Happy Father's Day

This year it's gonna be more fun. Allison's old enough to kinda understand what Father's Day is.

After having been a dad for 3 years, you realize how much work (and money!) it is to be a parent. I'm perpetually exhausted; I don't sleep long anymore. I've aged significantly, numerically and physically, in the last few years. I've lost most of my hair, beating even my dad (in that picture, circa ~1980) so far. I worry- about boring things like life and disability insurance, college savings funds, school systems, and the general state of the world.

Yet, despite all the work, it's a blissfully magical thing to have your princesses give you hugs and kisses. To have a crappy day at work but to come home and have your kids make you feel like you're truly the king of the house.

Happy Father's Day, to all the dads out there.

To mine, and also (wherever he may be) HIS dad.

 

 

(that's dad holding me and my older brother)

 

(me as a newborn in my Ah Kong's arms. Damn I had a lot of hair then)

Social Media and Patient Confidentiality

I'm motivated to blog about this after a recent posting I read in one of the social media sites. With how fast things are evolving, it's pretty common these days to get a 'curbside' from colleagues via the internet.

Either emailing, or posting clinical challenges, lab results, radiologic or physical exam findings. After all, it's good for patients for us to be able to reach out to experts elsewhere, and it's good education for us doctors too to share cases.

However, with the ease of sharing these diagnostic dilemmas, comes the potential for misuse or downright abuse. A few recent events I read on a certain website comes to mind. The first was a series of pretty graphic pictures of the genitalia showing some pathology. Though this was not identifying of the patient, many doctors who belonged to that group was unprepared to see those images in such a public forum and found it offensive. And while I imagine the doctor who took the pictures had asked for the patient's permission, I'm pretty sure it was not exactly proper informed consent: "Please let me take a picture of your genital for me to post on Facebook..". The second incident was an image of a test result; the person who posted that image in all its glory conveniently forgot the patient's name and DOB was listed for all to see. I am also reminded of a blog of a medical student who some years ago started to post pictures of his pediatric patients with their faces clearly visible. Though permission was "obtained", these were children who were not able to legally able to provide proper consent.

As physicians, we are in a priviledged position, of being privy to a person's deepest, darkest secrets. We leave a person with very little remaining modesty as we poke and prod and push and percuss and auscultate and do other unmentionables, while they lay there vulnerable. We have taken the Hippocratic Oath, which among other things, to "respect the secrets that are confided in me, even after the patient has died..." (OK, to be accurate that was the Declaration of Geneva version).

And so, it's easy to forget that in a brisk click of the mouse, we may be revealing more than we should, and that we might be betraying the trust given to us. Even if it was done with no malice but with total beneficence for the patient. It's easy to think, "Hey, this is a really cool MRI, let me share this" without realizing the patient name is clearly visible. Or that picture of the goiter also happens to reveal a person's face.

We owe it to our patients to be more discreet about these things. The truth is, in some parts of the world people are fired or sued if they are found to have done some of these things. So, before you share your pictures, or X-ray images or whatever it might be, do take a moment to ask- is this suitable for social media? Am I overstepping the scope of the consent the patient has given me?

Home Brewed!

Yup, I brewed my own beer.  And I'd have to say it came out pretty good, too. Nothing like a cool drink on a warm day. Especially one you brewed yourself!

This is going to be a new hobby....

5 Years

I can't believe how fast time flies.

Five years.

Five years ago I married my best friend (well, at least our first wedding in the USA- we did a 2nd wedding in Malaysia in July).

Now, 5 years later, we're settled in in the Midwest, with a rambunctious 3 year old, and a 10 month old.

Happy Anniversary, honey!



Iodine: The love-hate relationship

As an endocrinologist, I don't usually have patient situations so dire that I fear for their lives. Sure, I'm frequently involved in sick patients, the post-cardiac surgical patients or the trauma patients who are steps away from death. But my patients, people I play a direct role over?

Yesterday was one such day. I hesitantly put her in harm's way, and referred her to see a surgeon- she was quoted a 10% chance of mortality in the OR. It was an extreme case of amiodarone-induced thyrotoxicosis.

