Physician Running

Review- Griffin adidas iPhone Sport Armband

2012-02-12T10:14:00.001+08:00

Taken with Instagram

This is the adidas Sport Armband for iPhone by Griffin. I have been using the accessory for the past 3 months. I got for S$70.

Pros:
1. Comfortable fit, the silicon strips on the inner portion of the armband gives excellent traction even when you're sweating a whole lot.
2. Quickly adjustable, even on the go.
3. Dries quickly, doesn't get smelly
4. Single key pocket- I don't find it very useful though

Cons:
1. A bit difficult to insert the iPhone in as the opening is narrow, however the phone fits in like a glove once it is in.
2. The see through plastic window turned cloudy after use and it is difficult to read the iPhone display under direct sunlight. The plastic window also hovers on top of the iPhone screen- making tapping the screen a bit cumbersome- another fit issue.
3. I wish the top flap of the armband covering the top portion of the phone was a bit more streamlined once the phone is in. In reality the top flap somehow flares like a hoodie.
4. No reflector panels- a red pulsating LED will make the whole armband perfect, but a couple of nice reflector stripes on the band and case itself will increase the runner's road visibility to drivers at night.

Overall, I will still recommend the Griffin adidas SportArmband for its comfortable fit and armband qualities. Needs improvement on the display screen and the top covering.

Brooks ST5 Racer Review

2012-01-01T15:45:00.001+08:00

For the Standard Chartered (Half) Marathon, I decided to take a chance and use racing flats.

I browsed all the running stores that I could and decided that these are just right for my budget (S$169) and foot type:

(Taken with Instagram)

The Brooks St5 Racer

Based from the website:

Surface : Road/Track

Pronation : Mild, Moderate

Build : Small, Medium, Large

Competition : Road racing

Arch : Flat, Medium, High

Category: Competition
Weight: 8.6 oz
Platform: Universal
Construction: Strobel

Sizing Note: Men's Sizing/D width only.
Launch Date: February 1, 2011

I must admit I didn't fall in love at first sight with the colorways, but during my comparisons with other brands most of the racing flats had really loud colors anyway. The orange and blue combination sure screams "look-at-me!"

The weight of the shoe is unbelievable, at under 260grams running a 21k will surely be less tiring than lugging around a full support/antioverpronator shoe.

Most of the reviews of the shoe were generally positive, the only complaint were the laces. They are actually very flimsy, requiring double knots for security during a run. However, I assume Brooks focused on making the shoe as light as possible.

Since I run early mornings before sunrise, I just wished they added more reflective panels.

As for the feel for the road, at first the soles felt a little stiff and figured some breaking-in was in order. After a few kilometers on my first use, the stiffness gave way and I was running with a grin on my face. Since I have wide feet, I felt that my forefoot to midfoot area made more contact with the pavement than my adidas stability response shoes.

Looking at the underside of the shoe, I noticed that the sole is quite thin and other reviews noted that the rubber quickly thins out after use. Again, keeping the weight of the shoe down was the primary reason for the thin rubber sole.

After the first run, the fit of the shoe was snug and none of my toenails died. When I used the pair for the Standard Chartered (Half) Marathon, the shoes were wonderful. The fit was snug, the skin on the top of my feet were not pinched and I didn't get any blisters.

All in all, the Brooks ST5 Racer is a very good racing flat for those with flat feet. Great price, great colors (the colors just grow on you) and a comfortable ride- I'd buy another pair if it would still be available (I've been told that a new model is coming out).

2 Stories of Growing Old in Singapore

2011-12-18T14:13:00.000+08:00

(taken with Instagram)

Story 1

Mdm. A is a 87 year old lady who has been living in a destitute home for the past 3 years. How she got there is the story I am about to tell.

In April 2008, Mdm. A was seen waking along a road. She hailed a taxi and told the driver she was unwell. The good taxi driver brought her to the hospital. Unfortunately, Mdm. A. did not have any identification with her. She was unable to recall her identification card number, her own address and even the names of her own children. The hospital had to involve the police to determine her identity. None of the family members had submitted a missing persons report to the police. Eventually a police officer came down to the hospital with her information.

Mdm. A was previously diagnosed with dementia and she was transferred to a destitute home for continued care. Family members were contacted about her transfer, and of all the children she had, only 1 came to visit her in the destitute home. The sole daughter who came was unable to take Mdm. A back not only because she had her own family to take care of, she was also taking care of Mdm. A's younger sister. The rest of her siblings did not want anything to do with Mdm. A.

Mdm. A's health gradually worsened in the following years and had to be taken to the hospital for generalized weakness. She had lost her appetite and needed nursing care. After we had treated the electrolyte imbalances, provided nutritional support and physical therapy Mdm. A became better. She was ready for transfer back to the destitute home. However due to her increased dependence on others for feeding, bathing and clothing, the destitute home was unable to take her back.

The last time I saw Mdm. A she was still waiting for a bed in another nursing home. She has nowhere else to go.

Story 2

Mdm. B is a 68 year old lady. She was diagnosed with lung cancer about 3 months ago. This lung cancer has already spread to her brain and was treated with radiation. She is due for the next step in her cancer treatment which involves injecting chemicals into her veins to kill the cancer cells. The metastatic cancer cells in her brain caused Mdm. B to become weak and dependent on her only son.

Mdm. B goes to 3 different hospitals for her cancer care. One for the chemotherapy, one for the radiation therapy and another for brain tumor management. This means a significant strain on Mdm. A's physical condition, financial stability and emotional condition. She needs her son to bring her to the hospital, to get her medications and to take care of her at home.

Mr. B, the son, is currently unemployed and has been recently convicted for criminal charges has to serve a prison term. With the Mr. B out of the picture, what will become of Mdm. B's care?

Growing old: The Outlook

The population of elderly in Singapore is steadily growing (www.singstat.gov.sg). In the year 2000, the population aged 65 years and older comprised of 7.2% of the total population. In 2010, the number has increased to 9.0%.

The elderly working population is also booming. In the year 2000, 10.8% of the elderly population were in the labor force. In 2010, we see that the number has increased to 17.6%.

There is marked reduction of the death rate among elderly citizens, with the rate in 2010 of 34.1 deaths per 1000 citizens which is much lower as compared to the year 2000, there were 42.3 deaths per 1000 citizens.

As for those elderly patients admitted to hospital, the duration of hospital stay is improving slowly. In 2000, an elderly patient will stay with an average of 10.3 days. In 2010, statistics show we have decreased the average hospital stay to 9 days. With regards to cause of death (Heart disease and cancer), the statistics are also show a decreasing trend since 2000.

I would say the outlook for Singapore's elderly patients is quite grim.

Private nursing homes are often out of the reach of many families unable to take care of their elderly loved ones. The volunteer nursing homes and destitute homes are operating at full capacity and the waiting list is long (wait 3-6months).

Time will tell how things will turn out.

The higher the position...

2011-12-09T22:29:00.001+08:00

After work one day, my colleague asked me, "MO (Medical Officer) life better- right?"

Puzzled, I asked him, "How so?"

He goes on to explain that, MOs get to go home by 5PM, don't have to stay on and do administrative stuff, attend tons of meetings, make reports, etc. He laments, "We don't have a life anymore."

(photo credit: Medimanage.com)

When you think about it, you absolutely get more on your plate as you go up the ranks of any profession.

However, when work starts to consume your "own" time and you begin to neglect the other important aspects of your life, when do you say, "enough!?"

Standard Chartered (Half) Marathon 2011

2011-12-04T22:02:00.000+08:00

December 4, 2011

The Standard CharteredHalf Marathon - “Who said Singapore was flat?”

2:50AM- woke up to thesound of my alarm clock.

3:05AM- had my breakfast

3:25AM- took shower andchanged into running clothes

3:55AM- left the houseand headed for MRT

4:08AM- boarded the MRTto Sentosa- the whole train was packed with runners- of all ages,sizes, and most of them running the full marathon. Compressionclothing was the norm, with 2XU as the most common brand. Some slept,some of the runners talked about how they prepared, while otherstraded running routes.

4:50AM- arrived atHarbourfront MRT station. Headed towards the bag drop behind the businterchange. I was expecting long waiting lines- but there weren't any. I was able to deposit my post race gear within 5 minutes. The support staff there were very courteous.

5:30AM- ate my last solidfood before the race- 2 slices of banana bread from Giant. Yum! Satdown at the entrance of Sentosa and gulped down 2 cups of mineralwater while waiting for the starting gun.

6:10AM- runners lined upat the starting pen- while I lined up for the loo.

6:20AM- the raceannouncers were shouting their lungs off, wishing all of us a goodand safe race. There was little wind, and that meant a really hotrace later on.

6:30AM- the start gun Iwas expecting were turned out to be football horns blasting away furiously, signaling the start of the race! With 19,700 half marathoners running (the count post race- around 13,000+), we were sent off as bigbatches. The field was dense and we actually walked for about 100mbefore getting into a light jog. The first 1km was comprised ofrolling terrain into Sentosa. There was a lot of shufflingand shifting of places. There was a mishmash of languages- Japanese,Tamil, Mandarin, English. At the end ofkilometer 1, we all groaned as there was a bottleneck about 500mbefore the hairpin turn at km 2. Another few minutes of walking before we couldreally get going. That was pretty much the only downside of the racedesign.

