Pioneered Dynamism

I elatedly cry out of my heart,

to leave and learn the state-of-art.

There's nothing less than patience,

to remedy the young nation;

As all the tainted lungs sob,

I'm about to follow the footsteps

of the education that molded me;

not just to vacuum but to be a pioneer

that I've no fear to be here,

and see the paws of mine,

not limited in the land of mine.

The oath sworn three years back,

is about to see action.

Religion and race not to mention,

I'm prepared to kick racism out.

The blessings I prayed for,

to ride through the purple patches,

with faith and dynamism to hatch.

He's listening to the theme song of DAP for the GE 08 "Just Change", lyrics by YB Tony Pua. He's a strong believer that he will return home one day and prove to the world that no other country is better than his fatherland as depicted within :- All races will stand as one & Forever! Malaysia must come first!

Engineered Move to Australia

Like any others, just about to step into a brand new year, I am writing this post. It always goes this way where people pen about their regrets of the year and new year resolutions.

What makes this post more valuable is that for whatever that I write would be based on the ups and downs toiled through in the motherland. For the next decade of life, it's going to be an entire different journey to be walked. Time zone will still be the same with only occasional daylight saving of an hour difference. But the people, the culture, and the language spoken will all be alien to me.

Yes, I engineered this move to Australia. But why? It is all due to the incapability of my beloved country to offer at least on par education and job opportunities that would shape my career as compared to foreign countries. I know my friends share the same values that we will return home one day to serve our country.

I remember reading an English poem way back in form two, citing about acquiring knowledge abroad and return home proud one day. That's very motivating.

I have not looked back of what I have not achieved. Instead, I am satisfied with my hard work in polishing my clinical skills. I had the chance to exchange views and ideas about medical education with a Malaysian student who entered directly into the University of Tasmania. She's a 3rd year med student that has gone through a year of clinicals. I know I am not too far behind.

My uncle recently has become my first ENT patient for BPPV(of posterior semicircular canal). I am elated that I managed to brainstorm the diagnosis based on the history taken and provide the appropriate diagnostic test of Dix-Hallpike and treatment by Epley's maneuver.

Life's wonderful in the sense that you will never know the results of every minute ahead till you have gone through it. Tireless and enthusiastic commitment have since become a trade embedded in me. I don't mind going hours extra to learn.

Even the simplest things like gloving and putting on the sterile gown may seem like some petty issues in the eyes of some. But that's what I called them the basics. The confidence exchanged is priceless.

I want to do my best, at least be on par with the levels of those that directly entered UWA. My elder sister has recently graduated as a doctor; she will be the goal I want to surpass!

My heartfelt congratulations to my sister; you have made us proud!

Neoplasm, So What?

I am privileged to be scheduled for a half a year break due to the commencement date of Australian universities. Never I thought I would spend 95 percent of my time working in a health care set up till today; it's almost five months plus to be exact.

I started off with Lam Wah Ee hospital (LWEH), the place where I first did my elective in a private hospital and absorbed paramount experience as compared to the nightmare I had in Penang General Hospital one year ago. I am very grateful to the following consultants, Mr Khoo ST, Dr Ng HH, Mr Khaw KT, Mr Leong WS for their delicate teaching in their respective fields. The staffs were very pleasant to meet. You would somehow feel respected though you are only a medical student. Friends met in the OT, clinics, and A&E were wonderful as well.

I have to commend LWEH despite being a non-profitable Hospital, they are able to cater the needs of the majority of the patients. Every hospital is there to serve a different class of patients.

I limited my time to three months plus in LWEH as I felt I needed to see some much higher profile cases to further improve. You can't be seeing the same cases for months. So I thought it was timely to go over to Island Hospital, a so-called tertiary regional referral private hospital.

It was true. Hereby, I am extremely thankful to the following consultants, Dr Aaron Lim BK, Dr H'ng PK, Dr Hwang YC, Dr Francis Lau, Dr Goh HK, Mr Goh TM, Mr Badrul and Prof TJ Wong. The learning curve with each consultant was challenging. My mind has to be armed with the perfect acumen to pop up with probable diagnosis, differential diagnosis, investigations, pathophysiology and so on at anytime.

