Between Tiger Meat and Inhaler

While I was doing my morning ward work one day, I overheard a visitor talking to the patient's mother:

" I think tiger meat is good for asthma. That what I heard from my friend."

" Yeah? But tiger meat is hard to get. You have to look hard for it, and I heard it is pricey too."

" Otherwise, my grandparents used to serve me crocodile meat when I had asthmatic during childhood. It does cure my asthma. Until now, I never had any attack."

Common cultural practice and medicine is inseparable. As a doctor, you can't stop the patient from practicing what they believe. You can only suggest, but you can't decide for them. Tiger meat, crocodile meat, squirrel meat, termites and even the human placenta are still being use as a treatment modality for bronchial asthma. Do they have a role? Certainly. Do they have efficacy? I am not sure.

Generally, the traditional medicines are cultural bound, passed on from generations to generations and believed to be effective in a way. They are not clinically tested to show their efficacy. The rarer the item, the more therapeutic it become. When does the traditional and modern medicine cross their path? Generally none. We can't force people to take our advice. We can treat a person unless the person want us to treat them. If they take only tiger meat for asthma and be cured of asthma, good for them. It they come in with asthma attack and request for treatment, we will still accepts them the same way.

Everyone has their choice, this I have to constantly remind myself, so not to impose my own value on them.

Doctor, how is my daughter?

"Doctor, how is my father/mother/brother/son/daughter/neighbour's uncle's friends?"

This is the single most asked question I faced during ward rounds and especially visiting hours in the ward. And the most irritating one as well.

If you answer only once to the above question, it's perfectly well. However, when the second visitor come to take shift, they ask the same question again. And then come the third shift again, then they asked again, and again...

Generally, I would predict the worst for the family members. "Oh, your daughter, her condition looks grave. She might need surgery. But everything is 50:50. We can't guarantee her to be 100% perfect after the surgery. She might need Intensive Care support and ventilator after the surgery."

Why would doctors generally do so?

1. We were generally on a VERY TIGHT schedule. I wake up 5.30 am in the morning, reaching the ward by 6.30 am, start working until 7 pm. On on-call days, the working hours will be till the next day, non stop.
   
2. We are generally overworked and underpaid. On top of that, the ministry had slashed 50% of my Cost-of-Living Allowance (RM 100) and 100% of my Housing Allowance (RM 250)for a shared triple room per month. Others get a single room with nice and clean bathroom. Imagine, RM 1050 (350 x 3) for a room that is so horrible?
3. Patient conditions varies by day. No one will remain the same for the same period of time.
   
4. Some family member taking advantage by showing their filial piety by using doctors. Scolding doctors for not doing what they think is doctor's job or not doing fast enough.
5. There is no simple data to what the prognosis is. Everything is calculated based on 50% of the patients with the same illness. And there can be no same patient in this whole wide world.
   

What you can do to help the poor doctor:

1. Please keep your relatives informed about patient's general condition. We will help to bring updates, not to start storytelling one by one.
2. No BS in front of the doctors. We shall know who is the real and who is the fake.
3. Help doctors to help your love one. Let us do more important things to help your important persons in life.

We can't work alone as doctors. We need collaboration from all area. So please help us. Help me.

OCD: When Heart and Mind are not Functioning as One

Have you ever have a feeling that you need to go and check the car, strong urge that it wasn't lock, only to find out later that it already was?

What about waking up in the middle of the night, fearing that you didn't shut the gas stove properly, and the thoughts keep on haunting you until you need to go and check it?

What about having all this symptoms, but en core over and over again, say, 10 times until you exhaust yourself? This is what an Obsessive-Compulsive Disorder person is going through.

