OT Call: Sampai Dua Failed Spinal in A Day

November 04, 2019

-warning: Entry ni banyak jargons. Maybe susah for non-medical persons to understand-

Starting this year, we MOs are divided into pools ie OT pool and ICU pool.
Everyone will remain in the pool for the whole month and then we either rotate or stay in the pool, depending on our boss.
I was in OT pool in Sept, then Oct in ICU pool - which explains why I had so many thoughts on critically ill patients in mind.
I am now in OT pool until next January - that is 3 months yeayy.

2nd Nov was my first OT call after switching pool. Dah lama x buat spinal wey.
But thankfully I had L, a floating MO to tag with me for 24 hours.
He does most of the work, I was there mostly to supervise and decide some minor things.
And he had two failed spinals that day. No, this entry is not to bitch about him, it is just for me to read back in the future about some of my cases I experience during oncalls.

Caesar yg kena convert GA
First case yg failed spinal tu was for EMLSCS for an unstable lie in labour.
O&G post kt L - G2P1 unstable lie, os 2cm, contractions 1:10mins tapi last meal belum cukup.
Ada lagi sejam lebih before the fasting time (6 hours) complete untuk patient tu. For those who don't know, patient nak op akan kena puasa at least 6 jam.
Lagi lagi klo patient pregnant sebab nanti ada risiko tinggi untuk tersedak makanan, masuk paru2 and mati - senang cerita. Igt suka2 doktor nk suruh patient jangan makan?

That time I was doing appendix case, and ada lagi 2 appendix menanti..
And since surgical team dah ada dalam OR, and salah satu appendicitis tu in sepsis, TWC 26 - I called that one first.
So I rush the current surgeon untuk habiskan appendix tu cecepat.
Aleh2 dia bagi HO dia close the skin, I said "Okay tapi klo HO u lambat sgt, u hv to take over sbb I hv EMLSCS"
Obviously HO dia lambat la, tapi dapat la jgk stitch more than half of the wound.
Sekali patient ni pulak lambat banguuuun. 15 mins post reversal, the kid still hasnt emerge from anaesthesia - lalok lagi adik tu, x boleh extubate.
Last2 lambat jugak induce appendix yg sepsis tu.
I was already fidgety that time, kang tiba2 O&G post unstable lie tu as fetal distress, dah kena bukak second OT. Kan susah.

And I texted Farahin tnya - kenapa os baru 2cm and contractions 1:10 dah kira in labour?
And betul la apa Frhn ckp; os dah bukak, and dh ada contractions, in labour la tu.
I got confused between in labour and active phase of labour.
Seb baik tnya Frhn dlu, sbb klo tertanya O&G sini, maluuu.

Kena pulak appendix yg sepsis ni complicated, Masz x dpt nak release tip of appendix hence Mr I scrub in and korek keluar appendix nye.
At least mencepatkan lah, boleh la pggl caesar tu cecepat.

Pastu tengah2 L membagi spinal, tiba2 ada aspirate blood pulak.
In the middle of administering spinal drugs, usually we aspirate sikit nak tengok the CSF again. And we usually can see the "cloud" coming into the syringe - ie the CSF lah.
Tp yg L pnya ni, aspirate keluar blood la pulaaak. So ktorg betul2 kan, position balik etc, dpt balik CSF nye.
Tp by then dh mendak kot ubat spinal yg lain hence the block jadi patchy. Patient still sakit bila surgeon testing kt perut 😣

So terpaksa la call Boss John - discuss next step.
Boss kata GA je lah. Uhhhukss. Utk yg tak tahu, men-GA-kan perempuan mengandung adalah sesuatu yg seboleh2nye MO Anaest nak avoid.
Bahaya wey, banyak risiko nye. Paling menakutkan, klo hypoxic smpai mak tu brain damage. Kau nk jawab kt court?

Nasib baik tadi tggu utk last meal dia habis and siap ter lambat sejam lagi sbb buat appendix dlu.
Baby nurse terus call Paeds utk standby sbb mummy under GA kan.
And intubate la itu mummy - uneventful. Op pun uneventful.

Baby je lalok. Mula2 keluar menangis pastu lalok pastu kena PPV. Last2 admit NICU under CPAP for TTN 😞

Indian yg Failed Spinal
Ini memang nk ketok L.
Bunyi mcm rasis, but no. Not rasis. Patient ni memang India mari, barely speak Malay or English hence everything was translated by the Indian employer.
Nak debride wound di kaki nya, so L bagi la spinal.
Spinal tu nampak mcm smooth je - I wasn't really paying attention sbb by then mcm dh trust L, and I started documenting BP HR sume.
Nak test level pun susah sebab the patient mmg tak faham ktorg ckp. So suruh surgeon proceed je drape.

