Library

Do you remember those days? Slogging it out in the main campus library at Auckland Uni. For me, that was about 13 years ago.. Robbie Williams's "millennium...." pounding out from the aftermarket Panasonic speakers, custom-fitted in my silver jap-import Mitsubishi 4-door Mirage. 

We (me and a handful of mates) were quite particular about where we wanted to sit. It had to be the 5th floor, the English literature and Arts section. The view of the city was the best from the 5th floor you see, and it was the most popular floor for everyone. That meant going there early to "reserve" our desks - putting a notepad here, a bag there, and a jacket here, so no one dares occupying our corner. We would disappear for lunch and dinner, leaving only when the library closed its doors at 11pm sharp. The rest of the gang would go home, and I would join Anthony in the Engineering Lab, till the mercury drops to 5 degrees or so. Those last few hours in the day were probably the most productive. Hardly anyone used a laptop back then, what is the point when you couldn't connect to the internet? An Ericsson T28 was as cool a gadget as you could get. What phone were you using then? I can remember my "banana" Nokia 8110, and of course the changeable shell of Nokia 232.. Who would have thought Nokia's phone division would one day be bought out by Microsoft?

When my son, in 15 or so years from now, tells me he's going to the library to study, I'll know what he is up to.

Thank goodness WiFi was not widely available back then.

Fast track to 2013. I found myself once again sitting in the library - Health Sciences Library in Uni of Calgary.

Hospitals

Prof Harry Rea gave a Grand Round lecture at Middlemore a few years ago. He eloquently talked about how his grandchildren might ask him the following..

Granddad, did you really worked in a ward where no one had time to answer telephone calls, patients have to wait for long time to be taken to toilets, and there are always all these people milling around the few computers in the nursing station but they don't really have time for you? I heard that when you're sick, you're likely to see 20 or more new faces in one day, some of them introduce themselves, some don't. And even if they introduced themselves, you don't really know who they are, what they do, and why you're seeing them. How embarassing must it be, especially when you're in those hospital issue PJs....

So why aren't I surprised when I read this piece from the Royal NZ Herald? Because what she described is all too familiar to any healthcare workers in New Zealand, and dare I suggest, any public hospital worker in the Western world. Why restricting to the Western world? Because in the Developing world, for example China, India, Vietnam, you don't even get the basic treatment if you have no money.

Now, the Surgeons say the appendix was not inflamed, but the mum reckons it was. Who do you believe? Probably the surgeon. But yet again, it proves the point. It is not the fact that matters, it is the perception that counts.

Medical podcasts

American College of Cardiology

Annals of Internal Medicine

BMJ

AAFP CME

Journal of the American Medical Association

Johns Hopkins Medicine

National Institutes of Health

The New England Journal of Medicine

laws, morals, virtues, and ethics

So Boobs on Bikes will go ahead, Judge Mathers said the decision was made by considering the law not morals. Also she said "some councillors may deem the parade to be offensive" but she did not agree, even if it was tacky.

Yes, laws need not to be morals. The struggle for abolition of slavery comes to mind.

Primary school principal Mrs Armstrong is struggling too, she said "reports of increasingly violent and unacceptable behaviour in primary schools were indicative of a society losing its moral base and leaving schools to deal with the result."

Yup, we've heard that one before. Yes, Auckland Mayor John Banks said something similar a while ago as well. He said he is against the Boobs on Bikes. Yet the laws, or the system, is structured such that as a Mayor, he can't really do much about the parade either. What a shame.

Elsewhere, the headline reads "Doctor facing charges of sex with patient". The Health and Disability Commissioner found that under certain circumstance, even if sex was mostly consensual, a relationship can be deem unethical.

The current "go easy", generally "non-confrontational", libral, "it's-ok-as-long-as-it-suits-you" culture in the society is rampant.

Medical advances, as with most things, can be a two way sword. One example is the pill. FDA approved in the 50s and highly effective as a mean of contraception. In human history, never before had sexual activity been so divorced from reproduction. Morals aside, the social consequences of pre-martial sex and promiscuity is probably beyond the imagination of those who developed the pill in the first place. It's interesting to know Japan didn't approve the use of the pill till 1999.

Comparing Losec to Herceptin?!

I'm not sure whether one can call "Indigestion" a self inflicted, lifestyle disease, but at least Dunedin GP Dr Sue Walthert think so. Which ever way you look at it, I think it's still really drawing a long bow.

Many doctors hate Pharmac, whilst I can understand their views, I often can't identify with them. Pharmac can never please everyone.

