Harvey Simulation Training

Today I attended another session for Harvey training for trainers. Prof Scalese aka Ross was an entertaining and enthusiastic teacher from Miami, the centre for simulation in medicine.

I remember having to travel all the way to Singapore 5 years ago. I enjoy travelling but not when I am nursing and that day I still remember hubby sending me off to KLIA in the when it was still dark (he goes to HKL roughly 7am, so we would have left home before that).

Then, waiting for flight and travelling to NUS, luckily traffic wasn't that bad in comparison to rush hour in KL. I remember the simulation unit in NUS was quite large, one whole floor. The staff were friendly. I cant remember much about the demonstration, but again we had a very mixed group ranging from lab technicians to medical lecturers, same as today's crowd from cardiologists to nurses, all the way from Thailand and Indonesia. I lucked out, only heard about the workshop a few days ago.

When I joined USM, I was impressed with the huge Clinical Skills Centre they have there because I dont remember using one as a student. The only remote thing I remember to using simulation as a student was performing a per vaginal exam and inserting a speculum in a mannequin, and using manneqins for basic life support, paediatric life support and advanced cardiac life support during training after graduation.

Then I joined Taylors and was very impressed with Harvey. I remember the murmur clinic we attended during final year, it was one cold morning where they gathered about 30-40 patients in an outpatient clinic, and all us 100 or so medical students went around listening to all the murmurs, taking on average maybe 3-5 minutes per patient and we were done by lunch time.

I have never heard so many different murmurs in so many different patients in one day, the rest of my life so far. It was a very intense session, and I'm sure more beneficial than not having any at all. But my point is, murmurs are not easy, even after many years of practice. So Harvey is a brilliant idea. You can listen as long as you want, whenever (depending on the opening hours of the clinical skills unit) you want, and keep practising as much as you need until you are confident. I wish my medical school had a Harvey when I was a student. Another point I'd like to make is that murmurs, although not that common in clinical practice, is extremely common in internal medical exams, both at the undergraduate and postgraduate level because patients are usually well, and the physical signs are usually stable, the ideal exam patient.

Harvey is also the ideal exam patient, and more ideal that patients themselves as Harvey does not get tired and doesn't mind being poked and prodded. One setback is you may require more than one unit if your OSCE has more than one cycle. Sometimes, it may also overheat. So remember to let it cool during the break.

I learnt today that Harvey is named after a cardiologist by a doctor who created Harvey, whose name is Gordon. Dr Gordon was so impressed with Dr Harvey, who basically uses bedside skills and a stethoscope to make diagnoses equivalent to what other doctors would need an echo to do.

Upcoming developments for Harvey: they will soon release more diseases (currently there are only 30) between 10-20 more and will also feature a faster heart rate of 90 beats per minute (currently Harvey's rate is 60 beats per minute).

No, they are not planning to have an Asian version, nor a female version, nor a paediatric version of Harvey. And the reason Harvey is big is that they need the space for all the contraptions that make it work.

Points for students:
Do not eat or drink near Harvey.
Do not use a pen near Harvey (use only pencils). Ink will stain and become a permanent tattoo.
Do not press too hard on the arterial pulses or you might obliterate it (I think this is the same for real patients).
You can palpate the jugular venous pulse in Harvey but it is not palpable in real patients (this is due to the mechanics of how the pulse is formed)

Other points for students:
Revise the JVP double flicker or complex wave components.
Understand why a and v waves are formed.
Describe why cannon v waves are formed.
Apex beat/PMI - why is it felt and what are the reasons the wave or impulse could be slow-rising.
Other abnormalities of the pulse such as parvus at tardus, bisferiens
Causes of displaced apex beat
The effects of increased preload - hypertrophy, increased afterload - dilatation

I was disappointed that the session did not start 9am as planned as I arrived 15 minutes earlier. Prof Scalese was there even earlier. We started 9.15am because we had to wait for people who were late.
 

UPSR 2016

First of all I must say I am grateful that my eldest son sat for UPSR this year, and that my second son will be setting for UPSR in 2017. The 2016 batch will be the first. I just attended a session at my kids school this morning where the teachers took time of on a Saturday to describe the details of the new exam format.

It is helpful to know the format of the UPSR 2015 exam and then look at what has changed. In general, the main changes are:
1) There are more subjective questions in all four subjects Bahasa Malaysia, English, Maths and Science.
2) These subjective type of questions require 'higher order thinking' (kemahiran berfikir aras tinggi KBAT) which the aim is avoid mere memorisation and regurgitation of facts to pass the exam. Instead, students will need to apply what they have learnt in order to answer the questions correctly.
3) The English paper will be divided into two papers and two separate grades, so next year the aim will no longer be 5A's, it will be 6A's.

There were notes provided for the session and the teachers also recommended:
1) downloading and looking at the questions at the Lembaga Peperiksaan 
2) buying books so that students can start practising answering now during the holidays, however, the teachers also said that book publishers have not started to print books yet as there are some uncertainties regarding the format of the questions.

When reading this post, I have used:
Italic fonts for Bahasa Malaysia
Brackets ( ) to compare with previous format
Bold to denote the different papers

BM Pemahaman

Masa diberi 1 jam 15minit

The main difference will be addition of subjective type of questions "objektif pelbagai bentuk" and "respons terhad".

There are two parts to the paper, bahagian A dan bahagian B. 

Bahagian A ada 20 soalan, markah 20. Bahagian B ada 5 soalan, markah 30. Jumlah markah = 50.

(Mengikut format lama, BM pemahaman ada 40 soalan objektif).

Bagi soalan subjektif respons terbuka;

Jawapan 1 markah adalah jawapan satu perkataan, jika ejaan salah contohnya Baik dieja BaiK, markah adalah kosong

Jawapan 2 markah adalah jawapan yang memerlukan ayat lengkap, ejaan tidak sepenting jawapan 1 markah.

Jawapan 3 markah adalah jawapan yang memerlukan pelajar berfikir (hello? Maybe my attention lapsed while writing the notes).

BM Penulisan
Kertas penulisan pula ada tiga bahagian, A, B dan C.

Bahagian A (10 markah, 15 minit)

Gambar diberi dan pelajar harus membuat ayat penuh berdasarkan gambar yang diberi. Ayat penuh bermaksud mempunyai subjek dan predikat.

(Berbanding 2015 penekanan adalah kepada penggunaan kata kerja).

Bahagian B (15 markah, 25 minit)

Memberi ulasan, contohnya kebaikan dan keburukan berdasarkan sesuatu maklumat yang diberi, contoh soalan adalah piramid pemakanan dan pelajar harus memberi pendapat mereka tentang piramid tersebut.

(Format 2015 ialah menulis tentang nilai murni yang terdapat dalam perenggan yang diberi).

Bahagian B boleh dikatakan lebih senang dari format terdahulu.

Bahagian C (25 markah, 35 minit)

Karangan, 2 soalan diberi dan pelajar boleh memilih salah satu. Panjang 80-120 perkataan.

Masa diberi 1 jam 15minit

Pendapat Guru-guru mengenai penukaran format BM:

Seorang dari guru yang hadir baru sahaja mengikuti kursus kecemerlangan bersama En Mat Arifin, penggubal soalan.

The question samples are not exhaustive. 

UPSR baru mirip PT3, tak boleh spot soalan.

Kita tak tahu bentuk soalan yang akan keluar.

Bentuk soalan adalah tidak muktamad. 

Untuk menjawab soalan KBAT pelajar perlu banyak membaca (doh!)

English
There will now be two separate paper and grades. The reason behind this move was vaguely explained...something to do with empowering English Language to a higher level, or rather, the students acquisition of such.

English Comprehension/Bahasa Inggeris Pemahaman

Section A is 20 marks
Section B is 30 marks
Time given 1 hour 15 minutes
Mixture of objective and subjective questions (previously 40 objective questions/MCQ, 40 marks)

Bahasa Inggeris Penulisan
Has 3 sections, A, B and C.
Section A 10 marks
Section B 15 marks
Section C 25 marks (compared to 15 marks previously) 2 questions, answer one only.

Time given 1 hour 15 minutes

The term 'holistic' was used, in that the paper will be looked at as a whole as opposed to separate parts in forming the overall marks.

Sains
Seperti biasa ada kertas 1 dan kertas 2, markah dijumlahkan sebagai satu gred. 
Kertas 1 ada 40 soalan objektif (berbanding 30 sebelum ini)
Kertas 2 ada 8 soalan (dahulu 5 soalan) dan 40 soalan kecil/breakdown
Tempoh adalah 1 jam untuk kedua-dua kertas

Ada soalan2 objektif jenis yang terdapat dalam buku IQ, mengikut pendapat cikgu sains. Thus it might be a good idea to buy some of the IQ books for practice.

Dalam kertas 1 terdapat soalan jenis aplikasi yang memerlukan KBAT, contoh soalan fakta dan aplikasi ialah penggunaan bekas makanan dari polistirena yang tidak digalakkan dan pelajar ditanya mengapa.