The time at the I-Sports Centre to acquire knowledge about the management of Sport injuries was fairly good. It was an eye opener in terms of the perplexed anatomy of the knee. For instance, the Anterior Cruciate Ligament as easy as it sounds is much more complex that I first thought. I came to realize the emergence of physiotherapy in the conservative treatment of various orthopaedic problems. Most importantly, they do help relieve the pain!

The best time comes with Prof TJ Wong where I was given the opportunities that would only arise out of a blue moon to assist in most of his cases, be it a minor or a major surgery. And his keen interest in fighting against malignancy further strengthened my belief in becoming a world-renowned Reconstructive & Oncosurgeon one day. Don't ask me why I have much interest in tumors; it comes naturally.

Believe it or not, I have assisted in major cases such as Whipple's Op, Hepatectomy, Anterior Resection, Total Gastrectomy, Roux-en-Y reconstruction and so on and so forth.

The art of liver secondaries is beautiful. The tagline of "Neoplasm, so what?" has crossed my mind after witnessing the stories of the survivals.

I had the chance to attend various lunch time lectures to keep myself embedded with the latest happenings. Lectures like Enteral Nutrition, Procalcitonin, Phacoemulsification are pretty useful.

Some consultants were shocked when I told them that IMU provides the students with only two hours of lectures per day since day one. I was lucky to be sufficiently adept at the level I am supposed to be to. Hard work is the only word used to define this self-perceived brilliant type of education I have received.

Last but not least, I would want to remember the wisdom conveyed by Prof TJ Wong :-

1. Surgery is all about searching for the right planes.
2. Impossible is only about taking a longer time...

Once again, many thanks to all the consultants, staff nurses, paramedics and hospital staffs that coloured my second half of 2011.

Penang Cardiovascular Conference

Thanks to Servier for sponsoring me to the Penang Cardiovascular Conference!

It was a wonderful two days in terms of learning and keeping yourself updated with the latest happenings revolving around the field of Cardiology.

New drugs have come about quickly to remedy the flaws of the previous ones. I remember reading much about how effective Plavix (clopidogrel) as compared to Aspirin just one year plus ago. And now Brilinta (ticagrelor) is cited to have replaced Plavix as the front runner for post angioplasty.

That tells how paramount it is to make oneself to adhere to the adage of Lifelong Learning.

The debate of CABG Vs Angiography where the Protagonist Dr Hafiz Law, Consultant Cardiothoracic Surgeon and the Antagonist Dr Ng Swee Choon, Consultant Cardiologist was a good one. Both presented well with supporting facts from various studies. Well, in the end of the day, the decision still lies upon various factors. Nevertheless, it depicts the willingness to correct the flaws and come up with better solutions like from the first generation of stents to the third generation of stents now.

I came across new scoring systems :- [1] Syntax Score [2] Euroscore

And I met Johari from LWE and a few other SNs from the Island Hospital. "Everyday's a Learning Opportunity"

Daring to Be Aggressive

A simple surgical set of instruments can make wonders.

I have embedded "Daring to Be Aggressive" as my personal theme as an add-on to the Dynamism, I Envisage.

My ultimate aim has never swayed from achieving something extraordinary in the field of Reconstructive & Oncosurgery one day. It is going to be limited to resection & reconstruction of the diseased organ.

Many parts of the organs are often non-resectable when the patient comes in presenting to you with an infiltrating tumor or for some other reasons.

Many of times, the solutions are vividly surfaced on top of your table but due to high risk pre-op assessment, the patients are often being turned away. Or citing reasons that since it's a stage 4 disease, why still spend huge sums of money just for a palliative care that does not change much of the quality of life.

I am inspired by Prof TJ Wong's work on liver secondaries. His ability to convert the disease stage to a R0 (no residual stage) is encouraging. However, currently there are still limitations to certain parts of the organs for instance the small intestine, where you cannot afford to remove all.

But thinking about it, why not create a 'pipe' that mimics the small intestine to connect the stomach to the large colon? Change of mindset I call it.

It requires a gigantic courage to transform yourself to adapt to a situation that you can practise the core value of aggressiveness in the surgery without compromising the safety of the patient.