Sekali waktu surgeon test pkai forceps, meringkuk2 patient tu sakit. Alahai kesian.
Tapi kaki sebelah dah berat, cuma yg op side je still sakit and x berat sangat. Tilt tilt table, tunggu 15 mins pun sakit lagi.
Wktu tu dah 2 lebih pagi, mata dah berat - kes x habis lagi.
Nk convert GA alaaaaahai.
Last2 supplement Ketamine. Yeay wonder drug mmg do wonders.
Terus patient lalok and tak sakit. Tnya sakit ke (secara body language) - dia kata tak, sambil mata dia dh membesar dan bercahaya kerana Ketamine. Heee~
Terasa berjaya sangat.

Tapi bila dah kena supplement2 Ketamine ni, tak boleh la nak tinggal kan L utk jaga OT sesorg.
Patient sakit je which is about every 20mins, kena tambah 10mg Ketamine and so on.
And akhirnya berjaya habis op, tanpa perlu convert GA.

Ok habis sudah ceritera oncall.
Till next time :)

-Because life is a test-



First Screening for Masters Programme

November 03, 2019


Alhamdulillah, I passed the first screening of the Masters programme for MMed Anaes.
The registration for the programme was in July this year.

The screening is just a formality to screen and filter out applicants who do not fulfill the requirements eg those that are not yet 3 years in service, or those with insufficient LNPT marks.
So as (almost) expected, it was smooth for me. Alhamdulillah.

eHLP - Permohonan Berjaya

I am not sure about last year, but this year the exam board created a blog / website for us applicants to register for the Entrance Exam.
The Entrance Exam fee is RM250. Initially, the closing date for the exam registration was 1st November but that doesn't make sense because the release of eHLP result of the first screening has not been announced. Thank God they postponed it to the 10th November 2019.

So today, I paid the RM250 and registered myself for the entrance exam which will be held in mid Dec this year.
Let's start studying again :)

-Because life is a test-



Treating The Critically Ill

November 02, 2019


ICU settings

As an Anaest MO, I work in both the Operating Theatre (OT) and the Intensive Care Unit (ICU).
Needless to say, the patients I treat in ICU are all very sick patients. Most of the time, they are intubated, to allow oxygen being delivered to them so that they can breathe better, and easier and thus, relieving their bodies of the fatigue.

Often, we managed to save them.
They recover, extubated and then discharged to the general (normal) ward.
Sometimes they don’t do well, and we need to know when to stop, and when to say “OK, this is it. This is our limit and there is no more we human beings can do”. It is challenging to determine that point. I am always scared that I gave up too early. What if I just need to try a bit more to save him?

Give up? Or try harder?

Often, the line separating surviving from succumbing is grey.
And adding to the complexity - is the life after survival.
One might survive the ordeal but left with disabilities that render him / her dependant on others.
One might get through a severe infection of the lungs but the heart became weak and can't even stand walking to the toilet without feeling breathless.

I would often think - would the patient rather die of the infection or live with permanent disabilities? How can we know? Will the children know?

Jangan menambahkan penderitaan seseorang / tak nak dia menderita lama

So what if we can save the patient, but we know the outcome will not be good? Should we still try all out and get the patient to live - but only having his heart beating but without his brain and muscles functioning well?

And then comes miracle. How sure can I be that no miracle will ever happen?

Families cling to the word miracle like a stranded hiker clinging on her fingernails.
They need it, they desperately hope for a miracle. And I am there, shattering all their hopes.

No, please don't hold your hopes high. You need to understand, your father is not doing well and his heart might give way anytime soon. Please be ready.

Yes, I believe in miracles. But that is specifically why they are called miracles.
They rarely happen. And if they happen, no matter what we did, it will still take place.

ICU is a very specialised and thus, limited place.
Not all patients can be admitted to ICU - we need to choose our patients carefully, those who can benefit the most from an ICU admission and we have our own admission criteria.
Some patients who unfortunately do not meet the admission criteria; will be ventilated in the general wards. And it breaks my heart seeing these patients being outside in the normal ward, and die eventually. I usually hope the families will bring them home, so that they can die at home, surrounded by their family members.
But our society don't really do that.
They'd prefer their parents to die in the hospital, and most of the time, they don't agree to the withdrawal of care. They will agree to at most, limitation-of-therapy.