6:45AM- I was runningalong the beautiful Palawan Beach walk then into Siloso Beach walk.The sky was overcast, but it was a good thing because the air will stay cool longer. Kilometers 5 and 6 wasthe daunting climb towards Imbiah point. People started dropping back andpaces slowed to walking speed. Kilometers 6-9 pretty much made up forthe bottleneck earlier. I entered Universal studios, and ran throughFar Far Away, Jurassic Park, the kingdom of the Mummy and saw theBattlestar Galactica roller coasters on test runs! Kung Fu Panda, Marilyn Monroe and a couple of the penguins from Madagascar woke up early to cheer the runners, and some of the runners even stopped for a few photographs. After that it wasa short passage through what I felt was the zero oxygen undergoundparking lot. Every one was silent and focused at this point. All youcould hear were footsteps. After kilometer 9, I headed towardsVivo City and saw the start line at the opposite side of the road. Atkilometer 10, my watch read 1:02, and it meant I needed to push thepace up a bit. I felt a little hungry and anticipated the next waterstation ahead. I managed to grab a couple of energy gels (sponsored by Shotz)- I took abig suck out of one packet- it had the consistency and color of Karo but chocolate flavored-and I almost threw up. A fellow runner saw my reaction and offered apaper cup of mineral water- I politely declined and got my own papercup. I spat out the gel and washed my sticky hands. I felt a bit queasy after that but somehow I was able to shake off the weird feeling and focused on the race. After the waterstation was another short climb-the entrance into the West coasthighway. At kilometer 13, I was pounding the pavement in the AyerRajah Expressway. The sky continued to be overcast- with very littlesun and wind. I saw a couple of runners lying down on the road- they had hit the wall pretty bad. One lady had an abrasion on her chin. Otherrunners were applying Tiger Balm active feverishly on their thighsand legs. At kilometer 15 I could see the Marina Bay Sands as I ranthrough the East Coast Expressway. I was happy to see the SingaporeFlyer at Kilometer 17 and that meant the race was almost coming to anend. The half marathon route merged into Raffles Avenue (joining into the flow of runners from the 5k and 10km race) and it wasweaving-through-the-people-time time once again. I could hear thefinish line commentator as I passed through Esplanade drive- thecrowd egged on and cheered for the runners as they passed. The sunstarted shining and it was a bright sunny dash towards the finishline. I gave it my all on my last 150m and finished the race at 2:06(based on my own stopwatch). I was guided out of the finish line andinto the medal collection booths and I got my first half marathonmedal from the Standard Chartered Marathon! I called my wifey and shehad finished her first ever (and first international) 5k race. Thenit was photography time!

Running with music

2011-12-02T23:19:00.001+08:00

Music can be a great motivator, especially during running.
I find music keeps the adrenaline pumping and the fatigue sets in a little later.
I see that music is best for fast runs when you're trying to keep your pace at a target time.

Facing defeat

2011-12-01T21:57:00.001+08:00

I guess that's how life is...some things don't pan out the way we want.
Sometimes you can prepare/study/cram/memorize/train all you can and do your best but still fall short.
Time to pick myself up and get back on the horse.

Next time around I will be ready.

Diabetes can affect man, woman, child and...fruit?

2011-11-25T22:52:00.001+08:00

While I was doing grocery shopping with my wife, I happened to come across...

2011-11-24T22:07:00.001+08:00

Sunday morning--- Dress rehearsal at 6:30AM

Track session

2011-11-03T21:50:00.000+08:00

This afternoon I headed to the running oval for a baseline run.

The heat was unbearable even at 5PM. Although the sky was overcast and there was some wind, I was already drenched with sweat upon arriving at the track.

I decided to do 400m x 15 laps with moderate pace to try and get a feel for the legs.

Running so far has been limited to twice a week 4km on weekday and 5-10km on weekends (if I'm lucky).

Armed with my Timex Ironman 30lap wrist watch I clicked on the lap button every time I reached the start point on the red orange flooring.

At lap 6, I was starting to have doubts that I would be able to finish the 15 laps. However, I wasn't cramping up and my legs were still chugging along so I banished all thought of stopping and focused on making the rounds...one by one.

The local football team was on the field practicing, so I had to use lane 6 to minimize my chances of getting hit by a soccer ball.

The track was good to my legs, due to its almost bouncy effect on your stride. I was afraid my iliotibial bands would work up again, but fortunately the pain didn't come.

On my last lap, I was counting the number of meters left...600...400...on the last 50 meters I bumped up the pace and tried to finish strong. There was some juice left in the legs and managed to do a short sprint.

Finished my 15 laps in 38'58." My legs didn't cramp up even once, and that means I stayed true to my moderate pace for today. After a kilometer of walk recovery I ran home easy pace very happy.

The taste of chlorine

2011-10-30T22:26:00.003+08:00

Started Sunday morning with a quick run to the pool. It was still dark when I left the flat at 6AM. After 30 minutes of running through the park connectors, I saw the towering flood lights over the swimming pool complex, inviting me to get in quick.

The water was nice and clear, and I let in the familiar taste and smell of chlorine. It felt good to feel the water swoosh by with every stroke. My breast stroke technique has improved over the past 2 months and my freestyle stroke is getting better. I still need to get the kicking right though. I have youtube and the Mcfarlane book to thank for my progress.

I've been trying to convince my wife to jump in and start swimming too. She doesn't know what she is missing.

I'm happy to hear that FINA will be in town this coming November 4-5, 2011 at Toa Payoh. Will probably catch it on television, as I will be most likely swimming myself--as I have a few days on leave coming up.

One more month to go and soon I will be racing on the streets of Singapore once more as a runner, my first ever 21k at the Standard Chartered Marathon 2011.

One year in Singapore

2011-10-29T22:26:00.001+08:00

One year and 4 days.

I have been in Singapore for one year and 4 days. Working as a FT (foreign talent). There has never been a dull day at work, and I am enjoying all that Singapore has to offer (beautiful and equipped hospitals, inspiring mentors and colleagues, excellent transportation facilities, the great variety of food, the security and the high standard of living and excellent quality of life).

The question now is, what happens next? When my contract ends, how will I be able to continue working in this small but progressive country? The medical education landscape is changing right in front of my very eyes, from a British influenced medical system to an American style Residency program.

As a non-traditional source physician, where will we fit in this new system? So far the answer has been, "we don't know." Will the Singapore Medical Council require us to go back into residency so that we can progress from a physician with temporary registration to conditional (or full) registration?

Should I just sign up for the Staff Registry Scheme so that I can become a Resident Physician, with a stable job at the middle level for the next 6 years? Or should I aspire to pass the MRCP (if it is still regarded by the SMC as the final assessment prior to advanced specialty training) so I can reach for the rungs of Consultant and continue practicing indefinitely?

As I wait for the answers, I will continue to perform to the best of my abilities as a physician to the people of Singapore and to always (to borrow the words of my boss), "value-add" to the big picture of healthcare.

Feeling lousy & down with a cold

2011-10-03T22:30:00.000+08:00

Over the weekend I didn't get to go for a swim or even a run.I had little tickle in my throat last Friday afternoon and that usually meant a cold was brewing.By Sunday that little tickle matured into a non-productive cough that would make me bark suddenly.

Sleeping it off didn't help much and I had as much hot calamansi (lime) juice as I could. Today I still have the cough and I hoping it would go away quickly. My voice has changed too, having a deep timbre and my wife says I sound like I had just woken up (even if it was 8PM). My back muscles are a bit sore from the coughing and I feel more tired than usual.

Despite my general malaise, I managed to get through the day and saw a handful of patients which the beginning of the week usually brings (or unleashes) to the service. The time just slipped by so fast by the third time I looked at the clock it was 5 minutes before 5PM.

I hope I get well quickly enough before our up and coming 2nd wedding anniversary this weekend. So here goes.

Swim practice

2011-09-27T22:07:00.003+08:00

1...2...3....breathe! 1...2...3 breathe!

Counting every third stroke and breathing the right way during freestyle technique review was quite daunting. This afternoon I was able to get off from work on time and that meant I could have a pool session! After the long run last Sunday, it was time for the upper limb muscles to do some work.

Over the weekend I went to the public library and saw this:

taken with instagram

It was about time I get the strokes right and...also the breathing technique right. I've been breathing on my right side for the past few months and this book says it isn't right. I used to breathe bilaterally in the past for my triathlon training but I guess I've become lazy and have created bad habits along the way.

So today, I tried doing freestyle the right way, and man...it was difficult. The author did say that getting rid of bad habits will be tough and will take time, but if you stick to your plan you will eventually succeed. I was breathless after my 2nd lap and was gulping massive amounts of pool water whenever I took in air on my left side. I also felt my right lead arm drop a bit and do a bit of deep pull when the left arm goes back into the water.

Anyways, on next practice I will have to control my body rotation, relax a little more and pace myself. A little more tweaking on technique and the speed training will come later on.