Let me share a story:

Mr. Garry, 38 year old gentleman, assistant research personnel in a well known company, married for 15 years with 2 children. Since his teenager years, he started to experience excessive worrying whenever he is stressed out or under pressure. At times, the symptoms worsen until he felt like ' going to die'. With the attack, he heart beats faster, and he feels suffocated, out of breath as well. He tends to avoid crowded places whenever possible and seldom like to adress in front of his colleague. He is afraid of 'losing control of himself'. Generally speaking, his functions deteriorate with the symptoms. He smoked cannabis in the teenagers years but denied sharing habit now.

This persist until 8 years ago, his wife noted he starts to act strange. He would drive his wife to school everyday, but halfway through the journey, he would turn back to go and check the door again. This does not happen only once, but up to 7 to 8 times in a day. Halfway though work, he also can't fight the urge to go back and check on every electrical switch and gas stove. Subsequently, his wife is always late to school; the employer in his company aren't too happy for his absence from work. Despite knowing that the door is lock, there is repeated intrusive thoughts of not locking the door and internal urge to go and check again. This problem has worsen the relationship between he and his wife.

His problem came to medical attention when he went for a general practitioner, who subsequently referred him to a psychiatrist. Proper assessment of his problem was done and a diagnosis of OCD was made. He was given medications and behaviour therapy. His symptoms improved but there is still some degree of checking behaviour. So he device a method: using his phone, he took photos of the lock, the electrical switches and gas stove before he left. Whenever the thoughts came back, he would just check at the photos. Brilliant!

There are a few types of obsessional behaviours.

Obsessional (O.) thoughts is the repeated thoughts that intrudes the patient and patient will try to exclude them, labeling them as unreal. This differs from delusions, where patient entertains the thoughts and believe them as real. Furthermore, you can't change their false beliefs.

O. images are intrusive pictures, usually obscene and related to abnormal sex practices.

O. rumination is the internal debates that keeps on going on and on.

O. doubts is where patient have repeated doubts on locking the door or turning off the tap.

O. impulses is a form of urge to perform a violent act.

O. rituals are repeated senseless activity.

O. phobias is fear that one would loss control and harm someone else.

O. slowness is the recurrent thought that eventually leads to the slowness of the person.

The aetiology is believed to arise from genetic factor, organic factors and early childhood experience. Family members with history of OCD running among the members will have higher risk of getting OCD. Organic factors refers to lesion of the brain, medication or drugs used. and early experience that shape a person's personality is thought to be important to the development of OCD.

Treatment is by avoiding the rituals, medications and behaviour therapy. This disease is usually recurrent and requires long term treatment.

DA Blues

Developmental assessment (DA) has always been a crucial part of learning in paediatrics. You will never be complete in paediatrics if you do not know about DA. It is single most frequent task to be asked during our short case examination. Even a post-graduate student can fail their final clinical exam when they fail this DA.

DA is easier said than done. It requires the full cooperation with the child. If the child mood is not good, you can imagine what will happen then. It is like a minefield waiting to be stepped on. If the child cries, we won't be able to finish the assessment, hence the examiner will penalized us.

This week, I was at home for my Chinese New Year break. Exam is scheduled to be next week, so there are a lot of things to practice. Naturally, my nephew is the good practice candidates. He is about 3 years old, very cute and active little chap. Now he loves scribbling and drawing and he kept a book for his drawings. Mostly were pointless scribbles, but there was a page that caught my attention...

At 3, he was drawing a man already! The features of his 'man' are a big round head,with 2 eyes, a nose and a mouth. The torso and limbs are sticks. What amused me is that he must add in a 'penis' in every man that he drew! The reason? The man need to pee!

Drawing a man is usually started at 5 years old. There is always give and take in assessing the developmental status. DA has four parts: Gross motor functions, fine motor functions, visual and speech and social behaviours. Some children has slower aspect of certain developmental status than others, but eventually most will catch up. Most importantly is adequate stimulations from the parents and caregivers.

At this point of time, he is able to speak 2 languages fluently, which is mandarin and malay, thanks to the maid. Stimulations from the start will ensure a good developmental status! Keep on stimulating, guys!