Komen guru mengenai kertas sains 2016 adalah (berbanding 2015, the type of questions that can be asked is limited, contohnya salji, dan unta yang tidak terdapat di Malaysia, tidak boleh ditanya tetapi sekarang boleh). Pendek kata, apa sahaja soalan boleh ditanya. Contohnya proses pengaratan, soalan lazimnya berbentuk paku yang direndam didalam air, dan terdapat lapisan minyak diatas. Untuk berkarat memerlukan air dan udara. Soalannya mungkin, jika paku dan air dibawa ke angkasa lepas, mungkinkah proses pengaratan berlaku? Jawapannya tidak, kerana tidak terdapat udara di angkasa lepas.

Please go to the following links and download the sample questions:
http://www.moe.gov.my/my/pemberitahuan-view?page=1&id=4967

tbc

The Best Place to Get A Facial Done In PJ

A few weeks ago I was undecided on whether to have a facial or not. It had been two years since my last facial. I skip these things when I'm pregnant. It was 5 months into my new job and with a fourth baby on board, things were not looking great for my skin despite using a pretty expensive anti-aging cream which made me look (or was supposed to make me look 15 years younger), true, at the very beginning I was often mistaken as a medical student. Now that I've pretty much done away with the white coat, that case of mistaken identity happens less often.

So out of the blue, baby happened to be settled and the other kids were reasonably content, I dashed out to of the house with the objective of getting a facial done. I headed for one of the shops in the shoplot of this well known international skincare brand, thinking that this usual outlet was pretty quiet and chances of getting a facial done here are pretty good without an appointment. "We close at 6pm" said one of the girls with a pretty face at the counter. It was 5.30pm. My hopes were dashed. The initial excitement of getting prime parking just opposite the entrance quashed. I asked for a business card and was told that I need to make an appointment. No walk-ins please.

I looked at the card and tried calling for the same brand shop but in a favourite nearby (sort off) mall. That was even worse. Weekday facials need 1 day advance booking and weekend facials at least 3 days in advance to secure an appointment. Appointments don't really work for me because baby is unpredictable.

So then I remembered seeing a sign for facial at another shopping mall. I wouldn't call it a favourite shopping mall, because it is rather old, but parking is free and is has some advantages compared to favourite shopping mall no1. I looked at the clock and decided to try my luck.

I walked in and yes, the lady at the counter was very happy to give me a facial without an appointment! Great! My kind of facial.

The decor was a bit worn out but it was clean. There was no locker or place to keep my belongings, I just placed them next to me on the couch. There was no need to change into other clothing like the 'place that I usually went for facials but could not give me a facial without an appointment'. So I was a bit apprehensive.

The lady looked at my skin and said it looked dry and tired. She made some recommendations and I went with whatever it was. At the end of the 1 hour plus session, I felt great. The products were locally made. The owner of the shop was a Kelantanese. I felt the pressure applied for massage was a bit too much, but I didn't complain. The next morning I stood at the mirror and I could appreciate the difference in my skin.

I remember initially thinking that I was not going to bother with facials. I mounted my exercise bike and decided to look up "why we need to do facials" on my phone, and lo and behold one read one website which said something to the same effect "We need to have facials because daily skincare, like brushing your teeth, which must be done daily, can never have the same effect as deep cleansing that the dentist can give for your teeth".Reading that made me jump off the bike, change into outside clothing and quickly dash out in search of a facial, walk in.

Yesterday, a few weeks later, I arrived at favourite shopping mall no2 sort off, earlier than planned for an appointment. So I decided to have a quick facial. I met with the owner (recognised her Kelantanese accent, and she had beautiful skin), and went straight in. What I like is that the lady gave me a good "about 20-30 minutes express facial", at my request. I don't think 'the usual place where I had gotten most of my facials before this' would be able to cater to such demands. And so, I am very happy to recommend this shop as the place to go for facials.

Long Case and Short Case

One main difference between the American and British medical education system is the use of long case and short cases in the exam. I still remember my final medical exam, the long and short cases that is. I wouldn't recall much about the written examinations, except that there were essays, with some options, and MCQ's.

For most medical students, preparing for written exams should not be a great hurdle because majority would have developed a way of preparing for such. A huge part of preparing for MCQ type of exam is to practice doing questions. For the majority of people, the challenge is time. So during practice it would be smart to time oneself. Regular practice is needed and the momentum should increase nearing the exam, so that the candidate can 'peak' their performance during exam time. (Somewhat similar to training for a half marathon).

So if the NBME is two months away, and there are about 1400 questions in the question bank, average questions to be done daily is 1400/60 = 23.3 questions per day, do or die. If it is a real pain, in the first 2-3 days start with 5 questions per day then slowly build up momentum to achieve 25 questions per day and maintain this till the last week prior to exam, where you can up to 30 questions/day.

For essay type of questions, what we used to do was look at all the past year questions available, to have an idea of the type of questions and what had been asked in the past. Sometimes, there is a pattern, allowing some kind of 'prediction' and sometimes there isn't. That is irrelevant. Looking at the past year questions will allow one to focus on areas that could potentially come out in future exams. Never do anything blindly. Never study without first understanding how you will be assessed.

My general advice to medical students on how to operate on a daily basis is:
1) Spend time on the wards seeing patients, clerking patients, examining patients, don't read your books on the wards. You need to read but spend your time on the wards wisely. You can read later at home.
2) On the wards; work in pairs or groups of three, with colleagues whom you respect and are of relatively equal standing. Take turns to take history, do the physical exam, and present to each other. Practice, practice, practice. Then ask questions pretending to be the examiner. When you get a chance to present to a doctor, use it. It is a golden opportunity for feedback and how you can improve. Some students have the ability to speak fluently without preparation, you have an advantage, but talking nonsense fluently will not get you the marks you need. If you are the introverted type like me, you will need more practice on the presentation part, so present to your dog, cat, fridge, mirror, friend, anyone willing or otherwise to listen.
3) When you get home after the day is done with ward work and teaching, it would be best to sleep first (after meals, praying, shower etc) before studying. Some people love to study at night, others during the early morning hours. Find what works best for you. The main message is don't study when you're tired. You will not be very productive. Rest first and then study. The hours spent studying too should increase as you near the exam. What to study? Apart from doing exam questions, I also read around the cases I have seen during the daytime at the ward, plus the themes in the exam questions. Time is a limitation for most people, so I would discourage just reading text or textbooks for the sake of completion. Targeted learning and meaningful learning will allow the type of learning that relies lest on memorization and would last longer.

During the weekends, there are additional hours where one can spend doing other things like socialising, shopping for groceries, household chores, recreation, exercise and unwind. But do maintain the momentum of practising exam questions and studying. You can even make up for days lost during the week.

The long case

There are in general different understand and interpretation of what a long case is. The British system, which is what Malaysians follow, would usually involve a carefully selected patient who has a suitable history and some positive physical examination findings, often one who is not acutely ill, but rather with chronic, stable signs, and is able to give the history him/herself. Sometimes, especially when there are many students taking the exam at the same time, there may be a shortage of these 'ideal long case' type of patients, and less then ideal cases may be used. Less then ideal may mean that the patient is unable to give a detailed history, or there is a lack of history, or the presentation may be atypical for the particular condition, or the patient has no clear diagnosis after a barrage of tests which all comeback negative....so yes, there is an element of luck and the solution to reducing this 'unfairness' is the OSCE exam, where each candidate will be examined on the same patient, using several patients in many different stations.

The long case is easier than the short case because you will be given about 45 minutes to take a history and do a relevant physical examination without the presence of any observer, usually behind closed curtains. The unofficial advice to the student is, at the very beginning, to get the patient 'on their side' by explaining the importance of the exam to the student, that the exam does not in any way impact patient management, and to please do not contradict what the student says in front of the examiners later. In other words, build rapport. It is also useful to ask the diagnosis first, and work backwards, though this may not always work if the patient is unaware or unable to communicate.

The candidate is usually given empty pieces of paper and maybe a board to write on. It is a good idea to jot down the headings for example presenting complaint, history of presenting illness etc at the very beginning so that you do not miss anything, and leave large amount of spaces so you can add in information should you forget something and later remember during the process. You must also watch the time very closely and aim to finish the history and physical 10 minutes earlier so that you can arrange your notes, come up with a differential, and anticipate questions regarding management before the examiner walks in.

The examiners (usually there's two but there might be there is an observer wants to join in) would ask if you are ready at around 45 minutes - 1 hour. The earlier candidates may have less time than later candidates during the day, as the exam continues, this is just the normal process. After presenting, the history, physical examination findings, differential and management, the examiners will usually ask you to demonstrate any of the physical examination findings and then discuss management. They may give feedback regarding your performance or they may choose not to. At undergraduate level, the examiners usually give leading questions if one is straying away from the correct path/answer. The examiners will usually have a detailed note of the patients history and physical examination findings, plus the diagnosis, and they may have a checklist to ease the assessment process.