The book also showed how to do the backstroke. I always had difficulty with this stroke because I wasn't balanced well enough on the water so I gave it another try earlier. I followed the instructions from the book and surprised myself! I could do it! Well, that will be another thing to practice on, but for now it's freestyle in focus.

Long run Sunday!

2011-09-25T22:23:00.001+08:00

Since I had the whole Sunday to myself, I woke up at 5AM and decided to go for a long and easy run.
With the Standard Chartered Marathon coming up this December, I might as well get in the mileage needed for the road race.

I slipped into my running clothes and left the house at 630AM.
Destination: Woodlands Town Park. This park had a large lake based on the road map so I figured it would be worthwhile to check out.

Photos taken with Instagram.

My reliable pavement pounder

The roads were quiet as I headed towards the Park Connectors (asphalted pathways specifically made for cyclists and runners who want to go to one town to another in relative safety).

Heading towards Woodlands

I just love the fog!

Watch out for the cyclists- they share the Parkway Connectors with the runners

Yes, that is the Seletar Expressway up ahead.

I did make a few wrong turns and got surprised by a few dead ends, such as the last picture above. I had to double back and head for Woodlands Avenue 2. I had to rely on my GPS to make sure I was on the right path for a couple of times.

I passed by the Orange Valley Nursing Home Marsiling Branch. We usually get patients from this nursing home during nights on call at the hospital. The facility looks clean and quiet from the outside.

The Woodlands Town Park Lake

...and after 1 hour and 50 minutes I reach my destination! The first part of the lake looks simple. Only after you go into the park itself the lake shows off its beauty...

Uncle fishing...unfortunately that's litter floating on the water

The best shot of the lake

Need to rest my legs for a while...ahhhh..

The water is so tranquil

I love the reflection of the bridge on the water

I took a breather in this nice park and finished off the chocolate Marie biscuits I brought. I refilled my water bottles from the water fountain and headed back to base.

I got home around 10AM. Immediately downed 3 glasses of Iced tea (heavenly!).

I was out running/walking/phototaking/eating for 3 1/2 hours! My clothes were drenched with sweat, and my earphones were falling out of my ears. I traveled 23 kilometers today! Whew!

...Part I done...

2011-09-20T23:46:00.000+08:00

September 20, 2011 has come and will pass in the next hour or so. I (along with 3 other fellow Filipino doctors) took the notorious MRCP Part I written examination at the Prince George Park Residence Multipurpose Hall earlier today.

Finding the venue was tricky. Luckily my colleague did a recon yesterday and found the place for us in advance.

For a post graduate examination, some candidates came wearing shorts and flip-flops. Some didn't shave. Many were absorbed with their own handouts, books and tablet computers.

2 sets of papers with 100 questions each. Topics covered from anatomy to rheumatology.

You are given 3 hours to answer each paper. You can write all you want on the questionnaire booklet. You are not allowed to bring scratch paper or calculators.

We started the 1st paper at 12 noon. Airconditioning provided. Bring your own sweater.

40 minute break in between papers. Gobble down homemade sandwiches. Barely had enough time to grab some coffee sweetened with condensed milk.

2nd paper started at 4PM. We finished at 7PM. You cannot leave the examination hall before the designated end time. You all come in and out the same time.

You will use the #2 Pencils provided to shade the letter corresponding to your answer to a printed out computer readable answer sheet bearing your name and ID number.

It was hard as expected, but the Passmedicine MCQs definitely helped with our preparation for this big and expensive examination. It will take about 4 weeks until the results of our endeavors will be revealed. Until then we can only wait, and look at our uncertain future.

5 days to go until the MRCP

2011-09-15T00:10:00.000+08:00

It is now midnight and that means it's time to go to bed. The big day is coming up fast and I definitely need a whole ton of miracles if I want to pass the MRCP. All these facts crammed into my head, I'm sure there is a brain leak somewhere....

Of course I've been trying to maintain work-life balance and that means I still go out there pounding the pavement and getting in the laps in the pool. My swim distance has improved significantly and I am now reaching 1000m at every pool session. I also graduated from the TYR resistance swim shorts to the TYR jammers, which really feels fast in the water.

Got them on sale! Yey!

So here goes, wish me luck on my big day next week. I hope I don't doze off in the middle of the exam due to brain fatigue.

Work-Sport Balance

2011-07-24T18:51:00.000+08:00

Yesterday was great! I was able to go for a 2.4km Run-400m Swim-2.4km Run brick early in the morning. Yes, the distance may be laughable for its brevity but after more than a year of sporadic bouts of exercise, I am glad to see some semblance of a training schedule/regime.

After learning how to use the Swimming Complex in our Estate 2 weeks ago, I am so happy I can dip in the pool almost any day of the week and stroke my arms back to fitness. My arms have once again tasted lactic acid and I welcome the soreness after the swim.

The Singapore government promotes exercise among its citizens (and foreign talent like me) vigorously. I am thrilled to have a real race track (the surface made of "tartan," a layer of polyurethane), and a swimming complex nearby. The only excuse one has NOT to be able to get in shape is to say, "I don't have time."

So, now after a long day at work using my brain, I can now put the brain on the backburners and let the muscles do the working--at the pool or at the track!

Just keep marching on...

2011-07-02T22:24:00.000+08:00

Its already July!

I have been very busy the past 2 weeks thus I haven't had the time to sit down to reflect and think about things. I'm going into my 4th month in Renal Service and it seems my bosses are satisfied with my performance.

I had a nasty call last night, the admissions kept on pouring in, filling the wards with sick patients and not-really so sick patients. There was no end in sight until 8:10am when I eventually had to stop clerking the patients the A&E was sending in.

Working in a hospital is a very complex job. It involves a lot of multitasking and thinking on your feet, as well as running from ward to ward. It takes a lot of patience and understanding.

Imagine this scenario:

At 1:09AM a nurse suddenly calls you on your handphone that one of her patients on the opposite building is having difficulty breathing. She reads off the current vital signs rapidly and adds that the patient is deteriorating rapidly. While this is happening you are explaining to a patient's relative that his mother just had a massive stroke and the outlook is not good. You excuse yourself clumsily and run off towards the breathless patient.

While heading towards the other building, your registrar (senior doctor on call) calls and asks you to go over the cases you have admitted. You tell him nicely that you're just going to attend to one sick patient and ask to go over the cases at a later time. You reach the bed of the breathless patient and quickly assess her condition. You determine that she needs respiratory support and that means you need to go over her notes (its the first time you see this patient) quickly so that you can hand over to the code blue team who will be arriving in a few moments. The patient is intubated and you grab the ambubag. You squeeze the ambubag with both hands to ventilate and oxygenate the patient. You and the nurses scramble to bring the patient to Intensive Care. There is a lot pushing and bagging while you watch the portable vital signs monitor and oxygen saturation level. You finally reach ICU and the patient is taken over the by the ICU team.

Then you realize you haven't had dinner. Your phone rings again and the ward on the 10th floor has 3 new admissions that you have to clerk (interview, assess, institute preliminary diagnostic tests and treatment). By the time you get to look at the clock, it is already 7:30AM and you have to grab a quick shower and a coffee, check out of your (barely used) call room to start your own morning rounds.

Such is the life of a junior doctor.

Brain Exhaustion

2011-06-18T06:04:00.000+08:00

Finally I've taken the big leap (and spent a big wad of cash) and fully committed myself to taking the exam on September 20, 2011.

Slowly but surely, I've been hitting the books and doing the best of fives Q&A with the help of www.passmedicine.com. It is like being a medschool student once again. The reading part is already by itself quite daunting, add in the best of fives-- all of it just blows your mind away.

I've been feeling the pressure- and the passmedicine questions are...painful. The setup allows instant feedback on your performance and how it compares to the performance of others. It also tells you the chances of success (going beyond the grey area of the bell shaped curve). It also reminds you how many days you have left to study.

No wonder they call it revision. You may know things, but these things may not necessarily be the same ones the examiners would want you to know. Yes change is...difficult.

Now I have to go back and study.

I yearn to cycle...

2011-06-12T00:23:00.000+08:00

If I only had the luxury of time to....

...clip my shoes on to the pedals
...and ride these well paved roads
...spend a couple of hours with the wind on my face
...sigh

Revision...

2011-06-08T23:27:00.000+08:00

104 more days to go until part 1 of the big exam. Here in Singapore, the word for reviewing/studying for an exam is called revision. It does sound strange- does it imply you are "changing" what you already know?

I've had my first taste of the questions that I may be encountering this September 20, 2011.

Passmedicine's evaluation of my first 20 questions performance

(Taken with Instagram)

I sure need work with my "stuck" knowledge. Not only the test is tough, where about less than 40% pass every time, it is also expensive. For me to pass part I, one of my ward bosses recommended that I do 100 questions a day. Doing 20 questions is already daunting, doing 5x more of that will require my utmost dedication...(cringe!)

Passing the MRCP is an integral part of my continued existence as a physician here in Singapore. The work and preparation never ends. Whew!

Census is growing!