Life in an Incubator

It's just a norm! We human will not appreciate certain things around us when the things are aplenty. We take things for granted. Here I want to share 2 stories:
Last week I was posted into the Neonatal ICU, and I was taking care of this little life. He is just a premature boy born at 26 weeks (a normal pregnancy would go to 40 weeks, he is 14 weeks short!). Weighing just a little bit over 900 gram, he has a dark complexity and a body covered with fine hair (lanugo). He is slightly bigger than my palm. There was a respiratory machine hooked up with countless of continuous monitoring going on in him. This little soul was moving his tiny hand when I first saw him. Every breath he took seems so full of effort and every minute passed is a blessed moment that he is still alive. Although he had a number of complications from being very preterm, the will to survive is very strong.
On the contrary, I have a friend that had quited medical school just at the dawn of the final examination. Heard that medical life was not his thing and that he will never walk down this road again. It was a shock to all of us as a friend as the move he took was drastic. Everyone was screaming that this is a very big waste. Alas! The life is his. Whatever path that he chose to take in the future, I just wish him good luck and he will find his way someday.
Someone is letting go, yet someone is striving very hard to live. This is how contrary a life can be. Hope you found your way.

Hunter's Hunted

I write this post as a tribute to a young little soul that had laid to rest in peace earlier this week.

In paediatrics, students are trained to do a quick but thorough general examination as that yields the most findings and guide our further examination. Most of the time, we like to divide the patients into 'syndromic' facies and 'non-syndromic' facies. So one fine day in Teluk Intan, I came across this boy, with a typical 'syndromic' facies. I couldn't make out what syndrome he has, but generally, he looks too small for his age. There were abnormal movements as well. He loved to do 'scratching' activities, which is purposeless from my point of view.

The main reason that he came in was due to pneumonia. He had multiple episode of similar illnesses in the pass, according to his sister. As usual, when we as student do not understand certain things, we go straight to the case note. He had what we called a mucopolysaccaride metabolism disorder, leading to what we called as Hunter Syndrome. That raised further questions to me that night, as I never heard of this illness before.

Usually, Hunter Syndrome is a progressive illness with no successful therapy so far. The victims will live up to adolescent or late teens and usually die of the complication of the disease. This is one of the rare illness that we don't want to get. Maybe that is why he succumbed this time. I talked to the mother before, she was already in the stage of acceptance before the child passed away. She said it will do both of them good, as he doesn't need to suffer any longer and the parents can concentrate on the other siblings. So she opted not for intubation in case her child fails to breath by himself and refuses any artificial ventilatory support.

When the child was gone that day, the mother cried her heart out. The whole family cried for his loss. That makes me think again. No matter what the mother opted for, I will support her decision anyway. They were the one that faced him everyday. Sometimes, there were no right or wrong answers. There is only choice. With any choice made, we sacrifice certain things. What matters is how big the price we pay. when we earn something, we will give up something. Isn't that the way of life?

I just hope that this boy found his lasting peace. Sadhu.

Neglected Child

Last week I just came back from a district hospital in Perak. Nothing great about this hospital, just a small facilities to serve the local population. Doesn't even have a CT scan machine. I was posted to paediatrics in that hospital for a week.

The patient populations mainly from the lower socio-economic status. Mostly are children of estate workers, lorry drivers and fishermans. However, there was one little girl that caught my attention...

She was admitted on Tuesday. She was about 8 or 9. Short-haired, dirty ragged shirts and worn shorts; the first look give me the impression that she is a boy! She had a very red lips. Generally, she looks undernourished. There were multiple healed scars over the shins. She was crying frantically and the father threaten to throw her into the ditch. OMG. The father was a middle-aged man, dark skin and was having walking difficulties evidenced by his walking sticks. Mother was no where to be seen. A closer up with the father revealed nothing much except that this is his daughther. He didn't even know whether she was born full term or not, vaginally or through caesarian, and what illness that she is having. So I checked out the case note. She was a case of dengue fever. Not quite... Further down the page, there was a segment mentioned that she had a heart surgery done in Institut Jantung Negara (IJN). They were supposed to be followed up in IJN, but the parents did not able to make it due to extreme financial constraints.

