It's Ok...

It's Ok not to shake your doctor's hand...

... especially if you have just been digging your ears during the consult.

FYI: Doctors are anal about contamination and we (really, really) hate to wash our hands.

Halloween Special: Those Little Devils

I remember last time as a kid, I go see a lokun, always very scared. My neighbourhood family doctor was not at all friendly, he was the very stern, never really smile type. In the clinic, the mothers would be busy telling the kids to keep quiet and if the children were too rowdy, they were brought outside for a good scolding. In fact when I was growing up in the 70s/ 80s, you hardly see rowdy kids in clinic because parents only bring you to a doctor if you are really really sick (or not just drink leng yong at home la).

Yes, in those days, clinic was quiet except for some "Shhhssshh" from parents. The kids were all waiting and trembling in fear of seeing the doctor. It didn't help that in those days, lokuns also like to give injections for everything. Fever, kennah jab. Vomit kennah job. Stomache, kennah jab. Ah pek cannot mari kita also kennah jab (but by chiobu nurse)! My mother was a firm believer in injections and always said, "Ah boy ar, get injection liao then immediately will recover!"

Funny thing is that the injections really worked. Even funnier thing is that until today I cannot completely figure out what the GP jabbed me with all those times...

But injections are not the point of this post......

Fast forward 30 years, kids RULE the clinic. These days as we become more affluent, parents bring their kids to a paediatrician rather than your friendly neighbourhood GP. The paeds clinic are nicely decorated in bright colours and have play areas for the children. The children arrive in style inside their gi-normous ride, the branded strollers! Parents will then park these ostentatious things strategically so as to block everyone else in their way.

Instead of a quiet and sterile atmosphere, you have kids screaming and wailing at the top of their voice. Instead of adults disciplining kids, they are running after them, coaxing, pandering and bribing them with sweets, iPads and PSPs. The kid has got to wait for the doctor, WAIL. The kid has got to get his temperature taken, WAIL. The kid has got to be auscultated by the doctor, WAIL WAIL. The kid has got to get an injection, both kid and mother WAIL WAIL WAIL.

Of course kids don't cry all the time. Sometimes they enjoy themselves sucking lollipop and leaving their sticky fingerprints and HFMD enterovirus all over the toys. This is when the parents start trying to get them to perform tricks like clapping hands, hi-fives, roll overs, sit, fetch the frisbee..... And the parents coo over their children, "OOoooooo look so cute, ar boy just made an angry face at the doctor." Man, no wonder the kids are pissed; being treated like circus monkeys.

And me in a not too distant clinic room (heng I don't see kids) can almost hear those kids shouting, "WE ARE THE KINGS, YOU OLD FROGGIES GET OUT OF THE WAY!"

Moral of the story?

from http://www.beansbeans.blogspot.sg/

If you don't know what to dress up as during Halloween, why not try dressing up as one of these little devils. They will surely scare the hell out of your healthcare-worker-friends!!!

The (Flat)Line Between Life and Death

Disclaimer: All characters depicted dead or alive are fictional. Any resemblance is purely due to your own imagination.

One of the first thing you learn as a medical student is that in Medicine, 1 + 1 is not always equal to 2. To put it simply, if the ah pek (whom I often abuse in my many stories) take two Viagra, he is not going to enjoy himself twice as much. This was not an easy concept to grasp for someone like me who liked hard concrete numbers and predictability. 

Eyes Wide Shut!

The fact is that things are never straightforward in Medicine. They are never black and white but shades of grey. Unfortunately these shades of grey applies to Death as well. How do we really know if someone has died? Is it after that last breath he took like in the movies? But what if his heart is still beating? What if his brain is still thinking? And what if his eyes are still looking?

Flatline - Asystole

To verify and pronounce death, the attending doctor has to first make sure that all resuscitative efforts have failed or the criteria of not resuscitating are met. There should be no pulse, no breathing, the pupillary reponse to light and corneal reflex are absent and there is no response to painful stimuli. In the hospital, an echocardiogram (ECG) has to be performed to show a flatline.

On call one day, I was asked to attend to an elderly patient who had collapsed. He had the DNR (Do Not Resuscitate) status and there was really nothing much I needed to do. By the time I was there, there were no pulse or breathing on auscultation, no constriction of the pupils when the torch light was shone on his eyes and no response on sternal rub or supraorbital pressure. I hooked up the ECG lead from the defibrillator but there were still wriggly lines and waveforms on the monitor. I needed that flatline and a printout to demonstrate asystole (complete stoppage of the heart) before I can pronounce death. The time indicated on the printout is also used as the time of death.

After waiting for a few minutes, the ECG did not looked like it was going flat any time soon. I instructed the nurses to keep the monitor on and to call me when there is a flatline as I had another emergency to attend to. In the middle of the night in the hospital, you are IT and I had no time to waste.

15 minutes later, I was back up in the ward. When I got to the bed, I was shocked to find the bed empty! I ran frantically to the nursing counter and one of the staff nurse told me that the patient had been pushed to another room to be with the family for mourning. I went, "What the fxxk! What about my ECG strip!"

The staff nurse reassured me that she had already printed the strip and proudly passed it to me. I took a look and went, "What the fxxk! This is not a flat ECG!"