2011-06-06T22:48:00.000+08:00

The list of referrals the renal service is getting longer by the day.
As if someone decided that June is Renal Month!
With 7 hemodialysis machines, 1 medical officer, 1 registrar and 2 consultants, and our diligent staff nurses, Renal Coordinators and Medical Social Workers working their butts off everyday we are still meeting the demand.
As the Renal MO, I am doing my best to keep all the facts and numbers in my brain...

Pick your poison...

2011-05-29T20:58:00.000+08:00

As a physician, I spend most of the day...writing.

After speaking to a patient, you document that discussion in his or her case notes.
After speaking to a colleague, you document that discussion in the patient's case notes.
After deciding to change the medication regimen, you document that decision in the...yes you guessed it, in the patient's case notes.

Documentation is a very important aspect in the practice of medicine. If you didn't write it down, it (your action/decision here) did not happen.

Therefore, after 6 months of documentation, the best clicker ball point pens I have used so far are the following:
1. Stabilo 0.7mm
2. Pilot 1.0mm S$1.55 per pen
3. Uniball Jetstream 1.0mm S$1.85 per pen

The newest member of this select group is the Faber-Castell Grip 1.0mm. A discovery after a visit to the very much crowded Singapore EXPO today, the dark black ink and smooth writing glide of this clicker holds great promise.

Inception

2011-05-27T23:24:00.000+08:00

Summer vacation

2011-05-23T10:52:00.000+08:00

Taken with Instagram

Renal-wise...

2011-05-18T23:22:00.000+08:00

1 month and 18 days of being a Renal Medical Officer. How time flies. So far, I have inserted 5 femoral lines, removed 1 permanent catheter and witnessed uremic patients getting better after the first few rounds of hemodialysis.

I have become more confident at wet-reads of renal ultrasound films (the picture above tells us that the right kidney has quite a number of large renal cysts).

However, there is still so much to learn (and retain) and the challenges keep on coming. The past few weeks we saw an increase referrals to the Renal Service and we have more patients in the Intensive Care Unit. It may be exhausting work, but at the end of the day, you feel that you have practiced Medicine. It gives such a great sense of fulfillment.

I still do not know if I will still be the Renal Medical Officer next month, but it would be a waste of the learned skills I have gained if I were to be transferred someplace else.

Enjoying Post Call at Orchard Road with the Family

2011-05-16T23:09:00.000+08:00

My dinner

Finally, going back home...tired but happy!

Riding bicycles in Singapore- a few observations

2011-05-01T18:47:00.000+08:00

A few observations:
1. Bicycles are allowed on the sidewalk (only one cyclist pictured above uses the road) competing with pedestrians.
2. Many of these cyclists must readjust their seat post height to achieve pedaling efficiency.
3. Apparently cycling without a helmet is allowed in Singapore, a fine city.
4. Most bicycles I've seen are not given proper maintenance- underinflated tires, rusty chains and gears.

Diabetic Foot

2011-05-01T13:14:00.000+08:00

If you're going to the Emergency Room...

2011-04-30T17:48:00.000+08:00

If you're going to the Emergency Room (or A&E as it is called here in Singapore), it is best that you prepare yourself (and your sick loved one) mentally for...waiting. The waiting time is quite variable, and on average it takes about an hour or so.

Bring a book/magazine/handheld electronic entertainment.

...and watch your que number flash up on the screen.

The 2011 JP Morgan Chase Corporate Challenge 5.6km Run

2011-04-24T12:06:00.000+08:00

At last! After 1 whole year of being absent from races, I've put my running shoes back into the racing circuit.
This year, I may call it a promotion of sorts, is my first international run! Hehe!

I signed up for the JP Morgan Chase Corporate Challenge a couple of months back. The entry fee was sponsored by the hospital I was working in, so I decided to give it a shot. I also wanted to see if I still had my running legs. Getting ready for the 5.6km race was quite a challenge as hospital duties often get me real tired at the end of the day.

Time just breezed by and the big day was upon me. April 21, 2011.

4:15PM (15minutes to go before the bus leaves for the race start): I'm still talking to colleagues over the phone regarding discharge plans for the patients.
4:20PM: trying to get in touch with a vascular surgeon for a referral for arteriovenous fistula creation. Line busy.
4:25PM: Racing down the stairwell after getting my running stuff from the locker. To change here or at the race site? My phone rings. My consultant is on the line. She asks if I am busy. I say I'm off to the race I told her about. She lets me go.
4:27PM: I see the bus at the lobby. I think I can still change into running clothes. I see my wife waiting at the lobby. I rush to the comfort room to dress up.
4:32PM: I run out hopeful that the bus is still there. It had left. Gone with the wind. Explored options with wife. I wont be able to race if I am late. If I don't race the sponsorship will be withdrawn.
4:45PM: On the bus back to our flat. I decide to go ahead and take a taxi to the race site while my wife gets my post race clothes at home. We plan to meet after the race.
4:56PM: I get on the cab and hope I get to the race start early.
5:35PM: $22.00 later, I'm on my feet following other runners to the Esplanade bridge. I buy myself bottled water. I realized I hadn't filled my water belt canisters. I meet Cheryl, one of the pharmacists at the hospital. She too came on her own. We walk deep into the start line to search for our colleagues. Met the hospital CEO, smiling and chatting to a friend.
6:00PM: The championship runners were set off. The 1st wave of runners were to follow after 5 minutes.
6:05PM: The bouncers in black created a line in front of us, indicating the end part of the 1st wave. Just great. The 2nd wave (that's me included) will be set off after 20 minutes. The start was packed with people, different nationalities, different corporations (banks, telcos, supermarket chains,etc).
6:20PM: We hear the start horn and I set my watch to start timing. The run begins!

I was glad that the first 300m or so was the downslope of the Esplanade bridge. It ensured a good warmup for the run. I found my pace and saw that Cheryl accelerated ahead. I kept the pace just right and tailed a couple of runners who matched my speed.

You can get a brief view of the F1 pit on kilometer 2-3, and you can see the names of the F1 drivers on the left side.

The heat was incredible. It was like running at 12noon in Philippine climate. My water had run out. I was sweating like crazy. At the 1st water station, the race volunteers had trouble keeping up with the demand for water. The second water station also the same situation.

The heat was the most likely reason a lot of people started walking within the first 2km of the race. Perhaps about 80% of the time I was looking for "cracks" ahead, trying to overtake. I realized all my dodging caused me to lose energy. Of course with a race turnout of 13,000+ dodging was inevitable.

At kilometer 3, I too decided to take a breather. I went to the right side of the road and walked. At 6PM I couldn't believe it was still so hot. The dark clouds above threatened to bring rain, which would be very much appreciated but the rains never poured. I got back into the race feeling much better and increased my pace a little bit more. Before the U-turn the course will bring you to an underpass, and that meant a small climb on the way back. I decided to put the pressure on the climbs and hopefully regain some lost time.

I saw the finish line chute ahead after a few turns and was really glad it was there in front. My legs were burning up. I was able to get a cup of iced water from the water station and doused myself on the head. It was heavenly! A few hundred meters more!
I increased my pace further and held on. I dedicated this race for my wife who was waiting for me at the finish line. Must finish strong!

I crossed the line happy and validated. I managed to get a time of 31:21. Whew! I grabbed the free goodies (a cold can of 100Plus and a banana) and my finisher's t-shirt. My wife and I met up with the Team Captain and posed for photographs with the team.

We rewarded ourselves with a sumptuous dinner at Just Acia, where bottomless soda, coffee, hot chocolate and ice cream flowed! What a perfect way to end the day!

The first Femoral Line Insertion

2011-04-20T22:46:00.000+08:00

Today was the day I did my first ever femoral line insertion on a patient.

No matter how much you read about the procedure or watch it performed by a colleague you will never know how hard it is once you do it yourself.

The case is a 78 year old Chinese lady who was admitted because of persistent pruritus due to Diabetic Nephropathy. She was slated for peritoneal dialysis in September however her family could no longer stand to see her suffering. Her skin was full of excoriations, thankfully none had any secondary bacterial infections.

She was quite thin and therefore the ultrasound probe easily detected the femoral artery and vein.

I cleaned the procedure site with antiseptic and draped the patient.

After infiltrating the target site with anesthetic, the hardest part was next- placing in the needle that will deliver the guidewire into the femoral vein. My hands were shaking, and having the ultrasound probe only exposed my anxiety even more. I steeled my nerves and managed to get the jitters under control. Under the guidance of the Renal Registrar, I was able to place in the large bore needle into the target.

After that, the 2nd hardest part was creating the tunnel to bring in the 2 way catheter into the femoral vein. When they say resistance, it was easy to "feel" for the resistance. You see, some force is needed to drive in the catheter, but not too much to rip the vessel apart. With the dilator the Registrar showed how much force I will be needing to deliver the catheter. A give will be felt and the catheter will slide in easily after that.

Happy to have inserted the 2 way catheter in place, the next step was to check the ports if blood would flow easily. Thankfully the ports flowed with dark red blood without any resistance. I flushed the ports with normal saline and proceeded to suture the catheter to the skin.

Since my last surgical rotation was 6 years ago, I hoped my muscle memory would kick in and suturing won't be much of a problem. It did go well however the Registrar said I needed to review my suturing skills again. According to him, that's one of the things not so good with Residency training, once you select your specialty, especially the non-surgical ones, suturing skills become a thing of the past.