Orthopaedic Surgery [Week 2]

1. 60 yr F c/o pain at L Hip (1/7). H/O falling down while sleeping the floor. O/E: tenderness at L greater trochanter w/ mild swelling, active & passive movements restricted. X-ray showed # L Intertrochanter

• Evans' Classification (1949) :- Type I-Undisplaced 2-fragment #; Type II-Displaced 2-fragment #; Type III-3-fragment # w/out posterolateral support; Type IV-3-fragment # w/out medial support; Type V-4-fragment 3 w/out posterolateral & medial support; Type VI-Reversed obliquity #
• Boyd & Griffin's Classification (1949) :- Type I-Linear intertrochanteric #s (w/out comminution); Type II-Intertrochanteric #s w/ comminution; Type III-Intertrochanteric # w/ Subtrochanteric extension; Type IV-#s of the trochanteric region & the proximal shaft (# in 2 planes)
• Dynamic Hip Screw Fixation (! to check radiographically AP and Lateral planes to ensure the Screw goes through the middle)

2. 30 yr F c/o pain at central buttock region (2/52). no H/O trauma except falling down on a sitting posture. O/E: no swelling or obvious deformity, tenderness at central buttock region. X-ray revealed slight # at saccral-coccygeal region.

• Rx: Conservative Treatment

3. 6 yr F c/o L tip-toe walking since 4 yrs. Wanted to try physiotherapy initially, but failed. O/E: stiff Achilles tendon w/ permanent dorsiflexion. Unable to passively plantar flex.

• Percutaneous Z-plasty to lengthen the Achilles tendon
• Pt lying prone & resting positions noted:- ankle is dorsi-flexed (normal), when knee is flexed, ankle is supposed to be able to plantar-flexed 30'.
• 3 positions to incise - Medial, Lateral, Medial then manipulate to plantar flex.
• plaster cast for 6 weeks
• Complications if surgery not done: [1] osteoarthritis of lower limb joints [2] Limb-length discrepancy [3] Muscle wasting

4. 59 yr M c/o L Hip pain for months. No radiation from back, no pain at other joints, H/O locking screws across neck of Femur due to # 10 yrs ago. O/E: no obvious deformity or swelling, tenderness noted at L Hip, no loss of movements. X-ray of pelvis: avascular necrosis of L Head of Femur + erosion of L acetabulum, 2 screws were not parallel.

• L Total Hip Replacement

Orthopaedic Surgery [Week 1]

1. 80 yr F c/o falling down 3 days ago. O/E: tenderness, swelling noted at R hip, and externally rotated R hip. D/D: [1] # R Femoral Neck [2] # R Intertrochanteric [3] # R Subtrochanteric

X-ray showed # R Femoral Neck, Stage 4

• Garden's Classification - Stage I: Incomplete fracture; Stage II: Complete Fracture w/out displacement; Stage III: Complete Fracture w/ minimal displacement; Stage IV: Complete Fracture w/ marked displacement
• Singh's Index
• ! Avacular Necrosis due to the blood supply
• Bipolar Hemiarthroplasty - Anterior, Lateral, Posterior Approaches
• Lateral Approach (Liverpool's/Haldinger's Approach):- # Neck incised, drilled through the medulla, semen poured, implant inserted, H2O2, Bipolar Head

2. 23 yr M presented w/ obvious deformity at R arm. H/O MVA Car vs Bike. O/Eb: deformity at R mid arm w/ tenderness, radial nv not affected w/ functions intact. X-ray showed # R mid shaft of Humerus.

• Open reduction & Internal fixation (ORIF)
• Anterior approach:- biceps brachii retracted, cautious of radial nv (!wrist drop), reduced the #, 6-hole plate w/ screws, drainage w/ tubing

3. 50 yr F c/o MVA w/ direct concussion of R knee. O/E: tenderness at R patella, # pieces felt, weakness of quadriceps. X -ray showed transverse # R Patella.