As you know, about a third of amiodarone is iodine. Iodine is the substrate from which the thyroid gland produces thyroxine and triiodothyronine. As such, any exposure to high concentrations of iodine may induce hyperthyroidism (and hypothyroidism, but that's a different story) by means of an exaggerated Jod-Basedow phenomenon (also called type 1 Amiodarone induced hyperthyroidism) or thyroiditis (type 2).

Mrs. J was a 60-something woman with a history of hypertrophic cardiomyopathy, complicated by atrial fibrillation and other tachyarrhythmias. And so not surprisingly her cardiologist put her on Amiodarone in an attempt to tame the heart. After a year, her cardiac status did not get better- she kept going in and out of the hospital for congestive heart failure. During one such visit, she was found to be markedly hyperthyroid.

Her Amiodarone stopped prior to her visit to her. When I saw her, despite having been off this for 2 months, and having been on maximal methimazole therapy, her free T4 was above the upper limit of measurement for our lab (above 6), her free T3 was 12. Her levels were worse than they were the month before. And despite calcium channel and beta blockade her heart was ticking away at 120 beats a minute.

And so, this was a situation all endocrinologists hate. What the heck do I do?

The temporal sequence makes type 2 AIT unlikely, as thyroiditis is expected to have at least improved two months later. So we are likely dealing with type 1. You might consider the conventional therapeutic options for hyperthyroidism: antithyroid medications to slow down production of new hormone, radioactive iodine ablation or thyroidectomy. Unfortunately the norms don't apply here.

Because by the time you see them, the gland is already supersaturated with iodine from the Amiodarone, antithyroid medications have very little effect. Likewise, radioactive iodine will not work- one would simply pee out the I131 you administer. Which leaves you with surgery. But you'd need to find a gutsy (crazy) surgeon and anesthesiologist who would take a severely thyrotoxic patient to the OR.

You could wait it out, but the halflife of Amiodarone is 100 days, and it may take upwards of 10 months before they become euthyroid. Many patients can't wait that long. Mrs. J was one of them. Her cardiologist was nervous she was going to go into some fatal tachyarrhythmia, or die of congestive heart failure, if we did nothing.

Which takes us to yesterday. We admitted her a couple of days before the planned surgery to have a better hold of things. She spent some nights in the ICU, but on the day of surgery despite maximal doses of Esmolol, she remained tachycardic. But she remained strong-willed, and keen to have surgery. Despite the odds given by the surgeon, she was ready to proceed.

I saw her a few minutes before they wheeled her to the OR. She was in a room full of family, most of whom were in tears. Her husband held on to her, crying, worried this was the last time he'd see her alive.

I held her hand and told her she was in good hands- she had a good surgeon working on her- though deep in my heart I hated that we had no other option but surgery (some have published case reports suggesting plasmapheresis to perhaps be beneficial- but data is weak). I wasn't sure I would be able to forgive myself should something bad happen to her.

I came home from work worried and distracted. However at 3 PM, I got the call- she sailed through surgery and was in recovery. It was a big burden off my shoulder, and what a relief it was. I saw her before I started clinic today, and despite the JP drain in her neck, she gave me a hug.

But this was a reminder to me of what a challenge Amiodarone-induced thyrotoxicosis is to treat. As good as a medication it is, the truth is us endos have a love-hate relationship with this medication.

Admittedly, I'm getting hooked. I forgot how I loved looking at the celestial bodies, and just how fascinating this can be. But in the last couple of weeks I've found myself wishing for good weather, just so I can sneak out with the telescope to stargaze and snap some pictures.

And I have to say that for a beginner, I'm quite proud of these pictures. This was the moon, taken a few days ago.

 

And presto, this was the planet Saturn! It was a lucky 2nd attempt, using the DSLR as a webcam and then using astrophotographic software to stack things.

Something tells me this hobby is going to end up being very time-consuming!

Difficult Patients

Sometimes, you just can't please everyone. And I had to deal with a yelling patient today.