Our patient underwent hemodialysis shortly after the insertion of the femoral line. Whew!

The practice of Medicine...is highly restricted

2011-04-14T21:43:00.000+08:00

When one travels from one place to another, its easy to make comparisons between the familiar and what is new. It is almost always an eye opening and insight generating experience. Take for instance, tourist spots. In the Philippines, we have: 1) Boracay, 2) Coron, 3) Baguio etc. In Singapore, in its early years, it only had swamps, some forests here and there. Then somebody took charge and thought that things can be so much better. In a place of limited "tourist" potential, its leaders and entrepreneurs created the country's own set of sights and wonders for all to see. I can't resist taking pictures of the Marina Bay Sands or the Merlion at Marina Bay (which isn't the original Merlion after all) over and over again.

In a world that claims that there are no borders, that all men (and women) are created equal, boundaries still exist.

Even in medicine. Let's begin with one comparison = recognition.

In the Philippines, to maintain the practice of medicine at the highest of standards possible, doctors created medical societies. Societies that would watch over the performance of its members and issue sanctions for those who err. Here in Singapore, they also have regulatory bodies that keep an eye on its members. As long as they "recognize" you as a member, as a fellow or as a consultant, there will be someone watching you as you practice medicine.

What strikes me as strange is that, outside of their own territories, these societies/associations/regulatory boards do not "recognize" each other. I am a diplomate of the Philippine College of Physicians (PCP). It may mean something in the Philippines, but here in Singapore it doesn't really mean much. The Singapore Medical Council (SMC) doesn't "recognize" the medical school or the residency training institution I came from. The same goes for the Philippines. If you didn't train in a recognized institution, your diploma from Singapore or Pakistan may not be accepted with open arms.

Does that mean that the standard of Singapore is higher than that of the Philippines? In all the years of its existence, why hasn't the PCP coordinated with the SMC or Singapore Medical Association to recognize each other? Aren't we using the same textbooks? Don't we attend the same conventions/conferences and apply the same guidelines/protocols in our practice? Aren't we brothers and sisters in the so called ASEAN region?

Perhaps the reason is professional rivalry. We are better than you etc etc.

Sure, that may be the motto from both sides, however our patients still get sick, our patients still get sent to the ICU and of course our patients still die despite our best efforts. At the end of the day, the patient doesn't really care about which organization you are from, or where you studied pharmacology physiology and anatomy.

What matters is that you were able to provide the best quality of care for that patient and her family.

From one subspecialty to the next

2011-04-08T21:08:00.000+08:00

So after one month, I have said goodbye to Gastroenterology and said hello to Renal Medicine.

The Renal service is perhaps the most referred to service intradepartmentally. The patient list almost equals to that of a single ward but the patients are distributed all over the hospital.

Therefore it involves a lot of walking from one building to the next. Great exercise.

From the single consultant I had in Gastro, I have now 2 bosses for the month. Make that 3, because I have a registrar supervising my involvement. It appears that Renal Medicine or Nephrology isn't a hot subspec here in Singapore. It belongs to the "hardship" group of specialist training. Approximately out of 5 aspiring nephrologist consultants to be, only 1 is Singaporean.

Thus, no one wants to be a Renal doctor, but everyone wants to refer to Renal for their hyperuremia/electrolyte imbalance woes. It is also my impression that Gastro isnt a hot subspec among Singaporeans. I guess dealing with piss and s#!t every single day isnt all that appealing after all.

It may be a dirty job, but someone has to do it.

One of the goals for this rotation will be the acquisition of catheter insertion skills: Femoral lines and IJ catheters. In the Philippines, we refer to General Surgery for these kinds of procedures. That isn't the case here in SG. The Renal doctors do it, under local anesthesia and ultrasound guidance.

I have observed one femoral line insertion this afternoon. The next one will be assigned to me. So here goes!

All in a day's work

2011-03-22T23:34:00.000+08:00

Now this is what we call specialized medicine.

(This is what you call a blue letter, the document used by doctors who are seeking specialist opinion with regards to patient care and management)

Struggling Filipinos following Abraham's footsteps

2011-03-21T21:09:00.000+08:00

Last Sunday, the scripture reading came from Genesis Chapter 12.

Now the Lord said to Abram, "Go from your country and your kindred and your father's house to the land that I will show you. And I will make of you a great nation, and I will bless you and make your name great, so that you will be a blessing. I will bless those who bless you, and him who dishonors you I will curse, and in you all the families of the earth shall be blessed."

So Abram went, as the Lord had told him, and Lot went with him. Abram was 75 years old when he departed from Haran.

-o0o-

It occurred to me that I too have done the same thing as Abram. I left the Philippines in the hopes of a better future, for myself and my wife. A leap of faith, clutching at the promise that God will provide generously and trusting that He has a plan for me. I am not the first Filipino doctor to leave his homeland, and certainly I am not the last.

What was clearly missing in the story of Abram's departure was how he felt when he received God's command. Did Abram complain? Did he have reservations about leaving? At his age, I wonder how he internalized the fact that he was being uprooted, and to be transferred to another land. But not a shadow of doubt in Abram was recorded in the Bible.

Fast forward to the present. Thousands of Filipinos leave the Philippines every year, tearful and sentimental movies about OFWs have been made, and sooner or later the remittances come in and save the country from economic meltdown.

But no matter how homesick and lonely Filipino migrant workers are, it is only outside the country where they begin to succeed in life and profession. It is as if the Philippines is the cocoon that "traps" the butterfly within, and by only getting out with so much effort and energy one becomes the best version of himself or herself.

Did Abram ever look back, as he traveled away from Haran? I guess he never did. He had a mission to fulfill.

Witness the ERCP

2011-03-17T21:00:00.000+08:00

Finally had the chance today to observe not one, but two endoscopic retrograde cholangiopancreatography sessions!

ERCP as it is commonly known, involves the insertion of an endoscope into the first part of the small intestine and under radiographic guidance, enter the common bile duct and allow the operator to perform a number of things:
1. Assess the opening of the common bile duct that allows flow of bile into the small intestine (note for tumors or strictures,etc);
2. Assess the common bile duct itself for presence of gallstones or strictures, etc.

Being able to do a successful ERCP takes years of practice. It has a long learning curve and one has to possess fine eye motor coordination, since you have to maneuver a long black tube with a camera at the end way deep into the small intestine.

ERCP is becoming increasingly popular for the evaluation and treatment of common bile duct gallstones, even surgeons prefer to send their patients to the gastroenterology unit rather than perform the rather tedious open cholecystectomy and bile duct surgery (which I was able to observe way back in 2005 when I was still a junior intern).

The procedure had a magical quality to it. Once you enter the common bile duct the only "eyes" you have is the screen image from the C-arm fluoroscope. You can push in radiocontrast media and see the liquid flow out into the duct and almost instantly you can see if there are any stones (or filling defects as they call them).

Once you see the stone, you can attempt to get the stone out with the use of a basket mechanism.

Incredible.

Sunday morning run

2011-03-06T10:13:00.000+08:00

Woke up to a beautiful sunny Sunday morning today.

I grabbed my shoes, hydration pack and off I went. I chose a different path this time, hitting the main road only once. On the back roads, things were less hectic. People were heading to market with their plastic bags, construction workers on their bikes, and children were walking their dogs.

With such a variable work schedule I continue to wonder how I can make my running into a regular activity. The time I go home isn't the only factor that changes from day to day. One more significant factor is the level of fatigue you earn after a day's work. You can come home early (just like being post-call), but your nerves are shot and your eyelids feel as if they are weighed down by a ton of bricks each. Sometimes you go home late and you want to go out and run, but you have to set aside some time for studying.

Although this isn't a new problem at all, it continues to be a challenge. I am reminded by one of the ads by New Balance (photo from Advertolog.com).

As I wonder when my next run will be, tomorrow morning I will be wearing my doctor's hat and scour the wards for Gastroenterology blue letters and reviews. The work is so much different from a regular ward medical officer: you get to see patients at the clinics on your own, your co-MOs call you for GE opinion plus you get to see the ICU patients without the code blue team breathing down your neck.

So week 2, here goes. Running shoes, get ready for the next call.

March 2011- New boss, new responsibilities

2011-03-03T22:10:00.000+08:00

To my surprise, I learned at 8AM on Tuesday, March 1, 2011 that I was no longer part of Team Echo, the team of doctors managing the cases at the subsidized ward.

I had a new post, and a brand new one at that. I am the Gastroenterology Medical Officer for the month of March. First ever.

The caseload of my new boss apparently has grown significantly over the past few months now has an MO.

So here goes. Learning as we go along.

Investment part II

2011-02-15T17:39:00.000+08:00

I'm on annual leave, taking the time to recharge and collect my wits after a couple of months of learning the ropes here in Singapore.

So I've gone back to reading. After taking down a few pages of notes, I realized that I have so much to read and absorb.

What does a one do when the brain is full and cannot absorb information?

Run of course (...and a little bit of swimming, I hope)!