So good on Matthew Brougham, Pharmac's CEO. One can argue his article is very well "staged" but I don't care. At least, to me, what he says make sense.

Nurses are the worst patient, ask any nurse and they'll tell you the same. Doctors? possibily even worst. Ha... yes.... i'm being inflammatory and stereotyping too.

"Life … is a search for the true, the good and the beautiful," ..

Everyday we are exposed to new information which challenges our own pre-exisiting ideas.

Today at ACH's Grand Round we were told that the majority of HIV patient in New Zealand these days have no risk factors for contracting HIV. I didn't know about that before.

On the otherhand, this piece in the Sydney Moring Herald echoed deeply with my thought process at the moment.

"Life … is a search for the true, the good and the beautiful," the Pope told the pilgrims at the Hungry Mile last week. "It is to this end that we make our choices; it is for this that we exercise our freedom."

Miranda also pointed out that "Living in an era when faith and reason, art and mathematics, were inextricably linked, Renaissance artists would regard modern relativistic notions of beauty as ludicrous."

headache

Mrs M is one of those "heart-sink" patient. One that you try to avoid to see in your morning ward rounds.

I assume, for one reason or another, she hasn't been looking after her health for years. She has poorly controlled diabetes, on inuslin, had her leg amputated a few years ago and she still smokes. At a young age of 53, she was put on warfarin for her PAF some years ago. Strangely, her INR hasn't been all that bad.

She came in 4 days ago, with 1 week history of vomiting and diarrhoea. BSL was 30. The admitting registrar's impression was: "mild HONK, gastroenteristis, dehydrated".

On the ward round the next day, we tried to control her blood sugars better by adjusting this and that. Requested a diabetes nurse review... etc, hoping she'll be well enough for discharge within the next 24 hours. Why should we kept patient in hospital when they don't stay in the ward and keep wondering off smoking?

Day 1, dry retching somewhat settled. Day 2, a little better, but she still looked miserable. Day 3, she told us that she has a headache.. "how long has it been there?" I asked, as I was about to walk out of the door.. "3 weeks", she said quietly.

Well, that prompted me to do a full neurological exam, for there was a Fourth year medical student with me on the round, I can't really dismiss a complaint like that. Fundi looked normal, no focal neurological defect, no neck stiffness, no history of head trauma recently.. well, no red flags to her headache really.

A CT was ordered anyway, as she just didn't look right.

The CT showed acute on chronic subdural haematoma, with midline shift that even a fourth year student can see. She was transfered for neurosurgery within hours after the CT scan.

I wonder what's the moral of the story.

Headache from the Annals

Etiquette-Based Medicine

An article from the NEJM stated the obvious - a bit of manner goes a long way

Tears

I, along with a few in my team cried today. At work. Towards the end of a family meeting.

My role was to explained to Mr T, a non-resident who's been here for many years, and his family, that his immediate short term prognosis is grave. That there is no immediate cure to his cancer. Because he is not a resident, we're limited in how we can treat, and support him.

I, along with the rest of the team, all managed to "keep our cool", until Mr T, a Tongan man who, still have all his mental facilities intact, graciously thanked us for what we have done.

We were moved, genuinely moved by his generosity. For we have done so little. Our tears may also be an indictment to the care our dying patient receives.

lottery

In less then a few weeks, hundreds of registrars will be sitting the written FRACP paper. Most would have spend hours and hours of study on this post grad exam. Relationships ruined, old friendships broken and new ones made. It is, for some, a life changing experience, for better or for worst. It is however, a highly dissatisfing exam. Why don't you get to know what you got wrong??? It is not an ideal learning experience, at all.

Medicine is full of this sort of nonsense. The selection process is biased enough. Ha, it's all about 'traditions' isn't it. For what evidence can you show me to suggest an interview process select better doctors?

To those who got in this year, congrats. You may not save lives when you finish medical school, but you certainly bought yourself a "life insurance", a guaranteed income for the years to come.

To those who didn't, well, join me on my 7th night shift in a row and you'll be enrolling in anything but medicine.


Andrew Norton

Entry test for medical program

The use of lottery system in school admission

disquieting stuff

Everyday, I'm surprised by how much I don't know. Quite, disquieting.

How can a drop of Pilocarpine, or even better, a bit extra history from patient, can save a getting a head scan? read on.

Heard of the notion of complete disease remission for newly diagnosed overweight diabetics? We all know losing weight helps, but there are probably more to it then just weight. Surgery, again, may be the panacea.