It was an unusual Tuesday, but perhaps being the first day back after a long weekend, things got busier than most. I had to work in a patient over lunchtime. And another urgent request because she was pregnant and her diabetes was uncontrolled.

To top that up, I had a patient come 20 mins later (which really meant he was 35 mins since patients are asked to come in 15 mins early for our medical staff to reconciliate their medications and get the labs started). Clinic policy is that 15 mins or later we may ask for them to reschedule- something I try not to do but today was an exception. There was no way I was going to be able to catch up, and to make other patients who came timely wait because this person came late, didn't seem fair. So I suggested he reschedules with me at a future date, or see my nurse practitioner today, or wait until there was a cancellation on my schedule.

I was then told by the receptionist that this patient got mad. Really mad; was hollering and yelling and ripped up his papers before he stomped out. A few hours later when I had some downtime, I called to check up on him and to try to appease him.

Big mistake. I got an earful, from how I was "playing God", and how he was "only 10 minutes late" (really 35) and how he was offended that he was asked to see the nurse practitioner because they don't "know anything" (untrue- midlevel providers are highly trained and are able to work autonomously without physician supervision). He used some choice language and made numerous accusations. And when I asked how we could help work things out, he said he wasn't coming back.

It was unfortunate this happened. And my staff and I were as courteous as we could be. And knowing how busy the day was and how urgent some of the other patients were, there wasn't anything I would have done differently. That being said, it doesn't make the day any less unpleasant and needless to say, this one interaction spoilt the rest of my day.

I suppose such is life; there are some you can help, and there are some you can't.

C'est la vie.

Moonshot

I took this picture using the telescope last night. I have to say, I forgot how addicting stargazing and astronomy is. I've been taking the telescope out 2-3 times a week these days. And though I got the lower end 1300 mm 4" Nexstar SE, I've seen some breathtaking views of the moon, Jupiter and Saturn.

What's most surprising was the above picture was taken with my iPhone- I basically pointed the camera into the eyepiece and snapped a picture.

Am tempted now to delve into astrophotography....

Dr. Patient

Sometimes you never know where your patients may be coming from.

I saw H last week for the first time; he was a 50+ year old Middle Eastern man with type 2 diabetes. He worked as a pharmacy technician, so I wasn't surprised when we used some medical terminology at our meeting.

But I was impressed by his level of knowledge of pancreatic physiology, and prodded him a bit further. Turns out he was a cardiothoracic surgeon in his home country. But because his credentials were not recognized here, he needed to go back to medical school and residency before he could practice as a surgeon. At this age, he didn't think he had the stamina to do so, and so humbly worked in the pharmacy dispensing meds instead.

Reminds me of a cab driver I met while in medical school in Canada; he practiced as a neurosurgeon in Russia before his emigration.

And though he missed practicing surgery, he was happier with his new life there.

But it did get me thinking that it was a shame, not being able to use their talents just because of some bureaucratic red tape.

2 years

Hey buddy.

It's been two years since you left our world for the next. I imagine you've probably been watching over us and you know, much has changed.

We have another child now. She turns 9 months today; and yes, you're probably laughing over how I'm outnumbered by the females. Even the other male in this household- the damn dog has been castrated. And so I'm the only one producing significant amounts of testosterone (yes, you know females make this stuff too, but in minute amounts). And so, it's ironic that your roomate of 5 years who was always complaining of the lack of women in his life during those pathetic years, is now surrounded by them.

The world seems to be a different place now too. Or perhaps it's just me- I've learnt to see things with jaded, saddened eyes. The recent elections in Malaysia. Even the ongoings here and the senseless gun violence, with people on both sides of the gun-control fence yelling at each other. You've probably met the little angels from Sandy Hook. And you probably shed some tears too by the recent Boston Marathon bombing. Why? Why waste these lives, when others who tried to fight their illness so hard, had to lose? Why does Man commit evil towards his Brother?

