Haha. My travel mate(@l) this time I would say is some ‘travel freak’(jokes) hahaha who dreamt to visit the whole Europe, so is always good to have someone who enjoy traveling a lot in the trip which will make the whole trip much more interesting. Another thing is u will always have someone to bring you where to go without needing to use your brain much which made me felt that the whole trip was so relaxing. Just for that few days, I could feel the real ‘rest’ for my brain after stuffing all the medical info into my brain.

 

Another fun part of the trip was our jokes. I still remembered the joke of the day was regarding Mr K and his singing and we were  practically laughing for more than 20sec non-stopI think, so siao man. Others were regarding miss G and her tight pants, our endless interpretation and assumption, the fun of discussing some ‘special’ people around us and their attitudes etc….  I never knew @l can be so funny as maybe most of the time we only talk about serious matter. Hahaha.

 

As a whole, this trip was really worth a travel, not only knowing a good travel mate, but more importantly getting to know a friend better. And I cherish every moment of joy and I think it will be good memories in future when I think back.

 

3 Fridays ago…….

I went for my last class of my bible study of the semester or probably my last bible study in my university life. Our bible study was regarding the Book of Roman this semester. I hope somehow I gained something throughout.

 

2 Fridays ago…..

It was labor day. I wasn’t sure what I did. I think I spent whole day staying in the room, studying the whole day without any rest till at night. i think I was stress that time. Then at night, my ah kor gave me an orange…. Haha

Later, my neighbour invited me over to eat to celebrate his winning in the conference and his award as the best student. He cooked very very nice prawn noodle for us.

 

Last Friday…..

It was my last day of class for my university life. My classmates and some friends were very excited over it, they were hugging and congratulating each other for completing our university life. As for me, I don’t feel anything very excited apart from the part that I know I am 1 step nearer to graduation, coz I know there are still so many stuffs to study, still a long journey to go in medicine. I came across this saying:

 

GRADUATION

NOW, THIS IS NOT THE END

IT IS NOT EVEN THE BEGINNING OF THE END
BUT,

PERHAPS IT IS
THE END OF BEGINNING

 

LEARNING MEDICINE HAS NO END!!!

 

A step nearer to graduation, meaning a step nearer to go back home to start working as a doctor. 6 years of medical education, without knowing time flies. From preclinical to clinical and soon we are going to become someone who treats and cures. I always blame myself for not studying enough or feeling myself so inadequate to become a good doctor. I read this article and I find it quite good…..

 

MOSO

TH BAMBOO PLANT

The Moso is a bamboo plant that grows in China and other region s of the far East. After the moso is planted, no visible growth occurs for up to five years or 6 years even under ideal conditions. Then, as if by magic, it suddenly begins growing at the rate f nearly two and a half feet per day, reaching a full height of 90 feet per day within 6 weeks. But it’s not magic. The moso’s rapid growth is due to the miles of roots it develops during first five years, five years of getting ready.

 

It takes 6 years just to get ready to become a good doctor. Don’t be disappointed if you have worked very hard and still find yourself apparently inadequate. You have planted the roots well. Continue to work hard and a good doctor is in the making.

 

Don’t forget that common things are common and you should know them first – ‘ THE ROOT PRINCIPLE’. The problem is, have u putting enough effort in planting the root?? If you say ‘yes’, then what effort have you put in planting the root??..

I have been reading regarding fluids maintenance these few days. Here are summaries of my readings. Hope is useful :) :