My heart literally sank as this was not a flatline ECG and was STILL full of wriggly waveforms. The patient has technically not be pronounced dead and I needed to retrieve the patient / the body to get the proper ECG! I had no choice but to sheepishly enter the room where the patient /body was with an ECG machine. About 8 relatives were by the patient /body wailing loudly. I was a junior doctor then but I knew that approaching emotional relatives often resulted in catastrophic outcomes. I apologised to them for interrupting and asked if the relatives could excuse themselves for five minutes. Miraculously (yes in Singapore, nice relatives are miracles!),  they were kind enough to comply. I managed to get my ECG strip and quickly returned the room and the body to the relatives.

As I stared at the flatline on the ECG strip, I wondered if there WAS a distinct line between life and death.

Perhaps we will find out for ourselves one day...

or perhaps we won't...

Toilet Games Part 2

Someone left a comment that PJ / pang jio / urinating takes only a short time and the doctor should just go ahead. Of course not every lokun will hold his bladder for his patients (sounds darn wrong but I have no other way of putting this across). I have caught Medical Officers leaving halfway during their clinics to eat fishball noodles in the market across the road while their patients were waiting for them. For me, I really don't like to keep my patients waiting. When I go for my own medical appointments, I go on time and I expect to be seen on time. Likewise I try my best to accord the same courtesy to my patients.

A full clinic runs for about 4 hours. You would think that it is actually quite reasonable for a toilet break of 15 minutes to be included in a typical clinic schedule. But the hard truth is that in Singapore, none of the clinics in public hospital have toilet breaks scheduled. In fact the administrators like to double book or triple book a slot. Which means you are always trying to catch up and there is really no time to go pang jio la. It is not like Dr Og never feedback about toilet breaks to senior management but they just laugh in my face. You can't hold your urine, you better not be a doctor :(

Say I bochap that the patients wait until frustrated and still leave the room to pang jio pang sai, the patients see you leave the room dunno go where sure even more pek chek. Wah like dat sure tiok complain. But it is also quite strange for the clinic staff to broadcast through the PA system, "Dr Og from Room 10 going toilet ar, tolong tolong you all wait a while. He tahan a few hours already."

Some clinics also don't have staff toilets. So you quickly cheong out of the room, avoid the stares of all your patients waiting, cheong into the toilet, start PJing into the urinal, only to realise the person next to you in the next urinal is your patient! Worse, he looks over to your side and says, "wah lokun you very stress isit, stream very weak leh."

You get my point la.

For the above reasons, I prefer to just finish my clinic before attending to my physical urges. But hor, sometimes it is sibei irritating when patients are already late (by alot alot) and when you try to call them in for the consults, the nurse tells you that they have gone to the toilet. Some lagi jialat ones will even go makan first! Wah lau, hospital toilet and canteen very nice meh?

But then I suppose its wrong to expect patients to hold their urine like their doctors. After all, we have years of training through:

1) Medical Student: long boring lectures with super fierce lecturer who will kill you with their stares if you walk out
2) Junior Doctors: Super long ward rounds with lagi fierce Consultants who will kill you if you walk off from the round
3) Senior Doctors: Super long meetings with Chief Medical Board and/or Chief Executive Officer who will kill you if you walk off in the middle of their motherhood statements

(Please do not try to emulate these stunts at home. Like I say, doctors have had special training.)

Hari Raya Haji

Dr Og wishes all Muslim friends and colleagues,

Selamat Hari Raya Haji!

Toilet Games Part 1

From "http://blogs.telegraph.co.uk/news/donatahuggins/100166145/owen-jones-the-new-dave-spart-fearlessly-champions-the-right-to-proper-toilet-breaks/"

Dr Og often feels that one of my duty as a doctor is to dissuade others from joining this terrible profession. If you read my past posts, you would have realised that most of them are horror stories meant to give young impressionable pre-university (I don't dare say JC or not wait say I elitist) youths nightmares on the very mention of medical school. So here goes another one...

As a medical student, it became very apparent quite quickly that to be a good doctor, you have to be quite in control of your feelings. There can be emotional feelings and there can be physical feelings. Even as medical students, we became desensitised to emotions rapidly and soon acted like numb and unfeeling robots. It serves its purpose well when you have to tend to emergencies like resuscitation. You would rather be remembering resus algorithm and dripping sweat than to be all emo and shedding tears. After all, its enough that the nurses are already running around in panic like headless chickens. They are allowed to but as a doctor you ARE NOT. Period.

Whilst Dr Og never had much difficulty controlling my tears (as men we sooner shed blood of the non menstrual kind), I cannot say the same about controlling other orifices where fluids may overflow. Yes, this sounds gross but my blog has never been meant for the weak hearted and you chose to read this, did you not.....

Physical sensations are sometimes almost impossible to control. One day, I was sitting in an orthopaedic clinic as a 4th year medical student and the clinic ran from 9am to 1:45pm. During this time, the kopi-O-gow I had earlier was working its diuretic wonders. But those were the days when you guai guai sit in the clinic room to wait for the doctor you were tagging to come and left the room only after they left first. Going anywhere during the clinic session will earn you cold hard stares from the doctor and nurse and so going to Pang Jio (urinate) was never an option!

At the end of the clinic, the surgeon had obviously noticed my urgency from the frequent crossing of legs to aid my urethral sphincter. He patted my back and said, "You know, to be a good doctor you have to be able to hold your urine and tahan hunger! You will be ok next time. Come let me buy you a sandwich for lunch then we start afternoon clinic in ten minutes"

But..... er, Sir... Can I go for a toilet break first.