Monday, 30 July 2007

Back to Art (Part 1)

I bought a set of acrylic paints to start painting again. Just to get my mind off work. My masterpiece is on a piece of canvas and i am going to donate it to the midwife's coffee room. They may want to auction it to pay for a new microwave oven. Will show once it is completed.

Saturday, 28 July 2007

Cord Prolapse

Just had a cord prolapse about an hour ago. Received a call from patient who had informed us that she had just ruptured her membranes and noted 'something' in between her legs. We had 'blue lights' up to her and i had given specific instructions to the paramedics what to expect and what to do. Midwife was in her car, stepping on the accelerator trying in vain to reach the patient.

Got a confirmation from midwife...'Its definitely cord!' she made her way in with the ambulance.

I have assembled the theatre staffs, anaesthetist, paeds as well as SCBU. Scrubbed up at 0745 waiting anxiously for the patient to be pushed through the two operating theatre doors. The consultant on call was making her way in. It might take a while before she arrives.

In the next 5 minutes, the two wooden doors opened and in came two paramedics in their green uniform..and the midwife on the trolley with the patient in the semi recumbent position, her hand in the vagina. I can feel all the adrenaline rushing through my blood vessels. My heart was beating up to a 120 beats per minute. I can literally hear my own palpitations. The staffs were frantically getting her onto the table. I rushed them.

'Were there two heart rates?' i called out. 'How's the pulsation on the cord?' i asked again. 'It seems to have stopped about 4-5 minutes ago' the midwife replied underneath the surgical drape i threw over her and the patient after i had cleaned the patient's abdomen. I didn't had the chance to say hello to the patient or even looked at her face. She was under general anaesthetic the next minute. My surgical blade just inches above the area where i would make the incision. I performed the fastest c-section i can the very moment the anaesthetic reg says 'go'.

Patient was in the theatre 0755.

She was anaesthetised before 0800.

First twin came out at 0800.

Second twin was at 0801.

Twin one had the cord prolapsed. Pale and lifeless at birth, it took a while before the paeds got the heart rate and continued with their resuscitation. Twin two was crying nearby within the resuscitaire trolley.

I saw my consultant through the small window of the doors. She gave a 'thumbs up' as though asking if everything was alright. I managed a nod whilst closing up the bleeding uterus. She acknowledged.

The theatre was bustling with activities. Nurses running in and out to SCBU. Consultant Paediatrician making orders and registrars setting up lines. I did not hear a single whimper from twin one. I heard somebody in the theatre said 'she's got a heart rate and looking pink now'. I gave out a sigh of relief. At least its not a still birth. We are still to know how extensive the damage was. It would take some time before i get that answer.

I walked out from the theatre after about half an hour. Wrote my surgical notes and handed over to the next registrar on call. Tired. I changed and made my way out from the hospital. 'Were you on last night?' C asked. 'Yes' i answered. 'Hm mm i supposed that's the reason for the mayhem in the theatre, eh?' she teased. I laughed and said 'Well, you know me. Whenever i am on call, things do certainly happened and its almost always busy.'

Its bright and sunny outside. I can feel the warm summer sunshine on my face. 'I hope its going to be quiet tonight' i whispered to myself.

Thursday, 26 July 2007

Switchboard: I have a GP on the line for some advice please...

My bleep went off around an hour ago. Dialled switchboard to reply.

Switch: Switchboard...

Me: Hi..bleep *** obs and gynae SpR please

Switch: I have a call from a GP for advice please...

Me: OK.. Hello G'monin...its the obs and gynae reg here...

GP: Hi..i am 'so and so' and have a lady here with abdominal pain mainly at the supra pubic region. She has had previous laparotomy for ovarian cyst in year 2001 (6 years ago!) and 3 months back had a scan which showed a haemorrhagic cyst but was discharged later with conservative treatment. No surgical intervention.. 'mumble mumble with patient in the background'...