What are the 2 major body fluid compartments?	Intracellular Extracellular
What are the 2 subcompartments of extracellular fluid?	Interstitial fluid Intravascular fluid (1/3 of ECF is the intravascular fluid, where 85% lies in venous site and 15% in arteries)
What % of BW is in fluid	60%
What % of body fluid is intracellular	2/3 of body fluid = 66 %
What % of body fluid is Extracellular	1/3 of body fluid = 33 %
What is the composition of body fluid ?	Fluid = 60% total BW IC = 40% total BW EC = 20% total BW (rule of 60/40/20)
What comprises normal saline (NS) ?	154 mEq of Cl - 154 mEq of Na +
What comprises ½ NS ?	77  mEq of Cl - 77  mEq of Na +
What comprises ¼ NS ?	39  mEq of Cl - 39  mEq of Na +
What comprises Lactated Ringer’s (LR) ?	109 mEq of Cl - 130 mEq of Na + 28 mEq Lactate 4 mEq K+ 3 mEq Ca+
What comprises D5W	5% Dextrose in water
What accounts for tonicity?	Mainly electrolyte, NS and LR are both isotonic, ½ NS is hypotonic to serum
What happens to the lactate in LR in the body?	Converted into bicarbonate, thus LR cannot be used as a maintenance fluid because patients would become alkalotic
What is the 100/50/20 rule?	Maintenance IV fluids for a 24hour period : 100ml/kg for the first 10kg 50ml/kg for the next 10kg 20ml/kg for every kg over 20kg (divide 24 for hourly rate)
What is the 4/2/1 rule?	Maintenance IV fluids for a hourly rate : 4ml/kg for the first 10kg 2ml/kg for the next 10kg 1ml/kg for every kg over 20kg
What is the maintenance for a 70kg man?	Using 100/50/20 rule 100 X 10 =1000 50 X 10 = 500 20 X 50 = 1000 Total = 2500ml Perhourly = 2500/24                 = 104ml/hor maintenance rate   Using 4/2/1 rule 4 X 10 =40 2 X 10 = 20 1 X 50 = 50 Total = 110ml/hour maintenance rate (shortcut: 40 + weight in kg = hourly fluid maintenance Eg 40 + 70 = 110ml/hour)
What is the common adult maintenance for fluid?	D5 ½ NS with 20 mEq KCl/L
What is the common pediatric maintenance for fluid?	D5 ¼ NS with 20mEq KCl/L (use ¼ NS because of the decrease ability of children to concentrate urine)
Why should sugar (dextrose) be added to maintenance fluid?	To inhibit muscle breakdown
What is the best way to assess fluid status?	Urine output (unless patient has cardiac or renal dysfx, in which case CVP or wedge pressure is often used)
What is the minimal urine output for an adult on maintenance IV ?	30ml/hr (0.5 cc/kg/hr)
What is the minimal urine output for an adult trauma patient ?	50ml/hour
If 1L blood loss, how many Ls of isotonic solution needed to be replaced?	3L should be replaced coz 1/3 remain intravascular(1L)  and 2/3 in the rest of extracellular space
If 1L blood loss, how many Ls of colloid solution needed to be replaced?	1L generally coz colloids can stay intravascularly
If 1L of hypotonic solution is given, how is the distribution of the fluid?	1L of hypotonic solution will be distributed equally into all compartments.
How many ml are in 1 tsp	5ml
How many ml in 1 drop of the IV drip?	0.05ml (20drops= 1ml)
How to calculate drip infusion? (for infusion in 24 hour)	= total pint to be infused X 500ml X20                    24 X 60 Ex : 3 pint needed to be infused in 24hour = 3 X 500ml X 20         24 X 60 = 21 drop per min over 24 hours   3 pint in 24 hour = 21 dp per min 4 pint in 24 hour = 28 dp per min 5 pint in 24 hour = 35 dp per min 6 pint in 24 hour = 42 dp per min
What is a bolus?	A volume of fluid given IV in rapid manner, used for increasing intravascular volume and isotonic solutions should be used
Why not combine bolus fluids with dextrose?	Hyperlgycemia may result
What is the possible consequence of hyperglycemia in the patient with hypovolemia?	Osmotic diuresis
Why not combine bolus fluids with a significant amount of potassium?	Hyperglycemia may result ( the K in LR is very low 4 mEq/L)
Why should an isotonic fluids be given for resuscitation? (ie. To restore intravascular volume) ?	If hypotonic fluid is given, the tonicity of intravascular space will be decreased and H2O will freely diffuse into the interstitial and intracellular spaces.
What portion of 1 L NS will stay in the intravascular space after laparotomy?	In 5 hours, only approximately 200cc (or 20 %) will remain in the intravascular space.
Standard fluid resuscitation ?	10ml/kg bolus over 1 hour for mild dehydration 20ml/kg bolus over 1 hour for moderate dehydration 30-50ml/kg over 1 hour for severe dehydration or shock
What is the common resuscitation fluid for trauma?	LR or NS
What is the most common postoperative IV fluid after a laparotomy?	D5LR for 24 to 36 hours, followed by maintenance fluid
After a laparotomy, when should a patient’s fluid be “mobilized”	Classically, postoperative day 3, the patient begins to “mobilize” the 3rd space fluid (eg, interstitial space) back into the intravascular space. So must beware of fluid overloaded in patient and switch to hypotonic fluid and decrease IV rate

( reference : Kumar & Clark Int Med, Lippincott surgical recall, First Aids for the Wards)

I still remember the first burn case I saw was when I was doing my elective posting in KL when I was in 3^rd year. It was a fine quiet and windy evening, and we thought there wouldnt be anymore cases coming in A&E before the shift changes.