This poor girl had a hole in the heart that requires a 2-stage surgery. Yet she had only completed first part and the second part was already long due. So I examined her. Heart was not only enlarged, there was also cardiac murmurs. She was in cardiac failure but not taking any anti-failure maedications. This is like a time bomb waiting for the moment to come... Furthermore, she had sacral agenesis, most likely due to mother having uncontrolled diabetes mellitus when she was pregnant. Subsequently, she is not toilet-trained till now. There was walking difficulty as well as both her limbs were stiff. In fact, she was not able to attend the elementary school for this reason, despite already 8 years old.

She had 4 other sibling, 2 already given out as adoption to some other family members because the parents weren't able to rear them. Now left with an elder brother at 13 years old. The brother loved the sister very much. They slept in the same cot together (despite not able to fit both of them together) and the sister seems much happier when the brother is around.

Father had accident a year ago, left him with weakness and was unable to work as fisherman. Instead, he is doing some odd job now. The income shrink from RM 1500 a month to RM 250. Mother is a housewife. They received a minimal monetary support from government for their daughther, for about RM 190 a month. How can a family live a decent life with just RM 440 a month? To add on to the problem list, the mother is also currently a diabetic which was not on any treatment.

I can't help myself thinking, what if she was borned in a different family, will she end up becoming like this? For the least, the parent can bring her for follow up, and she might not end up having a heart failure. I don't know how is her diet, but what seems clear was she was not eating enough and well. Just few hundred km away, a girl who was loved, cared so much but was being abducted by some sick paedophiles. The whole nation is on a lookout for this child. If this patient is lost one day, will her lost even be noticed by the parents? I doubt that a search party will be conducted to look for her as well. After all, she is just a poor child borned in a wrong place at a wrong time.

More Than a Cageful of Tears

Here I am again. My story never ends, or rather my agony never ends. That day, everything seems like a turning point for me. That day, one fine couple came and see me. Immediately they had fall in love with me. They were saying something like 'adopting' me. I was over the cloud nine. How I wish to have a family, to call 'papa' and 'mama' when I learn to speak one day. Some one would care for me, caress me, hug me and play with me.

Alas! Everything was like a dream.


Being born prematurely into this world, it has taken toll on my body. Some part of my system is imperfect. Few weeks back, I don't know what the 'big people' are talking about, but I overheard that they want to do something to my body. Something like 'surgery'. Something like putting me to sleep and then open me up. That idea sounds scary. What will happen to me then? But don't harm me, please!

That night, an angel came to me and spoke to me. She said the family supposed to adopt me changed their mind. This is because I am not perfect. She said I need to be brave. To endure what lays ahead. And I need to be strong! I cried that night. Knowing that the fragile dream is already broken to million pieces, I am back to square one. Again, I ponder this question. Being born like this, is it my mistake? Why I am subjected to so much of human cruelty? Why am I being so unwanted? The angel left. Again, I went to sleep with all the questions unanswered.

Obesity and Adiposity: Friend or Foe?

People are in denial, I am also in denial. Obesity... it is always a weighty issue. Whenever climb onto the weighing scale, the mood of day can change. If I indulge in something good previously, I will cautiously check the scale, fine-tune the '0' mark and then only weigh. If the weight just maintained, I would be very happy. On the contrary, if I add another precious kilos onto my already 'heavyweight' frame, the following days will be dreadful.

Why are people getting obese? As far as I understand, the body weight is maintained by a balance of input and output. Input is from what we take or drink. Output is the energy expenditure. Obesity occurs when the balance of input is more than output. Too much input occurs when we overeat. Too little output means we lead a sedentary life style, working 9 to 5 in front of computer and is a potato couch. Simple explanation, rite? Not so...