Our employers expect us to take an affirmative stance when it comes to health. During meetings and conferences they don't serve cake or sweets for dessert. They give out fresh fruit. They don't serve soda, instead they serve oyster plant juice (which is quite good, by the way).

They also have weekly scheduled activities that encourage us to do something physically. The slow (Tai Chi & Yoga) and the fast (Running, Table tennis) are available throughout the week.

So I chose running. Naturally. Its something I love to do and feel good doing.

And to further enforce my running habit, I got this:

The Nathan Speed 2 Hydration Belt

Then, I also registered for my first ever race in Singapore. It will be in April, a short 6km run with my fellow employees at the hospital.

The work ahead mentally & physically requires endurance, perseverance and a ton of faith.

So here goes!

Investment

2011-02-13T18:51:00.000+08:00

The four letter word came up again 2 days ago from my fellow doctors.

MRCP.

Four letters that can induce fear and panic in any physician wanting to ascend the ladder in the UK based medical system.

The bosses want us to form a study group and prepare for the MRCP, and they also want to know when we are going to take the exams (Part I, Part II and PACES, etc). Quite a daunting task ahead.

So what should a NTS (Non-Traditional Source) physician do?

Read up of course!

So I asked around, some of the senior MOs gave their recommendations. One of our Professors also floated around some books he felt were good for the examinations.

Then my wife and I headed off to ResearchBooksAsia in Novena and picked up my investment.

After browsing through the books, I now realized why the other MOs were doing their physical examinations and worked out their clinical reasoning the way they did.

Now its time to adopt and learn.

Time frame: Six months to be as good or better than my fellow colleagues.

MRCP goal: Aim to take and pass the examinations before November 2011.

Lets hope I get the brain cells working and have enough money to get to UK before the year ends.

But before I dive into all that, I got a haircut (with Penel, my colleague from TTSH). Thanks to my wife who took the picture.

Working on it...

2011-02-12T07:17:00.000+08:00

We always want to be the best that we can be.

Especially if you're in the medical profession. We always want to know the answers at the drop of a hat. We want to be able to explain to the patient and his family what the disease process is and how we are managing it in the clearest and simplest way we can.

It is easier said than done.

So far, the feedback I get from my patients have been positive. They are happy that I can get the message across despite the language barrier and that I do not come on too strong, distant or cold.

Once in a while I get a husband or a son who complains that I don't have the comprehension of the Singaporean "beliefs and attitudes." It may be true, since I've only been here since November last year, but we must realized that people are the same in every part of the world. We want to be taken care of, informed of what is going about their disease and be given due respect and compassion.

On the other side of the fence, I reflect daily and look at how much I know and how much my Singaporean colleagues know. Sometimes I feel that the UK standard of training is more rigid and strict, making me believe that they are more knowledgeable than I am. It is like being on the other dimension in the TV series Fringe, where the other dimension is almost just like our dimension but with some slight differences. For example, I have taught that doing a rectal exam involves that patient lying on his side facing the examiner. Here in SG, the patient lies on his side but his back towards the examiner.

3 and half months of being Filipino doctor in Singapore. I'm learning and re-learning everyday, and for an Internist like me, the daily rounds, talking with patients, with colleagues from the other departments is making me a better doctor every single day.

Balancing act

2011-01-15T22:11:00.000+08:00

Concept: It is impossible to please everyone.

Without a doubt, no matter what you do, someone will complain or rant about something or someone else.
However, in my opinion, hospitals continue to "strive" to please everyone: patients, doctors, nurses.

Patients want everything done on time, quickly, no hassles, no lines, go home early etc.
Doctors want to get their slice of teaching, finish rounds, order the tests, trace results, treat then go home early, etc.
Nurses want to see their doctors write legibly and finish their rounds quickly, go home early, etc.

Its time that everyone should learn to be realistic.

Some diseases take time to be diagnosed, and/or treated successfully. Treating a disease is not like changing a car's spark plug, where the time to completion of the task is almost absolute.
Some medicines take time to be delivered to the wards. Most medicines do not achieve the desired effect overnight.
Doctors will always have lousy handwriting and do their best to be legible.
Discharge papers won't appear out of thin air.
Nurses will call doctors again and again during calls because it's important.

Be realistic.

Weekend off

2011-01-08T10:07:00.000+08:00

It's great to wake up later than usual...not having to rush breakfast and catch the bus...
Ah...the weekend off!

But time flies so fast here in Singapore...

Gotta catch up with my sleep!

First call as MO2

2011-01-06T06:57:00.000+08:00

I have survived my first call as solo MO2. It was terrible.

-handphone rings every 5 minutes
-you feel you're being pulled in every direction (um, ward)
-you worry if you still have time to have dinner
-you worry if you still have a call room you can dump your stuff in- and have a shower the next morning
-your arterial blood gases clot before they reach the lab
-your plug success & failures has a 1:2 ratio

Well, the good thing none of my patients in the wards I covered did not go into code blue or died.
Thank God.

There will be more of the same next week.

No longer a tag-on MO3 this January

2011-01-01T22:13:00.000+08:00

After 2 months of tagging along with the MO2 (Medical Officer 2) during calls, I have been "promoted" to MO2 status beginning January. That means I'm no longer the one following but the now the one being followed. A MO3 will be tagging along with me on calls.

Of course this means bigger responsibility when clerking the new admissions during calls and I am not sure if 2 months of preparation is enough but it appears that the powers that be have decided I am ready for the post.

Quizzically enough, I have not yet received any written evaluation of my performance for my first two months of work. For a hospital administration that thrives on feedback, I guess I'm doing a good job so far and I am meeting their expectations.

Here goes!

...and then there are bad days

2010-12-22T23:19:00.000+08:00

Had a bad day at work today.

Bad in the sense that I know my patients are dying, and I think they know it too.

They come in one by one, presenting with some fever or diarrhea or cough. The investigations begin and sometimes we find something ominous like a tumor.

Then its time to tell the patient and his family the bad news.

Tough.

Patient-Doctor Relationship

2010-12-16T20:47:00.000+08:00

"In the patient-doctor relationship, who has the upper hand?," asked one of the consultants in a seminar.

I answered, "The patient."

"Anybody else with a different opinion?," was the reply.

From the audience of 30 or so physicians, only one voice answered differently, "The doctor."

The consultant agreed with the other active participant. The rest were either too bored or apathetic to answer. The consultant stated that the doctor has the upper hand in the patient-doctor relationship because it is the doctor who has the knowledge and experience with the treatment of the disease of the patient.

However, in the era of Google, eMedicine and Medscape, this so called "upper hand" will soon be lost. Patients now can go online and search about his or her symptoms, the diagnostic tests that may be requested or the medicines that may be prescribed. The patient only seeks consult to verify what has been researched. At times, the patient may even know more than the physician. With the busy hours the doctor has to face everyday, it is unlikely he can Google all the information he needs for for his practice.

In Singapore, patients ask for the rates of complications for a particular procedure, the percentage of patients who have adverse drug reactions from a particular antibiotic or the what the percentage of getting a positive result from a particular test.

I still stand by my answer. It is the patient who has the upper hand. The patient-doctor relationship is based on trust. It can be terminated anytime by the patient, with or without the doctor's knowledge. Without the patient the doctor will not generate revenue.

You may possess all the medical knowledge in the world, but if not a single patient comes to your clinic for weeks on end, what good is that knowledge?

Think twice before bringing your kids when visiting loved ones in the hospital

2010-12-14T21:36:00.000+08:00

I couldn't help but notice the number of children (even infants) brought in by parents during visiting hours in our hospital. In a world of multi-drug resistant bacteria, SARS and meningococcemia I think parents should think twice before bringing children when visiting sick relatives.

There is a reason why we have isolation rooms, contact precautions, droplet precautions and sinks for handwashing everywhere in our wards. Not to mention the numerous signs and photos indicating the need for caution.

However, brothers and sisters carelessly breeze through these barriers intended to impede the spread of disease causing microorganisms as if they were just going to one bedroom to another. Children run around the wards where patients cough out gram negative populated sputum. They don't even bother to wash hands after contact with their sick relative.

Be careful.

Sleep, a luxury once more

2010-12-11T07:56:00.000+08:00

I have had some trouble with the internet the past few days...its so sluggish I couldn't get into the blogger site.

Anyways, I'm now in a new ward, with new colleagues, and new bosses.

The work environment is quite stressed as compared to the previous ward, and I have been seeing more mortalities in the first week of work. It seems when the money runs out, your chances of surviving runs out too.

I've been needing more sleep lately. I come home totally wasted and couldn't run anymore. I have to manage my psychological stress better.

Code blue activated at the wards

2010-11-29T22:35:00.000+08:00

This morning we had quite a scare at the wards.

One of our patients suddenly collapsed. He was unresponsive, cold & clammy, and drooling. Thinking he developed a heart attack we all rushed to keep his ABCs (airway, breathing, circulation) intact. Although I have participated in providing advanced cardiac life support many times during my residency, my sense of "newbie-ness" was acutely renewed as this episode was different in the sense that it took place in another country, where some practices may differ from what I would usually expect.