Me: And the urine is clear of any infection?

GP: Yes i have tested it. And...i think she ought to be seen by gynae because she has this cyst..

Me: ???? Huh..but what makes you think its the cyst that is causing her this pain? It can be anything at all right? And moreover haemorrhagic cyst tends to settle. Do you think we should think about other diagnosis as well or perhaps have a surgical review?

GP: must be since she had previous cyst problem (clearly quite annoyed with me)

Me: 'thinking to myself...what a lot of rubbish!' But we cannot be sure of that. It still can be a surgical case.

GP: Well..i am sure its a gynae case because yada yada yada (giving me a rubbish percentage for repeat ovarian pathology).

Me: No i think she should come to A+E and to be reviewed by the doctor there and then we shall decide whether she need a gynae review...

GP: 'mumble mumble' fine! ..'click' (and he put the phone down)

Me: (%$&*!)

15 minutes later i get a call from A+E:

A+E: did you just received a call from a GP?

Me: Yes i did...

A+E: We do not do triaging here in A+E (WHAT?? then WHAT does the A+E Do???)

Me: Then, can't the doctor there see first before referring because abdominal pain can be of any pathology..

A+E: Well..we don't do that..its for you to see and decide...

Me: Whatever (flabbergasted!!!)

so...what does the A+E doctors do then? and does it mean that all women with abdominal pain is due to ovarian cyst until proven otherwise?? Even if she has previous cyst problem it does not automatically means she has gynae problems now.


Wednesday, 25 July 2007

Being depressed

Its so funny that around 70% of the patients i see in the clinic had at one point suffer from depression whether treated or not (not randomised controlled study ya). And there was a point in time that the local newspaper published an article on this country being a HAPPY PILL POPPER nation. GPs here would prescribe 'happy pills' just like how vitamins are being offered.

And, to be honest lately i have been in this similar mood as well. Depressed? Dunno.... Bored? Dunno..... Need a break from work? Definitely! I guess working for the last month for every single day (on calls most of the weekend including this coming weekend) did take a toll on my mood. I felt like going somewhere to chill out. To relax. To get myself off medical stuffs or even work.

Have tried not to think about work by working on beginner's card magic tricks but hm mm its not working.

So, i indulged myself in doing online shopping. My favourite past time whenever i am feeling low. What do i buy? Well...mainly man's toys... but in particular underwater photography equipments. Got myself a new strobe... and a focus light. Am just waiting to use them. Maybe this year end when i am back in Msia.

Tuesday, 24 July 2007

First card trick (learned in one week)

I am into learning magic card tricks now...erm having seen some latest David Blaine Street Magic. Well i am still very very very VERY new with this... and i am sure experts out there would laugh at this trick. But hey..i am pretty proud that i am able to pull it off in a week. Hard finger workout which is good for further surgical work. Do enjoy...and comments are always welcome. Cheers.

Monday, 16 July 2007

I wanna go layang layang and similan

Nudibranch again
Originally uploaded by orcastyl
oh dear... i have got crave for diving again. aiyo just like how my friends here crave for chocolates after lunch, supper or dinner. i wanna go see some nudibranchs! ohhh...i crave for some compressed air.. hahhaha....

Besar Mak Ini (BMI)

I had two caesarean section to be done today under the elective list. Both patient weighing over BMI 35. One was for twins (again??? this is the third one this week! where the %£$%! this people get so fertile?) and the other was for failed induction.

First one had a stunning BMI 49! What the..'besar mak ini'! Yes is this asian chap weighing less than 75 kg doing a c-section on a lady twice the weight of him. Can you imagine? Obesity is definitely becoming a problem this century. Worst of all she is also diabetic on insulin for the last 20 years. Hmm not a great combination. i am sure if i were to ask, it would be not a surprise if she also smokes. To add to that...had two previous scars (c-sections) as well.