Just then, an Indonesian worker was sent in, and all I knew was the patient’s condition was bad and he was shouting in pain. I was guessing it was some burn, but not sure what kind and what degree was that. Then, his friend who sent him in told the doctor ….

            “ Kami kerja sama. Tadi dia bakar sampah kat tempat kerja kat kilang, banyak kerosene dia bubuh. Api sangat kuat tapi dia diri dekat. Tiba-tiba angin tiup arah dia, dia pun kena bakarlar. Masa tu tangan dia pegang kerosene lagi……..Badan dia kena api, semua badan tau !! Kami suruh dia golek kat lantai, lepas tu tolong padamkan api dan cepat-cepat hantar masuk hospital…..”

Meanwhile the MAs ,nurses and doctor trying to stabilize and resuscitate the patient. I was there to help too. 1 of the very important thing is we must get venous access as soon as possible. So, Dr. Y was trying to get a line on his right arm, and he asked me to get another on the left. The thing is, the patient got burnt more than 50% of his body, moreover he is dark!!!(sorry,not colour discrimination)I really couldn’t get a line, and Dr. Y asked ,

  “ Have you got the line, Ong? Faster!!!! Before the veins collapse!!!”

I was very tension but thank God an MA came to help me and he got a line so easily. Meanwhile i proceed to prepare the IV drip of NS. Well, I do admit sometimes the nurses and MAs are more expert than the medical students or doctors. Haha .

Choices For Access of vein First choice: Peripheral vein; nonburn area Second choice: Central vein; nonburn area Third choice: Peripheral vein; burn area Worst choice: Central vein; burn area

Next, I was asked by Dr. Y to count the BSA area. HUH?? I was just a 3^rd year medical student, not even entering my clinical years yet. I was quite confused bout calculating the BSA, because I only remember the rule of nine calculation method which I learnt from surgery. But that time I wonder whether Dr Y wanted that method of calculation or something else, and I myself wasn’t very sure that time whose palm I was suppose to use. Patient’s palm, or my palm?? What a joke!!!!

            “ Hey Ong, go and get me the Lund and Browder chart from the counter, and use the chart to count the BSA. Then, count the volume of fluid resuscitation for me with Parkland’s formula………..”

 

Opps, another ???, what is that Parkland’s formula?????

By the end of the day, I made few conclusions: 

1)      Becareful, even burning rubbish can get us into some serious burn

2)      Veins are hard to access in a burn patient, especially those with darker skin colour.  :)

3)      Make use of the Lund of Browder chart for accessing burn surface area. It is available in all departments.

4)    Not only the engineers have to memorize  formulas, medical students as well!!! Anyway, I will never forget bout the Parkland's formula for the rest of my life, probably it was the first formula I learnt from med school besides formulas from chemistry and physics.

Parkland’s formula Adult :4ml X  BSA X BW  Children :2ml X BSA X BW

FLUID RESUSCITATION FOR BURN

Massive fluid shifts occur during this period that can lead to a severe impairment in oxygen delivery to tissues. An understanding of these early fluid shifts is necessary in order to avoid hemodynamic instability and initiate the appropriate treatment modalities. Appropriate monitoring is also necessary.

Lund and Browder Chart (Accurate but time-consuming compared with the ‘Rule of nines’)

Rule of nine :

arm: 9%;

front of trunk 18%;

head & neck 9%;

leg 18%;

back of trunk 18%;

perineum 1%.

This generally overestimates burn area (better than underestimating). It is even accurate for those <10 years old.

A modified rule of nines for children :

From birth up to 1 year, surface areas for head and neck is 18% and each leg is 14%.

For each year, head loses 1% and each leg gain 0.5% - so adult proportions are reached by age of 10 years.

Fluid therapy

a) minor burns (<20% BSA in adult, < 15% BSA in children)

Encourage oral fluids which contain salt. Make by adding2 teaspoons table salt to 100mls water and flavour with orange squash

b) major burns ( >20%BSA in adult, > 15% BSA n children)

These patients require IV fluid resuscitation based on 2 separate formulas, 1 for adult and 1 for child below age of 12

The formula are a guide only and may have to be adjusted according to the condition of the individual patient.