The Short Cases

The short cases are a bit more tricky and the purpose of it is to assess your interaction with the patient, but more importantly, your skill at performing the physical examination and ability to discern between what is normal and what isn't. One average, a student may see three or four cases for the internal medicine part of the exam. Most of the time, as many as 10 or more patients will be placed in an area (maybe one ward prepared just for the exam) behind separate curtains or in separate rooms. You are not allowed to ask any questions other than "may I examine your......?" or " do you have any pain anywhere in your tummy?" before you start palpation.

You are expected to use your powers of observation to pick up things that will aid in the diagnosis, without obtaining the history, or using entirely the physical examination, to work out a diagnosis or differential, and then discuss the pathophysiology, possible etiology or management.

You must follow exactly the instructions given, which will be very specific for example, examine the respiratory system, look at the hands, look at the face, examine the praecordium, look at the fundus etc.

You may clarify if you are not sure what to examine, again, the examiner would lead the student if they are at lost or diverge from the correct answer.

It is best to give a running commentary while examining, and present as you find, although this may backfire if your findings are later found to be conflicting.

It is very impressive to examine efficiently, present the findings with the likely diagnosis or differential and then include a management plan. As long as your answer is correct. Usually, if the examiner doesn't interject, that means you are on the right path.

Do not spend minutes doing a part of the exam that could be done a few seconds. This can be very irritating to watch. Do not hesitate moving from one part of the exam to the next. Do not mumble when presenting your findings. Be confident, and this naturally comes with practice. Be confident, even if you are wrong, at least you sound good.

Make sure you know how to work the beds and how other apparatus works, this 'shows' that you have spent adequate time on the wards and can only be learned through experience.

Examples of Long Cases

I was the last candidate that day for the medicine long cases. In Trinity College Dublin, my alma mater, the long case for medicine is combined with psychiatry. So a student has a one in five chance to get a psychiatry for the long case. While I enjoyed psychiatry as a medical student, I cringed at the thought of getting one for the finals. Luckily, I did not get such a case.

Instead, the patient was a very pleasant, youngish middle aged lady who was newly diagnosed with leukemia. I cant remember which one. There wasn't much to report in the history. She had felt unwell and went to her GP. The GP did some routine blood tests and picked up the cancer. She did have hepatosplenomegaly. As I had explained earlier, had there been other more suitable patients on the ward, this patient would probably be a more suitable candidate for the short cases.

By the time the examiners came, they seemed rather tired and sort off 'fazed out' during the presentation. Thankfully, it was brief. The focus of the history though, was on the social part because anyone with newly diagnosed cancer will have a lot of issues to look at, can the patient continue working, how would they manage with chemotherapy, is there someone at home who can help take care of them when they are ill, etc. So if you don't have a lot of stuff to report, make sure you do a detailed social history (also if the case warrants it, for example a patient who is blind but has ischaemic heart disease, or a patient with diabetes who needs insulin but is unable to inject themselves due to rheumatoid arthritis).

I was asked to demonstrate my findings (hepatosplenomegaly) and then discuss the general principles behind the management of leukemias (and the different types), but not in great detail as specialists are not allowed to examine their own area of expertise, for example a gastroenterologist must not be an examiner for a case of crohns disease and a chest physician should not be the examiner for a COPD patient.

My husband got a patient with a stroke, another excellent case for the medical finals. The were only pure motor findings so the working diagnosis was lacunar infarct. The patient had difficulty hearing so my husband had to practically shout throughout the history and physical examination.

Other long cases for medicine include heart failure, multiple sclerosis, COPD complicated by cor pulmonale, lung cancer, cirrhosis....

One student recollected getting a patient for the long case who was unable to give any history at all due to a mixture of dementia and probably dysphasia. The student proceeded to do a mini mental state examination and a physical exam. During the presentation, the student emphasised the need to look for old medical notes and to obtain a collateral history. He passed.

It's funny that I can't seem to recall my surgical long case. My husband got a patient with Crohns disease with multiple surgical interventions, who was not aware if the diagnosis.

For paediatrics, I was introduced to a 10-12 year old boy who I was told should be able to give the history by himself. They were right. I was disappointed that the parents were not there, but that disappointment went away within the first few minutes when I realised that the patient was a 'professional' patient. It was pretty obvious this was not the first time he was included in the medical exams. He had stage 4 clubbing due cystic fibrosis. Admitted with pneumonia. All paediatric long cases must have their height and weight plotted on the centiles. Failure to thrive is as important a sign to pick as unintentional weight loss is in adults.

In the obstetric and gynaecology finals, each student will either get an obs or a gynae patient for the long case. There were no short cases, instead they had a viva, which is a live voice exam with two examiners immediately after the long case. If the long case was obs, mine was a lady post lower segment caesarean section, she was lovely but I cant recall any other detail about the case, then the oral exam would focus on gynae. I remember being asked about vaginal prolapse and chlamydia infection. It still amazes me that I can recall the event to that amount of detail more than a decade later. Talk about the effect of stress and memory formation.

Examples of Short Cases

If there is a patient with a murmur, no doubt they will be invited to participate in the exam. Make sure you are comfortable examining the praecordium and anterior chest of female patients. I find a lot of students dwindle at this, even the ladies. After examining and presenting the findings, you will be asked what type of lesion you think it is, and what the possible causes are. Instead of giving lists, it is more impressive if you can taylor it to the particular patient you just saw. "Given the young age of this patient, the most likely cause of the x murmur is infective endocarditis" is better than saying "The causes of x murmur include bla bla bla...". You may be asked about management.

Other favourite short cases include pleural effusion. Stony dull to percussion. What are the causes? Make sure you answer by dividing into exudates and transudates.

Rheumatoid arthritis hands. "Examine this patients hands".

Lymphadenopathy for example in the cervical area. What is the differential diagnosis?

Ptosis, bilateral in a patient with myasthenia gravis. Instruction was 'examine this patients eyes'.

For the surgical finals I remember seeing a lady with a new mastectomy scar. I was asked to describe what I saw, give the diagnosis and then was asked what I wanted to do next. I replied I would like to examine the remaining breast and the axillae.

I was taken to see a patient with a urostomy bag. I was asked where suitable sites for stoma bags would be (away from the umbilicus, bony prominence etc, apparently this is a favourite question), and whether the piece of gut used was retro or antero-peristalsis.

In the paediatrics short case I had a toddler who was screaming from beginning to the end of the brief exam. I believe the baby was upset even beforehand so it was not me that made the baby cry, but uncomfortable for me to continue with all the racket. I did ask the examiners whether I should continue and they said yes. The child had bilateral stumps at the ulnar side of the MCP joint, due to surgically removed 6th digits. I was asked what I would like to examine next, I replied the feet. I was asked "what one question would you ask the mother?"

For internal medicine, Baliga 100 Cases remains a favourite book and Stryders Short Cases for the MRCP will give examples that is meant for postgraduate exam but can be applied at the undergraduate level too.

Hope this helps.

Looking for a Photo Shop in PJ After Hours? I Recommend the one in Jalan SS5B/4

A few days ago I was at ends wit. The deadline for the submission of teaching permit was around the corner because of the accreditation and guess what, I forgot that I had to submit three passport sized photo's. Months earlier I had brought my certificates and letters from previous employers stating that I had experience teaching in a higher learning institution. But I forgot the pictures.

So I went out after 8pm because I wanted Baby to sleep first. The first photo shop nearby was already closed about 10 past eight. Just as well, the road was a very narrow slip and parking was not easy. This is near Jalan 222. So I remembered going to a shop in Section 14 maybe 20 years ago, near Joo Hua, to get passport pic taken. Headed that direction immediately. It was around 8.30pm when I got there, section 14 you have to go around the McDonalds because of the one-way streets. Traffic is always kind of crazy in that area with people double parking as the norm. Sadly, second store was also closed.

Then I remembered some 4 years ago now, I went to a photograph shop in Kelana Jaya. My second son had missed his graduation photo session at the kindy and the teacher had given me the gown plus hat and scroll, and I had to take him on my own to the store for his picture taken. If not, there would be no graduation picture for kindy (horrors). At that time I was busy with my previous full time job and three kids, so having to do something extra was a chore, an unfortunate chore back then. My son had taken ill during the original photo session. As soon as he was well, we went to the shop for his moment. There was no waze back then so it took some time to find the place.

It those desperate moments, the memory of the photo shop came back. It was 8.40pm and time wasn't on my side. I decided to try anyway. Nothing to lose. I googled for photo shop PJ half way there and an address in section 14 came up instead. I decided to forgot about that and continue to Kelana Jaya.

The moment I arrived, the shop had its doors open with lights still on but they had drawn the covers partially. I parked quickly (there were ample parking spaces) and clocked had ticked 9pm. I made a dash for it and asked as soon as I entered the shop whether they could do passport photos. A lady answered, is it for passport she enquired and I said not really, its just for teaching permit which required 3 photos with blue background. The lady was happy to help and said that they were almost closed. With the CD it would cost RM15. Yay!