Our desire to eat is govern by a complex brain activities called the satiety centre and hunger centre. Long time ago a bunch of scientist did experiments onto mouse; first they destroy the part of the brain believed to be satiety centre, thus the mouse always in hunger and no end to eating. In the end, they produced a super-obese mouse (pity the mouse). Based on the concept, some slimming medications were created so to decrease our desire to eat, which are of amphetamine-based.

Genetically modified mouse that knows no satiety.

Furthermore, our eating habit is also governed by our mood. We overeat when we are happy. During festivals, we (over)eat to celebrate. When we are sad, eating sometimes help to calm the mood and sooth the nerves. When we are promoted, feast. When we are demoted, compulsive eating. Chinese New Year, bigger feast. Our life has been surrounded by this concept of live to eat instead of eat to live.

The simplest method to determine whether you are simply overweight or obese is using a body mass index (BMI) calculation. The formula is:

BMI = (Weight in kilogram)/(Height in meter x height in meter)

For Asians, the body fat is more compared to Caucasians in similar BMI value. So we adopted a lower cut-off point for BMI. Normal range would be between 18.5-22.9. Below that is underweight. Overweight is a general term to grade a BMI more than 23. For a range of 23 to 27.4 is considered pre-obese. 27.5 to 34.9 is Obese Type I which has moderate heart and diabetes risk. 35.0 to 39.9 is Obese Type II. More than 40 (Obese Type III), you are running into a very high risk for all the disease of the rich people.

Other method of measuring cardiovascular risk is by taking a waist circumference. For men, the risk is increased when WC is more than 85 cm whereas for women, it is more than 80 cm.

So, Now you know where you stand. How do we tackle the problem?

1. Determination. Do you feel like you want to have weight loss? What is your target weight? How much to lose in how long a period? What method to achieve weight loss? If you have no answer to all the questions above, you are not yet ready. Buckle up, my friends. Determination is the first step to success and to maintain weight loss.
   
2. Keep a food diary. Record what you have eaten over 24 hours. Include all the main meals and snacks. Be honest to yourself. This will ensure that you aware of what you are taking, and not to be excessive.
   
3. Regular exercise. No one can help with this except you. As mentioned above, you need to have good output, so to tip the scale to a negative balance. Exercise for about 30 minutes for most days in a week. Studies shown that exercise help to makes you feels better, not to mention healthier as well. Some mild degree of hypertension can actually be controlled by exercise alone.
4. Food intake. Although some fad diets claim to help achieve weight loss, I personally don't recommend them. Stick to what is easy to attain, cost-friendly and most importantly, palatable. Don't try out fancy fancy stuff that in the end you cannot stick to your plan and all equal to zero.
5. Drugs. There are various types of medication used, but I will only discuss a few. First type is Orlistat, which is able to decrease absorption of fat from alimentary tract. Next types are appetite suppressant such as Sibutramine and Phentermine. Sibutramine not only reduced the appetite, but also help in increasing the metabolic rate. However, the use of this medication in hypertensive person must be cautious. Phentermine is amphetamine-based medication which has side effect of increase blood pressure and insomnia. Otherwise, medications that was proven to be ineffective are cellulite treatment, dietary supplements such as chitosan, fibre capsule and herbal preparations. Laxatives like slimming tea should not be used because of ineffectiveness in treating obesity. Usage of amphetamine, dexamphetamine and thyroxine is dangerous, and should not be used at all. Please consult your doctor about the choice of treatments.
   
6. Surgery. It is reserved for severe and morbid obesity where reduction of 50 to 100kg is required. Type of surgery includes gastric reduction by doing a vertical banding of the stomach or inserts a constriction bands around the stomach. Other types includes gastric bypass, which is to shorten the gut and induced malabsorption. Liposuction is not for generalized obesity, but to help getting rid of local fat or for cosmetic reasons.
   

Always ask for help. Ask your doctor about options available. They should be able to help you. You are not alone.