I can't believe how the last two years just flew by. It doesn't seem like that long ago when Kris and I got married, and you gave your Best Man's speech. Or when you got married; Nat King Cole's L-O-V-E still reminds me of your first dance- for a 'kayu' person you performed pretty well! I remember well that last night we met, when we had dinner at that food court in Penang. You were pretty nonchalant about it and pretended you didn't see the tears streaming down Kristin's and my cheeks. We knew that would be the last time we'd meet in this world- being the oncologist I'm sure you did, too. But I sure appreciated how you gave us that last chance to fly back and see you- I heard your condition worsened shortly after we (and Chairman) left. I'm not sure if the science backs this up, but perhaps you know if it's true- the dying sometimes have control over when they are ready to go. And perhaps it's presumptive of me, but it's heartwarming to think that you held out for us to see you one last time and to bid you goodbye. And Alli was under a year old, I tell her about you occasionally, and I'll make sure she remembers you.

And oh, did I tell you I met the family of one of your peers? He had metastatic esophageal cancer too, except he was much older, and was bitter of his diagnosis and couldn't accept things. Until he met you and was so inspired by your attitude and your peace. He passed away after you did, but I met his wife and daughter here in a strange twist. And we shared some tears talking about you and him.

We're settled in here pretty well. Perhaps too well; years ago I wouldn't have imagined myself in the midwest. Midsized city, in private practice. I always thought I'd be back in Malaysia. Or at least in some major academic institution like our Mothership. But sometimes fate leads you to unexpected places. Work is OK, I tell myself. There are things I wish was different- I miss the mental stimulation of being at the Mothership, of being involved in scholarly activities. I would have liked to have more involvement in the teaching of residents and fellows. But it's OK; I'm not complaining- I am a partner in my group, and I have some good colleagues. Though I wish I was less involved in the business aspects of things. I'm a doctor, a healer. I'm not an accountant, or a businessman, or a disciplinarian.

I miss our chats. As nonchalant or casual as we sometimes make it to be, I miss them. There aren't many I get to share my thoughts and fears and frustrations to. As a father and head of household, sometimes you have to keep a lot in. I miss our last-minute buffet meals at which we bitch and complain about the world. As minor and unimportant as those may be, it was therapeutic.

And needless to say, I miss my Halo wingman. You might have been proud of me when I finally completed Halo 4. Damn game took me a long time, and I was stuck many times on many levels. I still have your player profile on my Xbox, and I was saddened to see your name there when I logged in to play alone. And heaven knows my wife isn't a help; she'd probably end up killing us accidentally by dropping a grenade on us! And so, I played alone. Woke up at 6AM on weekends before the kids got up to play. And after 2 months, I completed it! Maybe someday I'll teach Alli how to play and be my new wingman.

Anyway, I know how you hate sentimental words. Didn't mean to embarrass you. Just that I wanted you to know that though you passed away 2 years ago, we haven't thought of you less. And know I look forward to seeing you again, I know it will be awhile. But do look over us in the meantime.

By the way, I found this old picture. This was our first ACP meeting. We looked so young back then, didn't we? Gawd.

Holy Shit!!

That's what my patient yelled.

Literally.

So loud that my nurse thought he was angry at me.

"Holy Shit!!"

 

When I saw him 3 months ago and did nothing to adjust his insulin program, he wasn't impressed. He wasn't happy that I instead suggested he spends some quality time with my diabetes educator.

"Why can't you just tell me what dose of insulin to use?"

 

Because things change. Diet and meals. Activity levels. On a daily basis. So rather than making a change for him, it's often best to provide a person the knowledge and tools of carbohydrate counting, and insulin adjustment principles. It was clear Mr. D would benefit from it as he had little insight on how to adjust.

 

And so when I saw him the other day and handed him his bloodtest result, and it showed his hemoglobin A1c to be 6.4%, that was his reaction. From a previous 13.3%.

 

As they say, give a man a fish and he will eat for a meal. Teach a man to fish and he will eat for a lifetime.

Well done, Mr. D.

Happy Nurses' Week!

Because I could never listen to a patient, to comfort one, to hold his hand when he's afraid, to change his clothes when he is diry, to cry a few tears when she passes away, to protect her and be her advocate when she isn't able to take care of herself, or do countless other tasks, as well as a nurse can.

Happy Nurses' Week!