I sat down at the back of the shop after some adjustment of lights and seating and had two shots taken. Ok lah. No make up. The natural look. Lack of sleep because of baby and work. I like it, sort of.

It only took a few minutes and I was out of there, one satisfied customer.

Accreditation

It has been a stressful week at work. Why? Accreditation. The only people in the world who do not hate accreditation is probably the auditors. I have heard that auditors too, do not necessarily enjoy their work.

I have worked in a government organisation when I first encountered an experience with being evaluated for Quality Assurance. The funny thing was, always in retrospect, that my boss at that time, and most of my working colleagues, were completely clueless as to the process. The leaders themselves were in the dark because the previous leaders had left without fully explaining the situation. So we just waited for the arrival of the internal auditors and 'prepared to be slaughtered'.

Thinking back I am reminded of what the whole process is about. In one word, it is about documentation. Everything that we do must be documented so that it can be evaluated by someone from the outside.

Yes, documentation is very important in medicine. Everything that happens to a patient during the course of a hospital stay or interaction as an patient in the community must be written or entered in a computerised electronic health care system. Why? For the records, so that when another doctor or health care professional attends to the same patient, they have accessed to the whole story, not just from the patients perspective but also from the doctors perspective. And, I guess more importantly, should anything go wrong, God forbid, there are records of what had happened so that such mistakes (if proven to be) could be avoided in future, or the records could prove that despite everything was carried out in the normal expected way, the patients deterioration was outside the control of the treating physician.

That worked well in the practice of medicine. I've written countless of entries into countless of medical charts, both electronic and hand-written, both in hospital and in the community. It seemed logical and the right thing to do. But in academia? Why? Who would want to read it anyway? It turns out that yes, every single organisation needs to document their operations and the academia industry is no exception.

At the department level, department meetings, and other standard operating procedures must be detailed in the relevant files. The funny thing is (ok, maybe its not that funny), is whatever you decide to write in the SOPs, must be followed through. So if you can't, then dont write it down. So the documents are not goals but rather reflects what is done in reality. And if it does not concur with reality then it is something that must be changed (either the documents or the reality).

For the academia world, curriculum is everything. Ok its not everything but it is very important. One of the first things the auditors will look at. From my experience in a previous institution, a person was hired to prepared the entire syllabus and who showed this to the auditors who were not even interested to flip through the hundreds of pages of medical school curriculum. Instead, I am told, they are looking for very specific things.

It seems the curriculum, timetable and lecture samples are the highlights from an individual level. From the customer perspective they look at contact hours, time spent on wards, ratio of lecturers to students, then of course there is the assessment. They also look at the logistics, are there enough lecture halls and facilities for students, the library, the anatomy lab, the pathology specimens, the hospital and wards available, and human resources, they scrutinize the staff hired, are they suitably qualified to what they are meant to do, are they being paid enough to prevent high staff turnover and so on.

My second experience with accreditation was a good one, they identified areas which require improvement, which I think regardless of how good an institution is, no one or thing is perfect expect God, so there will always be room for improvement. Then, they gave the green light that the institution was given accreditation for a number of years before they will return again for a routine review.

The scariest thing that can happen is if an institution does not get accreditation. That means there are severe deficiencies that make it not up to mark of standards that is acceptable for the organisation benchmark. The organisation is then left to make repairs and then subject itself to another round of accreditation.

If You Witness A Person Having A Stroke, Please Do Not Pierce Their Finger Tips and Earlobes

There is an annoying message going around in facebook and whatsapp groups again. Did you get the message which says that if one is witnessing another person having a stroke, one should get a syringe and poke the persons tips of fingers until they all bleed and if the persons lips is crooked, which is a sign of stroke, then one should use the syringe to poke the earlobes until it bleeds. Apparently, this "blood letting" will "cure" the persons stroke. According to the message, if the "blood letting" is not done and the person is taken to the hospital, "capillaries in the brain" will rupture causing the persons condition to worsen.

I include the original message here:

"Doc, can I have your opinion on this?
Just received this useful message. Forwarding it in the hope of saving someone's life. Keep a syringe or needle in your home to do this.... It's amazing and an unconventional way of recovering from stroke. Please read it to the end. You can help somebody one day. This is amazing. Please read and remember what to do. You will never know whether someone's life might depend on you. My father was paralysed and later died from the result of a stroke. I wish I knew about this first aid before. When stroke strikes, the capillaries in the brain will gradually burst. When a stroke occurs, stay calm. No matter where the victim is, do not move him / her. Because, if moved, the capillaries will burst. Help the victim to sit up where he / she is to prevent him / her from falling over again, and then the blood letting can begin . If you have in your home an injection syringe that would be the best. Otherwise, a sewing needle or a straight pin will do. 1. Place the needle/pin over fire to sterilize it and then use it to prick the tip of all ......10 fingers. 2. There are no specific acupuncture points, just prick about one mm from the finger nail. 3. Prick till blood comes out. 4. If blood does not start to drip, then squeeze with your fingers. 5. When all 10 digits are bleeding, wait a few minutes then the victim will regain consciousness. 6. If the victim's mouth is crooked, then pull on his ears until they are red. 7. Then prick each earlobe twice until two drops of blood comes from each earlobe. After a few minutes the victim should regain consciousness. Wait till the victim regains his normal state without any abnormal symptoms then take him to the hospital. Otherwise, if he is taken in an ambulance to the hospital in a hurry, the bumpy trip will cause all the capillaries in his brain to burst. 'I learned about letting blood to save life from Chinese traditional physician, Ha Bu Ting, who lives in Sun Juke. Furthermore, I had practical experience with it. Therefore, I can say this method is 100% effective. In 1979, I was teaching in Fung Gaap College in Tai Chung. One afternoon, I was teaching a class when another teacher came running to my classroom panting, and said: 'Ms. Liu, come quick, our supervisor has had a stroke!! I immediately went to the 3rd floor. When I saw our supervisor, Mr. Chen Fu Tien, his colour was off, his speech was slurred, his mouth was crooked - all the symptoms of a stroke. I immediately asked one of the practicum students to go to the pharmacy outside the school to buy a syringe, which I used to prick Mr. Chen's 10 finger tips. When all 10 fingers were bleeding (each with a pea-sized drop of blood), after a few minutes, Mr. Chen's face regained its colour and his eyes' spirit returned. But his mouth was still crooked. So, I pulled on his ears to fill them with blood. When his ears became red, I pricked his right earlobe twice to let out two drops of blood. When both earlobes had two drops of blood each, a miracle happened. Within 3-5 minutes the shape of his mouth returned to normal, and his speech became clear. We let him rest for a while and have a cup of hot tea. Then we helped him go down the stairs, drove him to Wei Wah Hospital. He rested one night and was released the next day to return to school to teach. Everything worked normally. There were no ill after effects. On the other hand, the usual stroke victim usually suffers irreparable bursting of the brain capillaries on the way to the hospital. As a result, these victims never recover. Therefore, stroke is the second cause of death. The lucky ones will stay alive but can remain paralysed for life. It is such a horrible thing to happen in one's life. If we can all remember this blood letting method, we can start the life saving process immediately. In a short time, the victim will be revived and regain 100% normality. (Irene Liu) IF POSSIBLE PLEASE FORWARD THIS AFTER READING. YOU WILL NEVER KNOW IT MAY HELP SAVE SOMEONE'S LIFE FROM STROKE."

I've added in another identified source:

http://www.sportonlinegroup.com/needle-can-save-a-patients-life-in-case-of-stroke-here-is-how/

(which makes one wonder about the validity of all the other available information from the same site).

One of my friends messaged me in facebook to ask my opinion regarding the content of the message and this is my opinion: What a load of nonsense. 

Who makes up this stuff? And who circulates it without verifying the contents?

I remember the unnamed author writing something along the lines "I know it works because I have practical experience". The writer then describes one encounter with a person who was having a stroke. One encounter, that's right, one person having a stroke (and I have reservations regarding the diagnosis because the person writing the message is obviously not a doctor) is treated with the "blood letting" method and supposedly recovers. What most likely had happened is the person suffered a minor stroke or transient ischaemic attack, which is similar to a stroke, but the clot causing the blockage gets dislodged and the vessel unblocked so that the patients symptoms disappear if not very quick then within 24 hours.

The Science Behind A Stroke

The pathophysiology of stroke or cerebrovascular accident, the term medics use, basically is a disruption in the blood supply to the brain. This can be caused by a bleed or a blockage in the brain vessels. The vessels which bring oxygen is known as arteries. A similar problem in the heart would result in a heart attack.

The arteries that bring oxygenated blood to the brain supply the brain tissue in such a manner that blockage or bleeds of certain arteries or branches of arteries cause different signs or neurological deficits such as weakness in the arm and leg of one side of the body including the face, disturbance in vision or speech, numbness in one side of the body and so on.