The following occur almost simultaneously, in an orchestrated manner:
I immediately called for the team registrar.
We transferred the patient from his chair and onto the bed.
Parameters were obtained: Blood pressure, heart rate and pulses, assessment of patient's breathing, glasgow coma scale. Patient was breathing. Pulses were intact.
Ambubag and face mask applied with jaw thrust, patient given high flow oxygen 10liters per minute.
IV line was inserted, infusion of colloid done fast drip.
Patient hooked to cardiac monitor and pulse oximeter. His heart rate was regular and sinus rhythm.
Capillary blood glucose determination. Result was within normal limits.
Stat 12L-ECG.
Arterial blood gas and blood panels obtained and sent to lab stat.
IV sedatives prepped
Intubation set prepped.
Code blue team was activated- nurse, anesthetist and intensivist along with the ICU medical officers came to the scene within minutes.

Luckily, the patient regained consciousness after about 15minutes and we didn't have to intubate and ventilate him mechanically. His blood pressure did not drop and his 12 lead ECG didn't show any signs of infarction.

We sent the patient to telemetry for observation and requested for more tests to ascertain the cause of his unresponsiveness.

On retrospect, when you compare the Philippine setting and the Singapore setting in relation to caring for a patient who has collapsed, Singapore is slightly different in 2 aspects:
1. The use of colloid for fluid resuscitation
2. The presence of the Code blue team, a fully specialized team for ACLS.

I have to admit, I was impressed with the hospital system. Supplies are available, trained specialists on hand, always ready for any emergency.

I was glad that the episode occurred during the day shift where most of the hospital staff were present. Though I dread the time when a patient will crash during a call, I am thankful to the patient who revealed to me the process of handling and surviving a code blue.

It brings to mind a quote from the popular cartoon TV series, G.I. JOE, "Now you know, and knowing is half the battle."

Dinner! Sliced fish bee hoon!

2010-11-27T20:36:00.000+08:00

After a nice nap on the couch this afternoon, I woke up pretty hungry. It was already quarter to 7 in the evening. Above is what I've discovered in the neighborhood coffee shop. Sliced fish Bee Hoon! All for S$3.50.

In the rush to enjoy the meal, I think I burnt the tip of my tongue.

Private practice can make you rusty

2010-11-26T21:10:00.000+08:00

So I have sort of mentioned that the work here in Singapore is almost like going back to internship. You do lots of scutwork (meaning IV insertion, blood extraction, indwelling foley catheter insertion, etc).

But despite all that poking and blood drawing, it is only by working in the hospital setting that you can get to see different cases. All the complex cases I've seen in my two years of private practice as a general internist in the Philippines can be matched by a single day in the wards here in Singapore.

Pituitary adenoma.
Hypopituitarism.
Metastatic esophageal cancer.
Wegener's granulomatosis.
Liver abscess.
Bronchiectasis.
Child's C classification Liver Cirrhosis.
Metastatic Breast Cancer.
Congestive Heart failure in a post CABG (2x) gentleman.

Can I name all the signs and symptoms of the diseases above? The diagnostic workup? Or even suggest a treatment plan? I must admit, I'm rusty.

Rusty because I have forgotten how to differentiate hypokalemia from hyperkalemia in an ECG tracing, how to calculate the dose of acetylcysteine for paracetamol overdose, etc. Can I name the tests required to ascertain primary hypopituitarism?

Now with every single day I put my stethoscope on my shoulders and go on rounds, all that rust is coming off.

Crummy day at the wards

2010-11-25T19:45:00.000+08:00

We always hear people say that doctors have "healing hands."

However, if you can ask the patients with chronic illnesses that get them admitted to the hospital time and again, you may get a different opinion. I have noticed that the only time I hold a patient's hand is when my other hand is holding a needle and vacutainer tube.

For almost the whole day I was doing blood extraction and IV line insertion. You may call me a whiner or whatever, but there will always be a patient who will be a problematic insertion or blood extraction. Its either they were born without any superficial veins or she has been in and out of the hospital so many times her veins have not recovered from the numerous pokes.

Today, I had two patients with the above description. Now, I can say I'm a fairly decent shot at getting the plug in or getting that blood sample for the renal panel the registrar requested. However, if I still don't get the job done after the 3rd poke, I think I'm doing more harm than good.

Once or twice I've heard patients say that we treat them like pincushions. I did a blood culture yesterday, and the patient was shocked that I took so much blood (well, thats 2 culture bottles) and he asked if I was going to do it again tomorrow. I sheepishly answered, "I hope not."

I do take the time to put myself in the patient's shoes. Do I want to be poked 4-5x before someone gets it right? Of course we want everything done right the first time. But until we develop some kind of bloodless technology where we use light beams or radar to determine the serum potassium level or the INR of our patients, it is the duty of doctors around the world to get the job done on the first shot.

A big thank you to all my patients for their perseverance.

Surprising comment from the wards yesterday

2010-11-24T21:38:00.000+08:00

Yesterday morning, a relative of one of our patients came for a visit. We usually update the family members of the status of their admitted loved one over the telephone. We were lucky that the brother of the patient came to the ward early, sparing us from making a phone call.

After we introduced ourselves, the brother of the patient expressed his observation, "Are there no Chinese speaking people in this big hospital?"

I'm Filipino, the Medical Officer in charge, and with me was my ever efficient House Officer, A, who is Malay. We were completely taken aback by his comment, and quickly explained that we ask the help of the Chinese nurses to translate for us when we talk to his brother.

It was really surprising, since the 2010 statistics of Singapore declare that 78% of the population is of Chinese ethnicity.

At last! My first run in Singapore!

2010-11-22T20:01:00.000+08:00

Yes! After so many months of not being able to do some knee pounding and pavement whacking, I have succeeded! My first ever run here in Singapore!

I managed to scrape enough cash to get a decent pair of stability running shoes. Its the 2009 Adidas Response Stability shoe in gray and orange. Since the model is a year old, it was on sale! Yippee!

I rushed home this afternoon, and changed into my running clothes and strapped on my new kicks! Absolutely fantastic! I didn't want to shock my legs too much so I decided to just have 2 rounds at the park. The birds were cooing about, kids were riding their bikes and their moms running after them. There was still enough sunlight at 6PM so I didn't need my LED headlamp just yet.

What is really great is that Singaporeans love running so much! Rain or shine, they run.

The shoes have the right amount of cushiness at the ball of the foot and the anti-pronator wedge at the medial side of the shoe did its job perfectly. The laces and the foam soles are so white, however they won't be staying like that for long.

Clerking an admission

2010-11-21T10:26:00.000+08:00

It has been 3 weeks of being the "new guy" here in SG, and so far I'm trying my best to be a fully functional physician.

In the Philippines, once a doctor has a new admission, this is the usual process:
1) he goes to the patient and does the history & PE first then
2) order labs/imaging on the chart, and,
3) makes the treatment plan on the chart.
4)Nurse carries out all the orders.
5) Physician is informed of the results of tests thru SMS or telephone call.

Here in SG, the process is a bit modified.
1. Nurse informs team doctor a new admission has arrived.
2. Team doctor gets the inpatient information sheet, goes to the COW (computer-on-wheels), and checks the CPRS (its a database of patient information that contains the patient's medical history- of course only accessible to registered physicians) and takes note of the previous laboratory results, previous imaging tests done, previous diagnosis, history of allergy, prescribed and dispensed medications. Team doctor also records all lab and imaging results obtained from the A&E (Emergency Room).
3. Team doctor now goes to the patient and does the History and PE. He or she gives a preliminary diagnosis and informs the patient (and relatives, if present) of the treatment plan.
4. Team doctor now goes back to the COW and inputs all the orders on the computer. He also fills out imaging requests (MRI, CT, Ultrasound, barium fluoroscopy etc) and referral forms to allied health professionals (Physiotherapists, Occupational Therapists, Dietitians, COPD or Asthma nurse, Diabetes Nurse, etc). He writes the medications, diet, IV fluid and Blood Glucose Monitoring for the patient on the IMR.
5. Team doctor does the necessary blood extractions for blood culture etc.
6. Team doctor gives the first dose of antibiotics/proton pump inhibitor, etc. Pharmacist reviews all drugs ordered on the IMR (Inpatient Medication Record). He or she informs the team doctor if there are issues with regards to dose, possible drug interactions among the ordered drugs. Team doctor makes necessary changes.
7. Results are traced and additional orders may be done, requested on the COW. Vital signs are reviewed on the Parameters folder.
8. Team doctor presents the case to the Team Registrar and/or Ward Consultant. They review all orders and make the necessary changes.

As a tag-along doctor for the past 3 on-call posts, I have observed that clerking takes about 20-30minutes depending on the complexity of the case, the language barrier and availability of informants.

Paracetamol overdose

2010-11-18T19:00:00.000+08:00

It appears that taking 20 tablets of 1000mg Panadol (paracetamol or acetaminophen) is quite common here in Singapore. In one week, we have 2-3 cases who get admitted for detox.

They come to the emergency room complaining of abdominal cramps, vomiting, etc. The reason for the ingestion is usually relationship based (father-son, BGR or boy girl relationship, teacher-student).

We do serum paracetamol measurements, liver function tests, renal panel, full blood counts and urinalysis among others. Psychiatrists, Medical Social Workers are mobilized and see the patient. IV detoxification is on-going while assessments are made, and the pharmacist comes in to monitor drug administration.