The calculation starts from the exact time of burns and not when the pt is first seen. The deficit present when the patient s admitted should be corrected fairly rapidly over the nxt 1-3 hours.

Orally, the pt is allowed sips of water only for the  next 24-48hour to avoid vomiting secondary to gastric stasis.

I ADULT FORMULA

1^st 24 hours

Colloid solution	0
Electrolyte solution (lactated ringer sol)	4ml X BW X BSA (1st 1/2 in 1st 8hr, nxt 1/2 in nxt 16 hr)
Glucose in water (5% dextrose)	0

 

24-48 hours

Colloid (plasma)	20 – 30% BSA = 200ml 30 – 50% BSA = 400ml 50 – 70%BSA = 600ml > 70 %  BSA = 800ml
Electrolyte solution	0
Glucose in water (5% dextrose)	Approximately 1/2 the vol calculated  the first 24 hr

 

II) CHILDREN FORMULA

1^st 24 hours

Colloid solution	0
Electrolyte solution (1/2 N Saline 4.5% Dextrose)	Normal maintenance requirement 2ml X BW X BSA
Rate of administration	½ over first 8hrs ¼ over second 8hrs ¼ over third 8 hrs

 

24-48 hours

Colloid (plasma)	0.25 ml/kg/BSA
(1/2 N Saline 4.5% Dextrose)	Normal maintenance requirement 1ml X BW X BSA

  p/s : rate of infusion is adjusted according to pulse, BP, urine output (adult : >30ml/hr, child : 0.5-1ml/kg/hr)
          in case of smoke inhalation, 4-6ml X BSA X BW

(** all the above informations are a summary of my  readings frm few sources and frm my elective posting learning, so free to leave a comment or if there are any mistakes..)

We learnt about autoimmune diseases and there are some autoAbs which are specifically or commonly found in some specific autoimmune diseases. Here, I try to recall some of it :

 

Anti-glomerular basement membrane Ab ---Goodpasture’s syndrome

Anti-mitochondrial Ab -----------------------------Primary Biliary Cirrhosis

Anti-epithelial cell Ab ------------------------ Pemphigus Vulgaris

Anti-double stranded DNA Ab --------------------SLE

Anti-centromere Ab ---------------------------Scleroderma (limited type)

Anti topoisomerase Ab ----------------------------Scleroderma (diffuse type)

Anti-histone Ab --------------------------------Drug-induced SLE

Anti-platlet Ab -------------------------------------ITP

Anti-Jo-1 Ab -----------------------------------Polymyositis/ dermatomyositis

Anti-neutrophil cytoplasmic Ab-------------------Vasculitis / Wegener’s Granulomatosis

Anti-tissue transglutaminase Ab --------------Coeliac disease

By the way, here are the differences between limited and diffuse type of Scleroderma :

	LIMITED	DIFFUSE
Raynaud phenomena	Preceeded other symptoms by years	Onset associate with other symptom within 1 year
Nailfold capilaries	Dilated	Dilated without dropout
Skin changes	Distal to elbow	Proximal to elbow with involvement of trunk
Telangiectasia, digital ulcer, calcinosis	Frequent	Rarely early, frequent in later course of disease
Visceral diseases	Pulmonary hypertension	Renal, intestine, cardiac disease, pulmonary interstitial fibrosis
Autoantibodies	Anti-centromere Ab	Anti-topoisomerase Ab
Joint and tendon involvement	Uncommon	Frequent
10 years survival	>70%	<75%

 

I've been searching for the answer for such a long time, till i am so so so tired, so so so exhausted....

I've been praying for it, but just then, sometimes i tend to use my way to solve things or to find out the answer that i want. I forgot that God is actually the one who is controlling everything, but not me.

Ups and downs, turning and wandering around the problem. Just without knowing where and when, God has answered me. I m relieved....

Things are not always as what we think or what we want, or sometimes the truth might be hurtful. But, at least we know what is going on and what we should do in future. Time heals i guess.

Things are so simple, and i am the one who made it complicated.

Pasts are pasts, i am letting it go!!! Just as what my friend said, sometimes when we look back, we will feel ourself so silly and i think is quite true.

Things just come to a full-stop so perfectly.