Conventional Medical Treatment of Stroke

In general, blockage of brain vessels by clots is more common than stroke caused by bleeding of brain vessels. Treatment of stroke depends on the cause. When the cause of the stroke is a bleed, treating the stroke may involve stopping the bleed or reducing its effect. When the cause of the stroke is a clot, treatment will include giving medication that can help prevent the clot from growing or worsening and medicine that will try and dissolve the clot (clot buster or tissue plasminogen activator).

Show Me The Evidence Please

I'd like to know how piercing the tips of the fingers and earlobes until they bleed a certain amount of blood, stops or reduces the bleeding or blockage in the brain causing the stroke. There is no explanation, is there? Followed by the crazy assumption that taking the patient to the hospital immediately after the onset of stroke will cause capillaries in the brain to burst, hence worsening the patients condition. Which capillaries? How does piercing the tips of fingers and earlobes stop capillaries from bursting?

No randomised-controlled trial or any research done to prove that "blood letting" works. Plus no plausible explanation of how the science works. And yet people believe it and help spread the non-sense.

If you find any research or science to contradict what I have blogged, please forward it to me. Thanks a lot.

This is another website which explains why this advice is wrong:

http://www.hoax-slayer.com/needle-stroke.shtml

What To Do If You Witness A Person Having A Stroke:

1) If person is unconcious, please start basic life support/CPR.
2) Get help and call for an ambulance immediately.
3) Get to person to the nearest hospital as soon as possible.

Me'nate Steak Hub, Wangsa Maju

It's been a while since I had steak. I must admit it is one of my favourite dishes, and it is not the healthiest of meals so we don't eat steak often.

I've seen a few friends post this place on facebook and even read an article about the owner, who is a Kelantanese and at one point was chef for Lady Diana, the late Princess of Wales. My Mum read the same article and was as impressed. So finally, we had a quiet afternoon and what better coincidence than my eldest son's twelve-th birthday.

Twelve years ago I was admitted to the Coombe's womens hospital on a Friday morning to be induced after going over 42 weeks, and today, we went to our visit lunch at Me'nate Steak Hub.

Finding the place wasn't too difficult with Waze. We took the DUKE highway and were very unhappy with paying the extra toll fare. Hubby dropped us at the shop front, which is an open air restaurant but with an air-cond unit at the back. Thankfully, during our time there, there were no smokers. As if the haze isn't polluting enough.

Upon arrival, the waiter gave two menus and left us to our own devices. I looked at the seemingly simple menu but couldn't make out what to order. I don't think the menu is 'user-friendly'. So I called the waiter and told him "I want to order the steak", expecting him to recommend something. 'For steak,' he said in a nonchalant manner, 'you have to look over there,' which was the huge freezer at the side of the very simple restaurant.

Yes, I remember reading about this in a blog. You have to select your own piece of frozen meat (which has a price tag and a description for example T-bone grain fed RM32/=. Which was the first thing I saw and said "I'll take that one". At the other end of the freezer was lamb. Might try that the next visit.

All five of us ordered steak, which came with a scoop of mashed potato and coleslaw plus a generous helping of gravy. Drinks are self-service with a dispensing machine at one corner of the shop. There is a reasonable choice of cold and warm drinks. Drinks refill is free, which is a great idea.

I do not considered myself a great meat eater. My limited experience of steak include Victoria's Station (my late Dad used to take us here many years ago as a celebration every time we came back from overseas for a break), Tony Roma's (ate there once a few years ago with a friend who is obviously a fan), Renaissance Hotel Kota Bharu (had this maybe two to three times), Chilli's (once or twice a very long time ago) and the Dome (ate this once). There is another restaurant in Laman Seri, Shah Alam but I cannot recall the name. My husband is not a fan of eating out, so we don't do as often as we should, and in comparison, during childhood our family used to eat out quite regularly as Mummy was a housewife and needed a break, and I think late Dad enjoyed dining out with the family too as a treat.

Based on my limited experience, I certainly feel I am not the best person to give this opinion, I am entitled to say that it is a reasonably tasty steak, though in all honesty I have tasted better, having said that the price is definitely unbeatable elsewhere for the same dish and package that comes with it. We went in the afternoon and the place was not packed, initially there was another family at about 1pm, we left at 2pm and there were more people then. It's a good place to take the kids too to see whether they have developed a taste for steak. My two younger children still aren't into the idea and ordered pasta instead.

Verdict: 8/10

Which is Better: Caesarean Section or Vaginal Delivery? Can I Wear a Bengkung After A C-Section?

This was the topic of discussion over lunch break today. A colleague is pregnant for the second time. Her first baby was delivered via elective caesarean due to a transverse lie, in other words baby's head did not go down and so her uncle, who happened to be an obstetrician, advised her to have an elective or planned caesarean.

I have been asked this question before.

"Since you have experienced both normal delivery and caesarean section, which, in your opinion, which is better?" 

Thankfully, for most women, if not all, that is not a decision to be considered. It's not like when are going shopping for a piece of clothing and can choose which colour of clothing to buy to go with our new handbags (that was cynical, by the way).

Understand That It Is Not A Choice

For the vast majority of women, the best way to deliver a baby is the 'normal' way. And believe it or not, that is the aim for almost all women who deliver in hospital. We doctors do our best, to assist the patient to deliver their baby's normally. And so do our midwife and other health professional colleagues (in Malaysia we have the traditional bidan, though I am not sure of their current role in the community).

Both Are Painful

Having gone through one vaginal delivery, albeit induced, and three planned Caesarean sections, I could honestly say that normal delivery is the best. Of course the pain of the contractions, was to me, something completely out of this world. I am lucky, never had to experience such an intense feeling of pain that you can't really think of anything else but the pain. I remember thinking to myself, during labour that, "Ok, I've had enough of this, please can I just go home?"

I must say that everyone's experience of birth is probably different. Plus every birth of each child is a different experience. So I can just share what I went through and what others have shared with me, plus what I see through my line of work.

My Experience of An Induced, Vaginal Delivery

My first baby was induced, and I have heard that the pain of induced labour is worst than if it started naturally. I was long overdue, 42weeks plus, the OBGYN was hesitant to induce earlier because in the earlier part of pregnancy, the scans showed a small baby. He was small for dates. At least we were told, and being first time parents we believed everything and bought the smallest clothes available for newborn, something XXXS. It turned out baby was huge, 4.42kg. The biggest baby on the ward.

Labour was horrible. I did not get any pain relief except the gas because it all went too quickly for a first-timer. When I told the midwife I felt like pushing, she laughed. My husband was getting ready for Friday prayers. They decided to check and lo and behold, baby was ready to come out. So there was no time for epidural or any fancy analgesia.

My First Elective Caesarean Section

For my second birth, which was a planned C-section as advised by the OBGYN. Since the first baby was big, their siblings tend to follow a similar pattern, and baby could get stuck so it was better to have an operation. All my births were planned. All four of them. I get to choose their birth date. I get to pack my bags and check in to hospital in the morning in an orderly manner. Nothing like what you see on TV or read about how other people get sent home in the freezing cold, awaiting the contractions to get real strong at the bus stop, or having their water brake in public places, giving birth in the taxi or on a wheel chair en route to the delivery ward, nothing dramatic like that. All well planned and orderly, sort of the way I like it.

The moment the OBGYN pulled out my second baby, I remember thinking to myself, "Wow, it's that easy" remembering the pain and agony of pushing, wave after wave of all energy consuming, breath-taking contraction, I had to do none of that and baby is out already. Well, nothing would have prepared me for the post-op pain, lying in bed for 24hours afterwards, extremely painful first attempt at breast-feeding baby since I was still less than 24hours after surgery and they made me try to lie on my side, then getting up for the first time, was the most horrible, postural hypotension plus vertigo plus weakness in the whole body after losing blood during surgery (if I remember correctly my Hb was only 8 at that time, and I've never such a low Hb my entire life). I tried to get up with the help of two nurses but had to immediately sit down, the world was spinning too fast. I had to sit down and breath a few deep breaths before trying again. I made it to the bathroom and had my first shower sitting down in a darkened bathroom as the two really nice nurses helped me undress and waited for me at the door in case I needed help. Once I was up and about, it was ok and I felt like I did not ever want to go back into the bed. I had morphine but suffered from morphine induced itch. I also learnt that my blood pressure which normally is quite low, became lower due to the anaesthesia and worried some of the staff that they had to keep checking it during the night and so my sleep was much disturbed. Husband also just dumped all the bags and when baby pooped, the nurse had to spend much time looking for the cotton and diaper and I couldn't get up to help. This was a public hospital in Ireland.

Delivering in Malaysia via Planned Caesarean Sections

My second and third Caesareans were in Malaysia, all my children were born in different hospitals, by different OBGYN's except the first was delivered by a midwife. After every surgery, all planned, I felt the pain was worse than the previous surgery, and recovery took much longer. It could be due to the post op analgesia, I did not received any morphine after the second section. I did get two pethidine injections after the third section. In Malaysia I find the OBGYN's like to give diclofenac plus some other stronger version of paracetamol, which is just not enough for me. Mobilising is slow due to poor pain control compared to the first section.