When asked by my patient "where you came from doc?", I often proudly proclaim "Hong Kong, been here 16 years!" I remember one patient asked me the same question a few months ago, but somewhat in a apologetic way, as if she really just wanted to find out where I'm from, without wanting to sound insensitive. The fact of the matter is, I have no issue of people wanting to know where I came from, for it's obvious from my looks, name, and accent that I'm not a NZ European. People will alway see race and ethnicity as defining characteristics, but I agree with the author of this article, that we should aim to "embrace the commonality of human experience that binds us together". Similar to vicar Glynn Cardy's view when he "camped with the Mormons"

Speaking on quality of care, until the day when a sample of every practicing clinician can pass both the written and clinical part of FRACP every year, I doubt anyone can think the Physician exam as it stands as a "relevant and meaningful measure of cognitive competence".

When is someone "disabled"? A brief review on how society sees and define disability.

We we giving out Losec like lollies?

Photo credit

Assuming the worst

From this week's journal watch:

Patient with disabilities, are you doing them a disservice? This piece examines this issue with humility - Assuming the worst

Is it knowledge, attitude or skill that your "problem junior" is lacking? A bit of a utopia piece for the rest of us but nevertheless an interesting read - The Problem Junior

These academics from my alma mater, a few I had the pleasure to worked with in the past, came up with this editorial piece. On the elusive grail of health service quality

The way we live

It has been a busy and interesting start to 2008..a few interesting observations

My trusting mortgage broker friend told me we all have to work on our relationships. Working hard on our "day" job is not good enough - for before you know it, your "day" job will be all you have.

Rather then just listening to Mike Hosking on Newstalk ZB and the occasional switch to The Edge, the BBC world service on 810AM is rather refreshing. Although it's not till I saw the flags at half mask on the harbor bridge that I learn Sir Ed passed away

Whilst we live in a "free world", we have access to internet.. can express different opinions.. etc. We have to try hard to keep a wider perspective. We do this whilst holding on to our beliefs hence doesn't make us "principle-less".

The anger of one angry person should stay with that person. For anger is like fire, it spreads in no time.

We see what we seek for, and often nothing further

The writers for Boston Legal are brilliant

Two interesting links:
http://www.ekklesia.co.uk/
http://faithinsociety.blogspot.com/

One of the things that makes my life interesting is, the consult is never about "a case of heart failure", it is about one person touching on another person's life.

doing our job

Doctor: I'm going to ignore the troponin, there's no evidence of heart trouble
Nurse: What do you mean you're going to ignore the trop, it's up
Doctor: It's been up before, he has no chest pain or ECG changes
Nurse: What is it normally? 0.28? this is high, have you talk to someone?
Doctor: Yes, but he has no chest pain, no ECG changes, I talked to a consultant, a chemical pathologist to get a Trop T done.
Nurse: So who are you?
Doctor: I'm the medical registrar, he won't arrest on you in the middle of the night
Nurse: Oh... ok, have you documented all this?
Doctor: Yes i have, here you go. Do you want my home number just in case?
Nurse: Yes doctor! haha..

You can't blame the nurse for being annoying, she's doing her job, afterall, despite in a very confrontational manner.

Everyone is better off with a laugh.

Hope

From this week's "journal watch":

Arson, Monk, and vertigo

Giving back

Merry Christmas everyone

back to work

Back to work today, to the start of a challenging 6 months.

A dying patient's view, and all those around her in "A piece of my mind"
An article on issues around Advanced Dementia
An excellent piece to read when the going gets rough at work - the role of doctor

last day of the run

Today is "the last day" of my run with the Stroke Team at MMH. Finished with 5 night shift, with 1 week of leave next week.

It has been a great 6 months, learn heaps, did heaps, had a great team and enjoyed every single bit. Again, like at the end of my run in OPH last year, I'm once again humbled by the courage of those who came in with an acute stroke - it's like a puncture tyre, so sudden and one's life get turned upside down. For a puncture tyre can be fixed in minutes, one's life cannot. It is in those moments, one's faith sees one through.

Look forward to the next 6 months in MMH, it's gonna be great.

CMDHB Clinical Science Symposium 07

The "Young Investigators Award" belongs to this team of dedicated people at the Acute Stroke Unit.

Nutcase

It suprises me how some registrars can ask their house officers to do the impossible; to request unnecessary/non-urgent investigations yet expect the tests to be done with urgency by other departments.

Communications help, but not if the boss is a nutcase!

The whole

The cure of many diseases is unknown to the physicians of Hellas, because they are ignorant of the whole, which ought to be studied also; for the part can never be well unless the whole is well . . . this is the great error of our day in the treatment of the human body, that the physicians separate the soul from the body.

Plato (Greek philosopher, c427–347 bc)