• types of #: Undisplaced, Transverse, Lower or Upper Pole, Comminuted Undisplaced, Comminuted Displaced, Vertical, Osteochondral
• Rx available: [1] Patellectomy [2] Circlage wiring of Martin [3] Figure of 8 tension band wiring [4] Interfragmentary Screw Fixation w/ combination of above any
• Tension band wiring done:- vertical incision, damaged capsule seen (+/- damaged muscles), drill 2 wires parallely through the 2 parts, K-wire used

4. 70yr F c/o weakness of L limb. Unable to actively extend R knee. H/O failed tension band wiring in Indonesia + L Patellectomy w/ reconstruction of quadricep tendon here 3 months ago. O/E: no swelling, gap seen between, no active movements, only passive movements

• Dx: snapped quadricep tendon

The Surgeon, The Baby, The Angels

The perceived disdainful impression,

instigates all the feared tension.

The cries of him being heard,

as all that it hurts.

Pacing through the busy footsteps,

we are here ready to stab.

The dark blues painted the air,

the sobbing continued to flare.

Diathermy, rubber bands, forceps please,

the boss ordered for impatiently.

The oozing blood paled the faces,

the angels wandering impatiently.

Exultant chuckling filled the spaces,

Wong-Baker Faces worked the wonders,

from Ten to Zero, from Zero to Hero,

gliding back with the smiling faces.

[Inspired by a case where the one year old baby suffered from laceration of the Left Middle Finger accidentally, the parents and the surgeon]

ENT - Head & Neck Surgery [Week 4]

• 1. 50 yr M c/o R parotid swelling X 3 days. H/O L parotid tumour Dx to be suggestive of Warthin's Tumour(Adenolymphoma) due to the lower pole and well-circumscribed appearance on CT Neck. O/E: R parotid-diffusely enlarged, tender, redness, warmth; L parotid- Lower pole well-circumscribed, mobile, lower pole tumour felt, non tender. Oral Ex showed no signs of deviation of the medial walls on both sides. CN vii normal on both sides.
• IV Antibiotics suggested for R parotitis
• Warthin's Tumour can be left as there's no risk of turning malignancy.
• ! never do Excision Bx for Parotid Tumours as run the risk of injuring the CN vii
• Only Pleomorphic Adenoma has a risk to become Pleomorphic ex Ca. Warn pt!

2. Sjogren Syndrome

• systemic autoimmune disorder attacking the exocrine glands esp lacrimal and parotid glands
• presents w/ dryness of mouth(xerostoma) and eyes.
• Dx by Schirmer's Test, Rose von Bengal dye, autoantibodies against Ro(SSA) & La(SSB) antigens
• variant: Mikulicz Disease [Triad of symmetrical enlargement of all salivary glands, narrowing of palpebral fissures due to enlargement of lacrimal glands, parchment-like dryness of the mouth]

3. Kimura's Disease

• benign rare chronic inflammatory disorder
• presents as subdermal lesions in the head or neck or painless unilateral inflammation of cervical LNs.
• Unknown cause.
• HPE:Lymphoid infiltration w/ eosinohilia present

4. 25 yr M c/o blocked nose for months. O/E: deviated nasal septum, bilateral hypertrophy of turbinates, enlarged tonsils, mild obesity noted at neck. Frequent snoring and frequent apnea noted by wife. Tiredness in the day time.

• suggest a Sleep Study to measure AHA Index (apnea-hyponea index)
• Friedman Staging for Obstructive Sleep Apnea
• Epsworth Sleepiness Score, Berlin Questionnaire
• high AHA Index; Severe OSA
• Plan [1]septoplasty [2] B turbinoplasty [3] B tonsillectomy [4] Uvulopalatopharyngoplasty [5] weight lost [6] Continuous Positive Airway Pressure (CPAP)
• repeat Sleep Study post-op
• ! OSA can lead to heart diseases

5. Autoimmune Inner Ear Disease

• rapidly progressive Bilateral sensorineural deafness
• could be Idiopathic or assoc w/ other systemic autoimmune diseases like Sjogren Syndrome, Systemic Lupus Erythematous, Rheumatoid Arthritis
• Rx: high-dose prednisolone, methotrexate, cyclophosphamide (! hemorrhagic cystitis, CI in children), plamapheresis