Delivering in a Private Hospital versus Public Hospital in Malaysia

Some of the good things about delivering in the private hospital in Malaysia is that at least they take complete care of the baby for the first few days. Most of my baby's had to have a few bottles of formula the first day because it was just to painful for me to even attempt a feed. The second day was mixed and by the third day, pain control is much better, I am able to sit out on a chair for longer periods of time and cant wait to go home. At least I had a good nights sleep and some rest that really helps the healing.

Can I Wear a Bengkung or Binder Right After Delivery If I Had Surgery?

After delivering my fourth baby, the OBGYN actually provided a bengkung or binder to wear immediately after the first day or when starting to mobilise. I found this helped very much to relieve the pain because it supported the wound and kept it in place. But it was troublesome to put on every time getting up and have to reposition it many times through out the day. Still, it helped a lot. I must remind everyone that all my sharing is NOT a substitute for medical advice. Please check with your own doctor/OBGYN.

Conclusion

In summary, vaginal delivery is a thousand times better than Caesarean section, faster recovery, less pain after delivery, easier to breast-feed baby, unfortunately the choice is not ours to make. OBGYN would recommend surgery only if the benefits outweigh the risks. I cant imagine how my second or third or fourth child would have been born without having surgery, and for that, I am thankful.

Is it Safe to Take Medicine When Pregnant?

One way to know whether you are a writer or not, is to try and go on for sometime without writing. Certainly the itch to write, and especially when you had a momentum going and suddenly missed a few days of writing, will draw you back to your blog. And all that time away, you were thinking about what to write and how to write it, what you could do to improve your blog, the pictures that need to be changed and so on. Almost like the CAGE questionnaire that we medics use to screen for alcohol abuse/dependence.

Even though I am not a general practitioner, not a obstetric and gynaecologist, not a paediatrician, people still consult me for free advice in those areas. One of the blessings or curses of being a doctor, depends on the point of view taken. This year alone, two people asked my opinion on whether they should take medication prescribed by their OBGYN while pregnant.

My sister whatsapped me to ask whether she could take maxolon because she really couldn't stand the nausea and vomiting of pregnancy (NAVOP) a.k.a. morning sickness.

I too, have suffered from NAVOP. I have four kids, and have been through it four times. Thankfully for me, My symptoms start around week 9 and go away (or at least lessen significantly) around week 12 to 16. If you are reading this and thinking, yay, I have only x number of days or months left to suffer from morning sickness (which is such a misnomer because I was pretty much nauseated in the morning, in the afternoon, evening and even at night), every women is different, and so is every pregnancy. Some of my friends had no nausea whatsoever while others range from having to drink every 30 seconds to counter the awful taste of their saliva through out nine months of pregnancy, to being admitted for dehydration from severe vomiting due to twin pregnancy.

My most recent episode of suffering from nausea and vomiting of pregnancy was last year, so it is pretty fresh in my mind. Certain smells for example cloth softener made me sick. What helped was eating asam (preserved fruit which is sour in taste), mango sprinkled with asam boi  when I pregnant with my daughter the third time some seven years ago, drinking very diluted fruit juice (it was orange cordial) when pregnant with my two eldest children more than a decade ago. Having an empty stomach made the nausea worse, so did eating very large meals, so it's best to eat small frequent meals which is not always possible, and wasn't when I was practising not too long ago. I remember distinctly, stopping to throw up along the corridors of the hospital while at work. I might have looked like a patient. Friends commented on how pale I looked. Those were the days. I am so glad they are over.

I never took any medication for it. I try to avoid all medications while pregnant. But I understand that this is NOT ALWAYS POSSIBLE, and none of my blog posts should be taken as medical advice. Every person and circumstance is different, so please do check with your doctor, and if you are not happy, get a second and third opinion.

So I told her my advice. And I guess being a doctor, we all have our own prejudices and biases based on experience and knowledge that others don't have. Once upon a time many years ago, a new medication was launched specifically for nausea and vomiting of pregnancy (I don't think I was born yet, it was that long ago and nowadays, many safety mechanisms and nets are put in place to avoid the same such mistake/s), and many women took this medication and was eating happily; no more nausea and vomiting, but nine months later were horrified when baby was born with no arms or legs. For most women like me, nausea and vomiting was worse during the first trimester, and this is also that time that baby is having organs and limbs formed so any medication taken during this time that has 'teratogenic' effects, can cause baby to suffer physical abnormalities. I've also worked in paediatric and neonatal ICU and seen babies with exomphalos, children with polydactyly, so I tell others that if they can bear with the symptoms, do not take medication, only if they are vomiting and dehydrated then they can get IV fluids and be admitted for treatment. Again, this is general advice, please see your doctor.

Last weekend, another friend whatsapped to ask my opinion, her OBGYN prescribed her casprin which is aspirin, I presume for severe neck pain which sounded like it was musculoskeletal in origin. So I recommended she try simple things like ice pack and hot packs for the neck pain, and massage. This does not apply to all neck pains, you must always consult a doctor. But she had tried all that and the pain is still unbearable. Looking at available information on the web, there is no known side effects of consumption during pregnancy, as long as it is not taken regularly. I am sure her OBGYN would know better and would have considered the risk benefit ratio before prescribing her that medication, and would have examined her etc. I was just giving my opinion.

In a nutshell, it is best to avoid unnecessary medication during pregnancy except the folic acid and iron supplements or any medication prescribed by your doctor/OBGYN. Please inform all health professionals that you are pregnant so they can prescribe medication which is safe (or at least safer based on existing information). 

Alkaline Water: Is It Good For Our Health?

This morning a friend asked my opinion regarding alkaline water. No, she was not interested to buy it. She just wanted to hear why it is not plausible so that she may answer the people who (I imagine) was trying to sell her alkaline water.

She is not the first person to ask and probably not the last. So I will take sometime and explain it here, and perhaps when the next enquiry comes, I can update this post and add more links to it to make it more robust.

For those who want a Malay version, please click here (versi bahasa Melayu).

The Science

From a very basic physiological point of view, the stomach has a very acidic content due to the secretion of hydrochloric acid. What is physiology, I hear you ask? That is the basic science of how human bodies perform. Yes, I have four years experience teaching and lecturing physiology to undergraduate medical students in both private and public university setting.

What Happens When We Eat Foods Which have an Acidic Content

It is not a good idea to eat very acidic food first thing in morning as some people have done while dieting, and later developed medical problems such as peptic ulcer or gastritis (the lay man term would be 'gastric' in Malaysia). Eating a lot of acidic food alone or eating sweets and then not cleaning teeth for a long time would allow bacteria to multiply in the mouth and produce acid while they breakdown or eat the food in the mouth, this would then cause teeth to go bad and give rise to other problems. So it is good to clean the mouth after eating such food and the reason why our toothpaste are slightly alkaline is because it helps to wash out food and also maintain the non-acidic surrounding that benefits teeth. Normal saliva too is slightly alkaline for this reason.

What Happens When A Person Consumes Water or Food Which is Alkaline

However, if one drinks alkaline water, it will go straight to the stomach which has an acidity pH of 2 due to hydrochloric acid which is secreted by the stomach wall in order to breakdown protein. This is completely normal, the high acidity. Neutral pH is 7. The normal stomach though, has a very powerful lining of somewhat soapy material that prevents the acid secreted from digesting the stomach wall itself. This layer of protection though may fail some times and it those instances cause illness like ulcers (like a wound in the stomach wall) and gastritis (inflammation of the stomach wall). We are not here to discuss disease though, so we will concentrate on what happens to the alkaline water. It will be neutralised in the stomach, end of story.

It's A Balancing Act

The human body has several different mechanisms to control or maintain the pH. To function normally, our blood pH can only be in the range between 7.35-7.45. Any higher or lower will cause problems and illnesses, to put it a very simplified way. The main organs that help regulate the pH is the kidney and lungs.

More Basic Science

To understand in further detail regarding the science behind this, we must explain what hydrogen ions are and also bicarbonate ions. Hydrogen ions cause a solution to be acidic, and excess of bicarbonate ions make a solution alkaline. Then there are buffers, solutions that can neutralise to a certain extent excess of hydrogen ions or bicarbonate ions, so that the pH does not change when it otherwise would in the absence of the buffers. The body uses buffers so that while the mechanisms that need to be kicked in to get rid of the excess H+ or OH- ions, the body can continue to work as normal.

So I really don't understand how consuming alkaline water can bring about any direct health benefits compared to consuming water which is of neutral pH.

If you are aware of any scientific studies which prove otherwise, do let me know.

Another Point: Zam-zam Water is Alkaline

Zam-zam water, we muslims believe, is a special water that first surfaced in the middle of the desert when the Prophet Ismail a.s. kicked the ground while crying as an infant, after being left behind with his mother near the Kaabah by the Prophet Ibrahim a.s. This water can only be found in what is now Masjidil Haram. Many muslims will bring back this blessed water when they visit Mecca for the Hajj pilgrimage or for Umrah. This water is freely available in the Mosque and is said to cure many diseases. This water is also alkaline.