Every critically ill patients have a story of their own.
They might be healthy and fit last week, but a severe infection of the lungs, or perhaps disseminated infection of bacteria into their spleen and livers, causes them to be incapacitated and fighting for their lives.
Sometimes, it is a motor vehicle accident - injuring their intraabdominal organs, their brain and/or their bones.
Critically ill patients can be any of us in the future.
Have you actually thought about it?
Would you prefer being alive but disabled permanently and relying on your family members or die trying?
Is life, or quality of life more important to you?

p/s: No I am not trying to say people that are already disabled to be better off dead. No no not at all.
It's just so hard to imagine living but not really living. You aren't even yourself anymore.

-Because life is a test-



Tweaked My Layout (Again)

October 30, 2019


Amalie Blog Template

Barely two weeks, and I have changed my blog layout again.
I dislike Carolina because it doesnt display all my posts in a page. It displays only the most recent post, and the rest are in grids.

Grids like these

I am also dissatisfied with the [Read More] fuction.
I don't like that function, it requires effort for readers to read my blog.
I'd rather read a blog which displays the whole post and I can read by scrolling down, and then able to read the next post.

For this Amalie template, I am still finding out how to remove this post footer.
It looked weird, the image in the background must have expired - hence it shows the triangle warning instead.

Getting rid of this footer soon

Still looking for ways to remove them and hope I will be satisfied with the outcome!

-Because life is a test-




October 28, 2019



This is Oyen.
She is not mine. I don't know whose is she.
I gave her that name this morning. She is currently pregnant - I don't know how far is she in her pregnancy.

I have never been a fan of cats. I don't like cats. I am almost scared of them.
I think I can't stand holding a moving living creature. It grosses me out. Maybe that is why I cringe waktu menyiang ikan - and I rarely do.
Aisyah, my sister is worse. She can literally cry when a cat comes near her, even when the cat is 6metres away.

Oyen started coming to my house around a month ago - or perhaps I started realising her these past few weeks.
Cats have been sleeping on my porch intermittently for now. But Oyen caught my eyes because she is pregnant hence she stands out from the other cats.
I started looking out for her lately. Maybe the maternal instinct kicked in, since she is pregnant.
Akmal started it first. He considered buying catfoods during our routine grocery shopping - the price was the only thing that stopped him. Why are cat foods so expensive?!
He then gave our leftover Texas Chicken to Oyen.
Since then I started giving some of our leftovers.
Then Akmal bought a pack of cheap catfood!

Her favourite spot - in front of my sliding door

This morning I saw her again.
She was lying in front of my door. I almost stepped on her as I was going out of the house to hang my laundry.
I was actually looking for her on my porch, not realising she was really beneath my feet.

Whosever she is, I think the owner is not taking care of her much.
She looks like she yearns human touch - if that makes sense. She keeps gesek-ing herself to my shoe rack, and my grille.
She gives the single mother vibe. Like she is now on her own, pregnant, surviving for her baby and must look for a place to give birth.
My colleagues said she is testing to see if I am trustworthy - if she can actually give birth here.
OhGod. That sounds like a commitment.

Cats used to sleep on my dustpan. I think it's because the plastic dustpan is warmer than my tiled porch.
But Akmal removed the dustpan, he put it upside down now. So cats don't really have a place to sleep on now.
And I feel bad for pregnant Oyen.
So I made her this.

Box bed - for Oyen

I put some cat food in it, she ate the cat food but did not sleep in the box.
She continued sleeping in front of my glass sliding door. Perhaps she needs more time to trust that box bed.
I hope no other cat will sleep there.
And I am prepared for Oyen to give birth to little kittens there, as long as they don't shit anywhere on my porch.

'til then.

-Because life is a test-



Sanggup ke Jaga Tracheostomy?

October 27, 2019


I am an Anaest MO. That means I work in both the operating theatre (OT) as well as the Intensive Care Unit (ICU).
Undeniably, the patients in ICU are very critically ill patients - they require intensive care and resuscitation and monitoring to keep them alive, of course dengan izinNya.

Some of these patients sadly, after surviving the most critical part of their illnesses, they don't recover to their previous state.
They might suffer a stroke along the way, or the prolonged acidosis in them have affected a good portion of their brain function permanently, or just in general, became very weak and thus will take a long time to recover. These are the state ICU doctors call "Poor/Slow GCS recovery".
It just mean that their mental state and muscle power takes very long to recover.
And most, if not all of these patients are intubated.

Intubation is a way of delivering oxygen and ventilation to someone through a tube down his/her throat and straight into the lungs. And we can't keep the tube in the throat for long. There are a lot of problems tagging along with a prolonged endotracheal intubation.