1. Type 1: Organ (ear) Specific

• Rapidly progressive bilateral SNHL
• All age ranges, although middle age is most common
• No other clinical evidence of systemic autoimmune disease
• +ve Otoblot (western blot 68kD or HSP 70)
• -ve serologic studies (ANA, ESR, RF, C1q binding assay)
• >50% response rate to high dose corticosteroids

1. Type 2: Rapidly Progressive Bilateral Sensorineural Hearing Loss with Systemic Autoimmune Disease

• Rapidly progressive bilateral SNHL
• Hearing lost often worst with flare of autoimmune condition
• +ve (SLE, UC, PAN, Vasculitis, RA, Sjogren Syndrome)
• +/- ve Otoblot
• +ve serologic studies
• Corticosteroid responsive + managed w/ targeted therapies

1. Type 3: Immune-mediated Meniere's Disease

• Bilateral, fluctuating SNHL w/ vestibular symptoms that my predominate
• +ve Otoblot
• Corticosteroid responsive, may need long term Rx due to relapses

1. Type 4: Rapidly Progressive Bilateral Sensorineural Hearing Loss with Assoc Inflammatory Disease (Chronic Otitis Media, Lyme Disease, Otosyphilis, Serum Sickness)

• evidence of profound drop in hearing w/ long-standing chronic otitis media
• may show inflammation of ear drum + perforations
• hearing loss progresses despite Rx of infectious agent
• -ve Otoblot
• Corticosteroid responsive + may need long term Rx

1. Type 5: Cogan's Syndrome

• recurrent inflammation of front of eye(cornea) & often fever, fatigue, wt loss, episodes of dizziness & hearing loss
• sudden onset of interstitial keratitis and severe vestibuloauditory dysfunction
• -ve Otoblot for 68kD; +ve Otoblot for 55kD antigen
• responsive to high-dose corticosteroid; resistant over long term
• atypical form - Logan Syndrome

1. Type 6: Autoimmune Inner Ear Disease-Like

• Young
• Severe ear pain, pressure & tinnitus
• -ve Otoblot & serologic studies
• ?unrelated, nonspecific inflammatory event that instigates ear disease
• not responsive to immunosuppressive drugs

*Reference: Ballenger's Otorhinolaryngology

ENT - Head & Neck Surgery [Week 3]

1. 36 yr M presented w/ Ca Tongue and has undergone Chemo & Radio Rx. O/E: Anterior 40% of tongue has been eroded w/ involvement of floor of mouth. CT Neck revealed eroded Anterior Tongue, otherwise normal.

• Suggest Total Glossectomy w/ Pectoralis Major Flap reconstruction

2. 60 yr M c/o epitaxis due to a papaya ~1kg hitting the nose. Epitaxis is of on and off. O/E: nasal septum deviation to L. Plane X-Ray of nose showed: [1]Septum deviation (trauma) [2]Haematoma in maxillary bone [3]Fracture in other parts

• Decompression must be w/in 1 week post-trauma

3. Carotid-cavernous fistula

• ! to be asked especially post trauma as it forms after that
• presents w/ epitaxis

4. 55 yr M c/o severe blocked nose unresponsive to medications.

• D/D: [i] Deviated nasal septum w/ Chronic sinusitis
• Operative findings were suspective as the bones were friable when FESS was done. HPE was carried out and reported back by the Pathologist as Vasculitis.
• Surgery to correct the air passage was successful. On follow-up, the healing was much slower that expected. Pt now c/o multiple itchy papules around the abdo, thought to be allergic to some medication.
• Systemic manifestation thought, suggestive of Wegener's Granulamatosis. Referred to Dermatologist for opinion. Skin Bx done. Reported as Vasculitis.
• cANCA w/in normal range
• All specimens and blocks sent to another Pathologist for 2nd opinion. Reported as Extranodal Lymphoma, Nodal Type and NO Vasculitis.
• Wegener's Granulomatosis: Triad of 3 systems [a]Upper & Lower Respi tract [b]kidneys, presenting as glomerulonephritis [c]vascular, presenting as necrotizing vasculitis
• Rx: cyclophosphamide, methothrexate, rituximab
• ! D/D: Churg-Strauss Syndrome