However, taking tap water, or any other water from any other source, then turning it alkaline by adding the necessary chemicals, does not make it equivalent or equal to Zam-zam water.

Zam-zam water is alkaline but alkaline water is NOT Zam-zam water.

Becoming a Writer

A lot of people out there are probably thinking about writing a book, dreaming about writing a book, becoming a best seller, getting published, how would I know? I am one of them.

The best advice I could give people at this moment is to write down your dreams and goals. Writing them down reminds us, and not just our conciousness, also, more importantly, at a subconcious level. Our subconcious mind is one of the most powerful tools in this planet, and most of us underutilize it.

Step 1: Decide What You Want

Write down the goals and put it somewhere you can see it several times a day. Keep it alive and feed it. Think of all the people you could help and that would benefit from reading your book and sharing the knowledge and insights you have accumulated all this while.

Step 2: Takes Simple Actions That Will Lead You Closer To Your Goal

The next step is to take action. Put time aside to write regularly. And this is why having a blog is helpful. A blog is free. Well, almost. You put in a little of investment in terms of money. Maybe you need to buy a computer or laptop or perhaps even write using your phone (havent tried that one yet). You need to get connected to the internet (and to countless potential customers). Those are the simple steps. Probably a good idea to start with the free blogs first. Or you can invest in the paid ones for a trendy (and easy to remember website address). The difficult part, at least for me, (imagine, a person who loves writing and would prefer to do nothing but), is to write and write regularly. Why? Why is it so difficult? The simple answer is, most of us are addicted to instant results. We want to do something today, and see a result tomorrow. If there are no results, or results are not what we expected, or are delayed, the vast majority of people are going to give up. I am not saying that if you do not get results, you should just continue and do the same thing, rather start first, and then adjust as you continue and seek advice or knowledge as you go along. The most important and difficult step is the first, once you start, keep the momentum going. Soon enough you will find time and make time for what you deem important enough (yup, we all make time for food, regardless of what our timetable looks like, right?)

Looking back at all the other achievements in my life (not that many, mind you), I saw a pattern, a common pattern of success. First, there is the desire. You want something. Maybe you want it. Maybe you need it. A degree, a post graduate degree, a job, a car, a house, a business venture, a project, an authorship, whatever it is, you decide what it is. Then maybe after sometime you realise you didnt really want it or need it (could this be buyers remorse, maybe, I'm not sure). Or it's not worth it. Then you can either stop pursuing it, or sell it, or change jobs, but then there are things that, even after time has passed, and if it was just a phase, you would have been way it over, but you are not, then that is something that you probably have to do, is your calling, and for some people, that thing is to write a book, and perhaps get published. It doesn't matter whether their book sells or not, becomes a best-seller or a flunk, as long as they get to write a book that matters to them.

 Step 3: Tell Everyone

This is very important for two reasons. Reason number one is, and this has happened to me several times, you will somehow attract people who have already achieved what you set out to do. And these people will be able to help you in some way, to emulate their success. There is no substitute to finding a teacher, coach and mentor these days that will hold you accountable to achieving what you set out to do. A person who has been through it before. Imagine climbing Mount Everest for the first time without a guide. Yeah ok, luckily writing a book and getting published need not be such a hazardous experience.

Step 4: Get A Mentor

Having a blog is a relatively low risk simulation where you get to practice your writing skills, hone them, generate an audience, and look at their response. So many people have given me this same advice over and over and I have ignored it like the rookie I am. I don't regret not heeding their advice though. That was the old me. I had to grow as a person before I could learn something new. Not just learn something, but also apply it in my life.

I also had many other challenges I had to overcome before the writer in me took over. A new baby, a new job, other commitments, but there comes a time when everything becomes clear, I realised it especially when reflecting on the sacrifices I had to make when pursuing my MBA.

So making the commitment and announcing it is so important. It will attract help and support, and other forms of encouragement from friends and family, or it might not, but another benefit is, these same people will remind you of your lack of achievement, or rather unaccomplished goal that you need to fulfill, so there's no escaping it.

Step 5: Set A Deadline

This is probably very scary if you are like me, a perfectionist. I real life, there is room for perfection. Ask anyone who has ever achieved anything worthwhile. Perfectionism is suicide. Being a perfectionist isn't. There's nothing wrong with being a perfectionist. I can't pretend to be something that I am not. I'd rather not take on a project if I can't do it properly, then doing something half-heartedly and I think (or imagine) most people would feel the same.

The truth is though, if you don't set some sort of deadline, it probably wont happen. I know because I'm there. I have gone through this issue before in so many other areas of my life, not just writing. So set a deadline.

And keep working towards that goal.

All the best, happy writing.

The History and Physical Examination

In the real world, my job does not exist. Many, many years ago, when schools, universities and what we have come to know as the 'conventional' education system, did not yet exist. So anyone who desired to study medicine or aspired to become a doctor, (a medical doctor by default, since PhD's did not yet exist), would basically search for one and then apply for an intern position. Or something like that. As an apprentice, the student learns the trade directly, through what we now call experiential learning. There are no formative or summative assessments. Imagine that, no exams. WOW. The student shadows the teacher for the needed number of years to master the art, or science, of medicine. After the student 'graduates', the new doctor is now licensed to practice medicine in his or her own capacity.

When I was a medical student, we did the two years of pre-clinical mostly lectures and practicals, followed by three years of clinical rotations, where we were attached to different specialities both in hospitals and also in the community. In each clinical rotation, we would follow the activities of the relevant team. Ward rounds, clinics, CME activities, grand rounds, on-call, accompanying the patient for investigations and so on. It was a reasonably exciting time and for the most part, I realised how little I knew and how much studying I needed to do, which never seemed enough.

At present time, part of my job description is to teach medical students how to take a history and perform a physical examination. This may seem deceptively simple. If I were to write a simple ten point "how to take a history and perform a physical examination", it could be done, but would simply not do justice to the topic.

The setting is important. History taking and physical examination is different for different specialities, and is different for the in patient versus the out patient setting.

Regardless of the setting, the medical student must remember that the purpose of taking a history and doing a relevant physical examination is to come up with a diagnosis, or list of differential diagnosis. Sometimes, a working diagnosis is most appropriate.

While there are differences between specialities, for example, there are different subheadings for a paediatric and obstetrics patient compared to a medical patient, in general, the lay out should be roughly the same.

Most people will start with an opening statement that includes some demographic details, for example...Mr X is a  fifty year old Malay man from Wangsa Maju...We must always mention the age and gender of the patient, the race if relevant, and hometown if it is important. Wangsa Maju was mentioned as an area which currently has an outbreak of typhoid fever.

The opening sentence must also convey the presenting complaint, which is the main problem that caused the patient to seek medical help. Mr X is a fifty year old Malay gentleman from Wangsa Maju, who presented to the emergency department last night with abdominal pain, vomiting and diarrhoea for two days. For in patients, it is also important to note how the patient was admitted, patients who present to the emergency department tend to have more acute conditions that require immediate or urgent treatment prior and during the early stages of admission. Another factor which helps differentiate the different conditions that can cause the symptoms is the duration of symptoms. This must also be stated very clearly in the opening statement.

The next part is the history of the presenting illness. In this subheading, the student explores the different symptoms and establishes a timeline of how the symptoms progressed or the nature of each symptom that would aid in the establishment of a diagnosis. Pain is a very common complaint that would cause a patient seek medical help. Chest pain and abdominal pain are extremely common complaints and have a variety of causes which each can be discerned by asking specific questions. The good news is, the causes are not entirely exhaustive. Two months in a general medical ward would allow sufficient exposure for the student to see a variety of common and uncommon medical illnesses.

Most medical students are very good at asking about characteristics of chest pain, for example, exact location, severity, radiation, nature, relieving and exacerbating factors. These tend to help distinguish whether the chest pain is cardiac or non-cardiac in nature, as the consequences of a cardiac cause of chest pain carries much cause of

To be continued...

Property Investment

Becoming an Expert in Property Investment

A friend of mine who is staying outside of Klang Valley, is getting a lump sum of money soon and is looking for a property to invest in. She asked regarding a property in Petaling Jaya, and since it was nearby I decided to have a look. It was a few weeks since I first heard of it. One evening, when I finally had some free time to ask, I whatsapped the agent and apparently, there were only a few more units available.

Everything sort of fell into place, Baby was asleep and sorted, the kids were fulfilled with lots of quality time together (not to mention some new toys), so I figured I had nothing to lose and was primarily doing a favour for a friend. This is not the first time I have made a recommendation for a friend living outside Klang Valley to make a property investment. Two other friends had asked for similar help before.

I don't consider myself an expert in property investment, but certainly we have some experience and knowledge that we can share with others who are interested to learn.