C-section was like hell... had to tape her abdomen up using elastoplast making sorta like X mark on her abdomen. And even then had to have two of my courageous assistants to assist me.

Next lady, another staggering BMI 47! Besar mak ini! Another X mark on her abdomen.

After this two hand was really aching. I am sure i saw my arm muscles twitching in agony.

Sigh... no rest however... as i am writing this...another patient is being wheeled into the operating theatre for c-section. Wish me luck.

Sunday, 15 July 2007

Sunday at Ickworth House

Ickworth House...the present house begun in 1795 by the Hervey family. There are about 70 acres of gardens, including woodland walks to the front of the house and the Italianate Garden to the rear.

About 1800 acres of woodland and parkland offering a variety of wildlife. Alas..the sky was gloomy and i wasn't prepared to get wet today hence just strolled around the house. The house itself play host to numerous fabulous paintings, furniture, silver and porcelain. No photography inside so i can't really show you anything.

Friday, 13 July 2007

She is doing alright..

Came to hospital tonight to do my last on call (for this week), the 8Th one in a row and the patient i was looking forward to review first was the one whom had the post partum bleeding.

She was already out from HDU and has been extubated since 1300. Had four units of bloods transfused and she was no longer bleeding. Brilliant! Observation had been stable throughout the day whilst i was sleeping and recuperating from last night.

She was with her husband, twins in her girl left and baby boy right.

One happy family.

One lucky patient who had survived the traumatic ordeal less than 24 hours ago.

We went through the events that took placed and even had the time to laugh about the whole experience. That scary 4 hours when she was still in the operating room, with her husband in the delivery suite holding on to the twins not knowing exactly what was happening is just too much for anyone to handle.

me: alright then...i have gotta go see other you take care..and i may pop in once a while during the night to check on you...

patient: thank you doctor

I left the room knowing she will do fine.

Unlucky Thursday Night going into Friday the 13th

Did a c-section for twins yesterday and maybe its my 'mulut celupar' i have told the patient and partner that i fear she may have uterine atony (womb lembik like dough!). That's because she has been in labour for hours and although relatively pain free with the epidural in situ, and on maximum doses of syntocinon...she wasn't really progressing or dilating her cervix. 8 hours into her labour...i had a look at the partogram ( graph showing labour progress) and decided i would throw in the 'white towel' and call it quits with any chance for vaginal delivery.

Had a chat with patient...and i strongly advise against her wishes to carry on another two hours. Everything she did was perfect...its just one of those cases where her uterus just wouldn't contract efficiently. So..brought her to theatre about 3 am. C-section was straight forward... no complications until...the uterus starts to relax. I generally ordered prophylactic doses of syntocinon (erm..hormonal drip to enhance womb contraction) but in this particular case...the uterus just refused to budge. Doses after doses of carboprost as well as per rectal misoprostol did not make any difference.

So, she bleed and bleed and although given other medications to stop the bleeding...she continued to bleed. Had to call the consultant in and .....after hours of massaging her uterus (another means of trying to contract the uterus), we ended up opening her abdomen and performed a B-lynch suture (will show illustration below). Well that kinda stop her bleeding after losing nearly 2/3 of her body's volume.


She was later send to the HDU for further monitoring. Sigh..what a night .... oh did i mention that half way through the re-laparotomy i had to rush to delivery suite to perform one ventouse delivery and assess a lady for manual removal of placenta, as well as another patient with thick meconium stained liquor (pooh in the fluid surrounding the baby in the womb) with pathological CTG.

That was how busy it can be on my calls. It has been busy calls for me ever since October 2006. It doesn't help when its Friday the 13Th.

one more night of on call to go....

Tuesday, 10 July 2007

3 more to go

Its about 0435 am now and i have 3 more days of 12 hours back to back on calls to go. I do hope i can survive till then. Am really looking forward to the weekend.

Does it only happen to me?