This was the pancake crew of doctors working the 630AM shift, serving breakfast to our nurses!

The aftermath

If you're Malaysian, you're well aware of the outcomes of the elections. Thousands of miles away, we followed the updates online.

Naturally, I was disappointed. Disappointed that the outcomes were not different. But even more disappointed by the tactics some parties used to 'win'.
If these allegations are true (admittedly social media is not always correct there appears to be video and photographic evidence)- in simple terms, they cheated.

I'm heartbroken as many of you are. Saddened and in mourning over what seems to be the lack of democracy and fairness.

And outraged by the seemingly arrogant and irresponsible remarks the man who is supposed to be the political leader and representative of all Malaysians, suggesting or accusing a certain race for the outcomes of the elections.

With even the PM stoking the fire, what future is there for the minorities in Malaysia? Who will protect their interests? And does anyone still look beyond skin color? I am fearful.

But, if there is a silver lining in all this, it was heartwarming and encouraging to see how most, regardless of skin color, was united in this cause. How, despite the reports of threats and violence, good people helped each other out.

Yes, I'm heartbroken; I still am. But this will heal, as I'm sure yours will. And perhaps someday, there will be enough who will say no to greedy, racist and corrupt leaders.

I shall remain optimistic.

The day of reckoning

I left Malaysian in 1998. Have since spent over a decade between Canada and the USA. But the saying that you can take the boy out of Malaysia, but you can never take the Malaysian out of the boy, hasn't been truer than today.

It's Sunday in Malaysia. Thousands of miles away, I am glued to social media sites, reading updates every minute. I am pacing the floor, anxious. I am outraged reading about the ploys and the tricks some resort to. And when dad sent me a picture of his finger after he voted; the amazingly undefeatable indelible (invisible) ink:

 

Malaysia, though we are far away, many of us still proudly call ourselves Malaysian, and wish the best for you. I pray for a peaceful elections, and that the party and its selfish goals that has been poisoning the nation and dividing her people will finally be toppled. I hope to wake to up good news tomorrow morning.

Historic GE-13

Whatever the outcomes this weekend, the 13th Malaysian General Elections will be a historic event.

For far too long, Malaysians have put up with a ruling government that emphasizes cronyism, corruption, racism and personal gain.

For far too long, powers-that-be have held on to that power, and signs indicate that the powers-that-be are fearful of losing that grip on the Malaysian people.

 

I tell my patients you can't believe everything you read on the internet. But with social media and all you read about, you can't help be worry and be disheartened about the desperate moves the ruling party appears to be resorting to.

 

Open vote-buying, bribery. Subtle threats of racial violence, or playing the racial card to divide and conquer. Phantom voters, even to the extent to apparently flying in foreigners to vote for them.

 

Whatever the outcomes, this will be a historic event, reminiscent of the Arab Spring movement. If nothing else, this highlights the power of the internet and the social media. The corrupt leaders and their illegal or unethical practices are no longer hidden. Someone, somewhere is watching, and if they see a wrong, somehow it will be exposed. Perhaps it might be too slow and too few to affect the outcome of this election (though many of us wait with anxious and open hearts that the ruling party will finally be toppled), eventually the movement will gain enough momentum.

 

If not this time, perhaps the next. But, oh, please let it me this time.

 

Ini kali-lah, Malaysia. Vote wisely; the rest of us who are abroad hope for the best.

Patient Art

A patient of mine came in with his arm in a cast.
I asked him what happened, but before he could answer I was paged out of the room.

When I came back, this is what I saw.

Pretty self-explanatory.

The "crap" was a nice touch. I would have used more choice language.

 

And they say patients have no sense of humor.

Clearwater, Florida

After a long lapse since our last vacation, we took a short trip to Clearwater, Florida. Just a 4 day trip, but this was also a good warm-up for the impending Malaysia trip- good to see how the girls would put up with the flight.

Well, this was my first trip there. We wanted a beachfront hotel; location was the priority, not the room. And so we stayed at the Hilton Clearwater. It was an older hotel; its age was apparent from the outside though the rooms were modernized and tasteful if not a bit small. If you were unlucky enough, you might get a room facing the ventilation system- section of the hotel which was something of an eyesore. Thankfully we got a harborview room.