My parents were not property investors. They lived in the same house for as long as I can remember. Not that I am complaining. They just never invested in properties. Perhaps if they were, our story would have started a bit earlier. It was actually two of my husbands friends who sparked our interest in property investment.

A Witness to The Power of Capital Appreciation

The first friend invited us over for dinner. This was many years ago when my husband had started working and I was still a student, I think. It was a brand new home and beautifully furnished with exotic looking (at least to me) Pakistani furniture, with the intricate wooden carvings for almost every piece. This friend bought two such units from the developer. As soon as the houses were complete, he sold one of and used the profits to settle much of the loan. We were very impressed with the capital appreciation, not to mention owning a home of your own.

Through out my years as a student, we had always rented. We didn't have enough funds to purchase our own property at that time. When my husband graduated, one of his friends sold off an apartment that he had used for the five year duration of medical school as he was leaving the country to practice elsewhere. The profits he obtained from selling the apartment was used to pay off all the medical school fees. This was the second time we witnessed the joys of capital appreciation and decided that we too, must look for a piece of property to call our own.

The Decision

It did take me sometime to learn and understand what capital appreciation meant. Remember, I was a science stream student since high school, with no business education or background. During the time we purchased our first home, I had just started working as a doctor and my husband was two years senior with a pretty similar state, his parents too were employees with no business or investment experience.

We didn't have kids yet and the banks wanted to be our good friends since we started earning. We did make a decision that buying a house was a good idea. Why pay someone else's mortgage when you can pay your own and then own the house when it is finally paid off? Not everyone agreed though. Some people think it is better to rent, but we decided based on facts and our own research.

Opportunity came one fine day and we acted on it. Our friends were moving into the capital city from posting in rural hospitals and had surveyed many properties in great detail. They decided on buying from this particular development and invited us to join along when they were paying the deposit. We did, and while looking at the show units, we found our first home. It was the last available unit. Our first property purchase. We obtained 100% financing and other government incentives. It was a good time to buy. This was in 2003.

First Time Luck

Being our first experience buying from the developer, we had to buy the furniture and furnishings, not to mention lights, curtains, washing machine cum dryer, dishwasher and other modern conveniences. So remember to add that to the budget. The only thing that came with the house was the kitchen tiles and cabinet, bathroom tiles and basics, home alarm and fire alarm system. We had to figure out insurance, now of course we have the islamic takaful option. For loans there are also islamic or 'syariah' complaint bank loans, however, it is my understanding that what is syariah compliant in Malaysia does not necessarily comply to 'international standards' and may not be deemed such in the Middle East, for instance.

Two and three

We also purchased two other properties, one a corner lot terrace from a developer and another, a tenanted apartment from a friend of my fathers. The financial commitment for the second property was low as we only need to pay for the 'interest' part of the loan (not sure how this works our for islamic loans), while the third property loan was being paid by the tenant. We stayed in our first home for one and a half years, rented it out for one year plus and then decided to sell it off as we were moving away. After about three years of ownership, we hired the help of an estate agent who was an expert in the neighbourhood and had sold many other similar properties. Within a short amount of time we received a good offer and decided to let go. Capital appreciation was 40%. There was no way, through working and saving alone, that we could have accumulated that amount of funds.

Since it was our first purchase, there were a few things we did not take into consideration when we made the decision. We forgot to take into account our place of work and what the daily commute would be like (imagine) and that was a bit painful. Looking back though, it was a worthwhile sacrifice.

We could have used the funds to settle the loan of properties two and three, however, my husband had career goals and ambitions, and this led us to jobs in another place which was in no way within daily commuting distance. I had never been to the new town so husband went there first and rented a decent enough place. By this time, we both had careers and two young children. So another extra factor to think about when buying a home, apart from distance from workplace is the proximity of good schools.

Number Four

We moved in to the rented home, it was small and miserable, located near a septic tank that (even though the developer claimed was underground) gave off a horrible smell during the day. That and the arrival of our third child was great motivation to look for another property investment. This was a small town (in comparison to the capital city) and there were no sophisticated means to search for property such as internet websites or newspapers (in 2007). I ended up driving through a neighbourhood i considered attractive (near workplace and schools), asking whoever I saw coming out of their houses if they knew of any homes for sale. A nice lady who later became our neighbour, lead us to the right person. We surveyed a few different options and settled for what we thought was a good buy.

We sold property number two because we were advised to either sell or use upon completion. Renting out would only 'destroy' the property and we were not staying near enough to manage it in case anything should go wrong. Capital appreciation from property two was 46% and we bought property four with cash from the proceeds. At this point in time we were living a very comfortable life, house and cars paid off, no financial commitments, decent government jobs. I had the option of taking time off from work to care for our third child, but like most workaholics, got bored after a while of leisure. We decided to sell of property number three as managing it became a hassle.

The Fifth

Our fifth property was a condominium right in the heart of the capital city. Bought from a relative who had bought it from the developer and got married so didn't have a need for it. We stayed in this property while my husband was working in a hospital nearby. It was interesting, living on the 25th floor smack dab in the middle of the city, with one parking lot, another had to be purchased for short term period for example every six months. On the whole, I do not think living in middle range condominiums is suitable for families with young children. This type of accommodation suits the working young professional. The kids did enjoy daily swims though.

Then Daddy passed away and we moved back to the house I grew up in to accompany Mummy. We sold off property number five. Capital appreciation was only 20%. We could have rented it out before moving in and after moving out, but again, I did not desire the hassle of doing so during those times. Our first child was starting primary school, so it was a time of transition. I was also starting a new job.

Number Six

It was also during this time that we came across two opportunities. One was a condominium that was going to be right in front of the hospital in the big city that my husband came across through work. The other was a house in the suburb, nicely located near the highway. Information came from another relative who purchased a nice property in the same neighbourhood.

I had developed an averse experience towards condominiums. So we decided to buy the house from the developer. It was our first islamic loan (that may not be deemed such, if we were in the Middle East). Today, the value of that house has increased by about 46%, quoting the price that two of our neighbours paid to purchase similar units from other buyers. I have recently started another job and our fourth child has recently learned how to crawl. I had taken a good two years off from working full time to pursue MBA and complete our family. I would never have been able to do so if we had not ventured into property investment.

An Important Lesson

By a strange twist of fate (or whatever you choose to call it), my current job has led me to the same hospital my husband worked in not too long ago in the busy and bustling capital city. Now, I get to see the completed condominium that we could have purchased years ago, and the capital appreciation or even cash flow we could have made. Ouch. It is painful.

However, life has thought us never to cry over spilt milk. So instead, we are on the look out now for more investment opportunities. The economy is in crisis and opportunities are abound. Go get them.

If you had been paying close attention, you would notice that we did not make gains from the sales of property number three, however it did, during the course of ownership, provide cash flow.

We own number four and six, missed out on two. One was the potential number seven and the other was...between number three and four. I had put down a small deposit for a condominium in a suburb near my parents home as my late dad recommended the buy, but somehow, due to the move from one town to another, new job, new addition, I let go off that one too.

By number six, I had lost count and had to go back and put numbers on my story. 

The Adventure Continues

So a few days ago, with the intention of helping a friend, I have put money down on number seven (corrected as number eight, look at paragraph ***below). 

Similar to our first buy, I did not go with the intention to purchase. But I learnt that the location of the property was excellent, a bit similar to property number six and missed number seven. There was also potential commercial development in a nearby piece of land. A friend of a relative also mentioned (or rather, complained) that rental in the area is a certain market price (had recently gone up to RM1800 for a similar piece of property) and a relative has another property in the area managed under pretty similar circumstances.

The decision whether it is buying to stay or buying to rent would help guide whether to invest and which unit to invest in. If buying to rent then you should know the rental market price. If buying to sell or rent, you also need to know the demand for properties in the area. Husband had also viewed another competing property quite recently, in the neighbourhood. Knowing the price per square feet is a good means of comparison.

Since we are in an economic crisis, developers are giving discounts and other incentives so if you can afford it, have done your research and have some reserve funds (recommended is at least six months total cost of living expenses including all financial commitments in fluid form such as cash or perhaps gold; the gold part, I came up with, but remember that the price of gold also fluctuates).

We are now at the beginning of the story. This weekend we are checking out another potential investment. Who knows, maybe a number eight (or more accurately, number nine, see ***below).

Leap of Faith

Ok, you have done your research. Read several books and websites, attended seminars, met and interviewed several different people with experience and talked to the experts, got your finances sorted, and now, you are ready.

You have looked at many different properties and finally found one that is the right buy.

The first step is to place a deposit, the amount which will be deducted from the total price. A copy of identification will also be needed. For the bank loan, standard requirements are 3 months pay slip, bank statement and income tax statement.

If purchasing through an agent, a lawyer is needed to sort out the legal documents. They usually charge a percentage of the sales price and if the lawyer is a friend, you may get a discount.

***Opps I forgot, in between number six and number seven, my husband had invested in another investment in the small town, some commercial hotel, where you purchase the room and the management rents it out for you. So number seven is in reality, number eight.