An intubated patient. [Source]

So we will usually counsel the family for tracheostomy. Tracheostomy is basically an operation in which the surgeon makes a hole in the front part of the throat/trachea, below the vocal cord and passes a tracheostomy tube through it. The tube is the same size as the endotracheal tube, but it is shorter.
It bypasses the whole chunk of throat muscles - the muscles which a patient needs to control in order to breathe properly, the muscles which a very weak patient might not be able to control.

Tracheostomy Illustration . 

Tracheostomy. [Source]

Living with a tracheostomy is not exactly easy.
It affects not just the patient, but also the family members. More so if the reason the tracheostomy was performed was "Poor GCS recovery"
That means the patient will be almost vegetative, relying on the family members to care for him/her.

Normal people produce phlegm all the time - we then either spit them out or swallow them subconsciously.
But tracheostomi-ed patients can't do that. Coupled with the lack of ability to filter inspired air, patients will produce a lot of sputum especially in the earlier months. Thus family members MUST MUST MUST be able to perform suction of the airway - imagine putting in a smaller tube into the tracheostomy tube and suck all the mucus out. And it definitely is not for the faint-hearted. The patient will cough and gag and the secretions are not going to be clean and white. They are basically phlegm, spit, whatever you want to call it. They are not nice. They are gross.

So frequent suctions need to be done. And the suction is not just once early in the morning, and then once more in the evening when everyone's back from work. The patient's airway will be blocked by then. There need to be a dedicated carer to care for a trachy patient - to perform suction every few hours, more if the secretions are copious. See the commitment we need from family members? See why doctors don't perform a tracheostomy on just anyone?

I have had a few cases where the tracheostomy patient dies at home, some was even almost deliberately killed by their family members. One mother allegedly covers the vegetative son's face with a pillow to end his life. But hey, he wasn't breathing through his mouth nor nose! The son's lifeline was that tracheostomy tube, mom! Please don't ask me what happens to the son and the mother, I don't know. But I know things like these happen. Imagine what kind of frustration must the mother must have felt to try and end her son's life. Perhaps she thinks her son is not even living anymore, just laying there vegetative. Perhaps she thinks it might be better and easier for the son that way.

Tracheostomy is also not an easily reversible decision. There is no turning back.
In intubated patients, when the family and doctors agree, we can withdraw our treatments when we see there is no more that we can do. We can remove the tubes and let nature takes its course.
It is harder to do that once a tracheostomy tube is there. It is hard to withdraw treatment from tracheostomy, as we dont really remove the trachy tube from the body to withdraw treatment.

It always breaks my heart when I need to counsel family members for tracheostomy. Most of these patients are elderly, and the family I counsel are the children.
I need to really knock into them the reality of tracheostomy. Knock knock knock - these are what you signing yourselves for if u agree for tracheostomy. You mother or father will still be lying there, weak and very dependant on you. Tracheostomy is not going to fix it. Tracheostomy is ONLY to deliver the air into them so that they can breathe easier.
It doesn't fix their brains, it doesn't make their hearts stronger, nor will it cure the infection your mother / father might still be having.
And you now have to discuss with your family members - who CAN and who WILL take care of this parent?

Brutal question huh?
If they can't agree on a carer between them, then doctors can't perform the tracheostomy.
Then they might feel they are not trying the best for their parents - they will feel the guilt of not going all out for their parents.
But is tracheostomy really the best though in these patients?
If they DO agree for tracheostomy, but then later are unable to care for their parents, that will be an even greater sin.
The sin of menzalimi mak ayah sendiri. The sin when they let their mother father die drowning in their secretions, because there are no one to care for the parents. The sin of hoping and thinking "Baik lagi mak ayah mati".

But if they can't agree for tracheostomy - it might make them feel like they are giving up on their parents.
Tough, tough question.

Maybe this is the reason why many medical practitioners in the west are tyring to advocate an advanced directive - although it will be very hard to implement and has many loopholes in it.

A quesiotn for you:
Would you want tracheostomy done onto you in the future?

-Because life is a test-

[p/s: The terms in this post is simplified to suit the non-medical readers]



New Layout Again

October 18, 2019

I think I get bored easily.
I spent so much time browsing through free templates and tweaking them and then decided against them.

I hope this "Carolina" template will last me long.
But I hate the slider. How can I remove the slider on top?
I've Googled and tried almost all methods, non worked.

Ok, let's sleep.
I am in ICU now, oncall.
Pray hard not to get any referral tonight!

-Because life is a test-