It sometimes puzzle me as to why some doctors are just plain ignorant. During my last few days of on call i have had a couple of referrals of which i thought could be easily handled by even the most junior doctor but... no...they had to be referred for a second opinion.

First case, a three year old girl who had sustained a perineal injury while playing on the slide. No child protection issue are of concern. Paeds registrar had wanted me to give an opinion of any possible laceration of the ? vagina. Firstly I wasn't impressed with the timing of referral as the child was admitted seven hours prior to this. Secondly, she had not even attempted to examine externally the child's perineum. How lazy can one get? We refer to the paeds when there are issues about ambiguous genitalia but they can't even tell whether there is any laceration on the labia??

Second case, a woman had just recently had a termination of pregnancy (which is entirely legal here in the UK under the Abortion Act) but subsequently passed out a piece of tissue which was said to be a fetus by the GP. Women was obviously distraught and came to the A&E for reassurance. Doctors in the A&E examined the product and inform me that it was definitely a fetus. So, i send the patient up to the ward for a review. The so called fetus? turned out that it was a piece of placenta tissue. i don't think it is at all hard to recognise a fetus. It should look like a very very small baby..with a head, upper and lower limbs! Poor lady was so convinced that she burst into tears and had to be persuaded to calm down and reassured..

I am not saying i am perfect but at least i try harder than these doctors...sigh...

Saturday, 7 July 2007


Hmm..its the seventh of the seventh month in the year zero seven..and i have seven more days of oncall to go. top that..i had also work on the sixth of the sixth month of the year, zero six last year.

i wonder who was born this morning at seven o'clock? As i was walking along the corridor this morning having done my rounds, a patient whom i saw earlier had really wanted her baby to be born today. She was admitted for induction for post dates and due to have an artificial rupture of membrane in the delivery unit. And she did said that as i am a 'chinese' i would be able to understand the reason she wanted the baby delivered on this auspicious day?????? how bizarre... i didnt know number 7 is good for chinese?? is it??

beep beep beep....alright alright... gotta answer my bleep now...

Sunday, 1 July 2007

Status 'tigris' epilepticus

I was kinda bored this weekend and decided to visit Linton Zoo which is only about 10 miles off Cambridge. Climbed out of bed, made breakfast, called home, and after a quick bath....grabbed my Lowepro bag with my 'ka chang' and drove to my destination. It was cloudy initially but the sun came out and it was just brilliant. Linton Zoo is not big...just small enough to house some big cats, zebras, lotsa owls, tamarins, birds and a handful of reptiles. Enough for me as i dont really wanna spend too long there anyways.

Paid £7 at the entrance and made my way around. Saw the birds...turtles....toucan...some owls... and then...the BIG CATS. As i was walking near the enclosure, some tourist told me to watch out as the 'Lion' was apparently spraying around. I then noticed that it was in 'heat' and erm..manage to get a glimpse of a courting and mating ritual. Guess nothing to do, so eat, sleep, shit, and sex loh..

Then i heard a roar...almost a roar...more like intermittent grunts. The sound was definitely from a big animal. I moved on...and the sound was coming from the 'tiger' neighbours. There were 4 tigers there. The next thing i know, i was witnessing an event that i have only seen in humans... status epilepticus. Status 'tigris' epilepticus..

I manage to capture that very moment with my camera. I was disheartened to watch that cat fitting away and nothing can be done. Hands tied. Some of us watching managed to get the keepers to help but i guess there isn't anything that can be done. The other tigers just refused to leave as though sensing something was wrong with their sibling. Its just amazing. It went on and on for at least 10-15 minutes. Tonic-clonic (shaking violently) all the time... with heavy breathing in between... then...finally it stopped. The tiger was very drowsy and struggling to be on its paws. It made a few steps and fell back to the ground. As though knowing what actually happened, another tiger seems to be encouraging it. Half an hour past before the tiger regained its composure...moving around the enclosure...being watch by new oblivious tourist.

i wish that tiger would be examined by the vet soon...