The beach, now that was something else. Long stretches of soft white sand. Right outside the hotel. It was easy to get to the beach, and back.

 

We loved it. The kids spent hours playing on the sand. Kris and I got to relax, and also went out on the jetski.

It was fun, right up to the point when she asked, "Are there sharks in the Gulf of Mexico?". I told myself I could swim faster than her if one ever came for us!

This was Ava's first trip to the beach. One we hope to duplicate in July when we go to the Jersey Shore. And again in November when we make our family trip to Pangkor.



One extra bonus was our visit to the Clearwater Marine Aquarium. It's resident Winter inspired the movie Dolphin Tale, and it was exciting enough for Alli to see some of the resident dolphins, and the other marine wildlife. But it was a treat to be able to see Winter as well.

Though the facility was small, and does not at all compare to the larger aquariums out there, and the cost adds up pretty fast, considering this functions primarily as a marine rescue facility, it was pretty entertaining for the kids, and the money goes to a good cause.

After a fun 4-day visit, and what felt to be a never-ending flight, we're home, just in time for me to start call this week.

Oh well. At least I have some tan lines to remind me that we had great trip before work resumed.

Winds of Change

Though I'm far away from my native Malaysia, every single day for the last 15 years I've been away, I have checked the local news. I wonder about her ongoings. And I have to say, like many Malaysians, have become more disillusioned about her leaders.

The circus that is going on in the recent weeks and months is a testament to how far some groups will go to retain absolute power.

And with one of the main opposition groups possibly off the ballots and its leaders possibly needing to go on the ballot of its ally, some are concerned if this will lead to confusion especially amongst those less aware of the recent events.

Some might also say they would never vote for a candidate under the PAS ballot.

Indeed, growing up, the Chinese have often seen PAS as a radical group.

But perhaps one of my good friends put it best: "Maybe this will show the real spirit of muhibbah in Malaysia".

Voting for a candidate not on the basis of skin color, or race, or religion. Instead, voting in the hopes that this candidate will have honor, honesty and integrity. Voting down corruption. The Chinese and Indians (and of course the Malays too) willing to back up PAS simply because of the dream that someday, we will be rid of the corrupt.

Malaysia, though many of us may be far away, I have high hopes for you.

I usually don't take offence at what a patient might say.

Today was an exception.

I saw a 62 year old woman for the first time- she had seen my colleagues in the previous months for her diabetes. She came in with no glucose logs (she hadn't been testing). She had not been taking her diabetes meds. Indeed, her blood pressure was 160/90 mm Hg; she had also deferred her ACE-inhibitor, and had refused treatment with a statin for her LDL of 168 mg/dL as well.

Not surprisingly, her hemoglobin A1c was 9.8%. And so, I urged her to consider changing her ways, and to take her prescribed medications.

To which she said, "I wonder how much commission you make prescribing these medications?".

I was rudely surprised at that question.

I firmly answered: "Nothing. We make zero dollars prescribing a medication".

Unlike some parts of the world, here we doctors prescribed and the meds are picked up only at the pharmacy (plus the medications she was supposed to be on are generic, anyway).

So I gently but firmly told her that if she wasn't willing to take our advice, and thinks we have ulterior (financial) motives, why was she choosing to come for her 3 monthly visits anyway? What good were these visits, if she didn't heed our advice?

34 years!

I found this in my album the other day. Yup, that's me in the back seat, with my older brother. Me, with the same stupid grin. And yes, I'm aware I look effeminate as a kid.

Gosh, that was the home in which I grew up (mom and dad still live there. I still call it 'home' despite us owning our house here- guess some things never change).

Anyway, it's surreal finding these, and then realizing that 34 years later my kid has the same stupid toothless grin. This was Alli 1.5 years ago. Before she grew fangs with which she devours everything.

These pictures were taken 34 years apart.

Except she's a lot cuter than dad way (digression: does ANY parent truly think their kids are ugly?).