Ironically, one patient who overdosed with Panadol developed fever documented at 39.2C this afternoon.

That meant more blood extractions, more imaging tests for the patient, and possible need for empirical antibiotic treatment, escalating the overall cost of treatment.

Surely, if you go looking for trouble, you'll get what you ask for.

When can I run again?

2010-11-17T13:30:00.000+08:00

Singapore is celebrating Hari Raya, and that means a day off free from work. Well, I did my rounds today anyway and got to discharge two patients.

I can't wait to get a brand new pair of running shoes. The malls have almost every brand! I can see people running with Brooks, Newtons, the ubiquitous adidas, New Balance and Nike.

Counting the days until payday so I can finally go out and run!

Finally, an orientation (Introduction) for my "doctoring" here in SG

2010-11-16T20:57:00.000+08:00

Last Saturday, before going on-call (in the Philippines this is known as being "on-duty") the new Medical officers were required to attend an orientation. We got to meet the big bosses, namely the Chief Executive Officer, the Chairman of the Medical Board, the Associate Dean (something like the Chief of Clinics), and the different heads of the departments.

They shared their aspirations and the vision they had for the hospital. Here are some tidbits I'd like to share, and maybe the hospitals in the Philippines can learn a thing or two.

"What is medicine today? It is the episodic compartmentalized health care of the body part."

"It is now the information age. Any patient can go on Google and figure out what disease he or she has, to the point that the knowledge exceeds that of the doctor's."

"When does good medical care happen? It occurs when our own family members come to our hospital."

"We have developed a system in our hospital where the clinics that matter to the patient are kept close together. We often see diabetics having to get checked by the eye doctor, so we put them near each other."

Each patient has an ID number or popularly known as the National Registration Identity Card number. Known for its high degree of security (see here) It is used for certifying identity before doing an X-ray or giving antibiotics or before a blood transfusion. It was one of plans of the GMA administration to come up with a similar system, but I believe it has died a premature death.

In Singapore, there exists a patient database accessible to physicians. A hospital physician can gather information pertaining to the patient's prescribed medications, his previous laboratory results, his previous imaging results and even the discharge summary from previous admissions. This has been set-up in order to achieve continuity of care. The team medical officer in charge of the patient has to call up the attending physician to update the latter of the patient's progress.

The coordination of the different departments are seamless. The dietitian comes to the wards personally to assess and counsel the patient. The pharmacist does her daily rounds to check drug administration/dosage and she could even suggest to the team doctors on how to use the medications to achieve the maximum effect. The Medical Social Worker coordinates between Nursing Home Staff, or meet with family members to discuss and manage caregiver stress or family relationships. The physiotherapist and occupational therapists train the patients in the spacious wards.

All these people, working together for one person, the patient.

It is incredible isn't it?

The orientation ended, and my call started at 4PM. It was non-stop work for the next 11hours over the weekend.

Going 2 weeks into MO-ship

2010-11-11T19:14:00.000+08:00

Yep, thats what they call us in the hospital I work in, MOs or Medical Officers. Something like the middle man between the newly grad MDs and the Registrars. A lot of S.C.U.T., paper work and doctoring in between.

Some of the doctors here ask me why I came over and decided to work in Singapore.

The reasons:
1. To experience how it is to work in a first class hospital.
2. For a better life.

The diversity of culture here is so immense. The common things, like the food, the drinks (had my first taste of milk tea this morning- it was quite good actually, refreshing at the least) the side of the road where people drive.

However, the most challenging thing for me as physician here is the language. The registrars (the rough equivalent of a resident physician in the Philippines) interview patients seamlessly using Tamil, Malay, Chinese, English and Singlish. I can only go as far as "Ni hao," "Sakit" and the Chinese thank you word (I dont know how spell it yet). A doctor here must learn to speak at least 3 languages to be able to elicit the best history and do the best physical examination.

But there are aspects that are universal in the hospital no matter what language you speak. The touch of the stethoscope in a patient's chest almost immediately elicits a series of deep breaths, or the beaming of the torch into the patient's mouth signifies you want to examine his or her throat. Of course, the grimace of pain when doing venipuncture or IV insertion is always there.

For the better life portion, of course Singapore has the best global indexes in the world. Safety, ease of business, world class healthcare, the works!

Learning the ropes at the wards

2010-11-04T22:06:00.000+08:00

So far I have spent 4 days of working as a physician in Singapore. To sum it all up with one word, tiring. No wonder my blogger doctor friends who also work here don't seem to have the time to write up posts as often as they would like to.

There is so much to do, but since I'm the newbie, I'm still scatterbrained with all the scut work and the rounds and memorizing all the facts and figures of each of the patients in our ward.

Of course the differences in management, like the absence of IV Paracetamol for fever and warm compresses for those with urinary bladder retention. Or the reluctance to use any antibiotic other than Rocephin or Augmentin for infections. For insulin, they rely on Insulatard to provide basal acting insulin for those with elevated BGMs (Blood Glucose Monitoring).

Even the way one writes the medication orders is different. Instead of BID for twice a day, one writes BD. If the medication should be given 3x a day, instead of TID, one writes TDS.

Culture shock. Different language, different orders, different management styles. Yes I am truly a foreign medical graduate. More comparisons to come.

Third world physician in a first world hospital

2010-11-02T22:38:00.000+08:00

Today was my 2nd day at work here in Singapore. Still learning the ropes of being a medical officer (same level as of a post graduate year 2), and asking for help & instructions again and again. The ward consultant told me to be more involved in the rounds and not just stand on the side like an observer.

Oh well, I have a ton of things to learn by heart, not only the patients themselves but also how to navigate the in-hospital electronic record system. The EMRs is almost like magic, with a few clicks you can see all the lab test results, the imaging test (Chest X-ray or MRI image) and results and even the past discharge summaries.

Security wise, entry to the different wards require an electronic key pass, something I still don't have yet.

The medical staff has been totally helpful, from the nurses to the House Officers and I really grateful for their guidance. I've been looking at the charts (electronic and hardcopy) the vital signs folder and the medicines folder trying to cram all the information into my head.

As for the language barrier, around 50-60% of the time all I hear is Chinese. One patient even told me straight up to not speak to him in any language other than Chinese. Yikes!

I'm dreading the day that I will be on-call...

A new home, a new country

2010-10-27T23:17:00.000+08:00

I am now a certified foreign medical graduate. A new chapter in my career as a physician in Singapore.
There are many challenges to face, people to meet and help get well.
Here goes.

I know they cost much, but don't wear them in the hospital

2010-10-22T23:44:00.000+08:00

In the pursuit of comfort, people have decidedly dressed-down in terms of clothing. I don't mind if you wear slippers at home or at the beach (which are the only places flip-flops actually belong). Be careful when you're at the mall and you've got flip-flops on, I've heard these things can get caught in escalators and cause injury.

But if you're a doctor, and you do your rounds wearing these, could you imagine what kind of message you are conveying to the patient?

(Photo from jkarmaconnection.blogspot.com)

Gulf Air OFW suicide as a symptom of....

2010-10-20T22:57:00.001+08:00

It has been the second time this year that the Gulf Air has been mentioned in local news. The first involved the discovery of a newborn in the trash bin of the airplane. The second incident involves the apparent suicide of an overseas Filipino worker in the lavatory of the airplane. The Philippine Daily Inquirer posts the article here.

We must ask ourselves, what is going on?

The overseas Filipino worker or the OFW has been hailed time and again as the "Bagong Bayani" (or the new heroes) of the Philippines. In 2009, the Philippines earned around $19 Billion in remittances, helping keep the country's economy afloat in these times of financial instability. However, the Central Bank has reported that the income generated by our OFWs have reached the peak and will soon plateau, and we must resort to other sources of revenue for our country to survive financially.

So while these OFWs work so hard until their backs break from the stress and pressure, the people at home spend the earned money as if it were allowance from mommy and daddy. Most people do not divert the remitted money to invest in instruments that generate income. Instead the money goes to the latest iPhone or electronic gadget their daughters or sons fancy. Guess what happens when the daughter or son gets sick with Dengue and requires admission....Do they have money for hospital treatment? As if the iPhone had apps that could increase your platelet count with one click.

But let us take a step back and look at the big picture. Why do the OFWs have to go and earn money abroad, face countless nights filled with homesickness and loneliness?

The answer is that there aren't good paying jobs here in the Philippines. It takes years to become a regular employee with benefits from a contractual or even a job order status. The current administration itself is also contributory to the helplessness & irresponsibility our fellow Filipinos are stricken with. With the conditional cash transfer (CCT) project in the works, it is the same "allowance" our fellow Filipinos are getting from mommy and daddy, but this time it is money from the government. Problem is, the money for this conditional cash transfer is not the money the government earns from taxes. It is borrowed money, and it is easy to spend money that is NOT yours.

Despite the notorious reputation of CCTs as a failure, President Noy-Noy is still steadfast in his decision to give P1,400 monthly to "selected" hand-to-mouth existence families in the country. We should be able to differentiate benevolence from empowerment. It doesn't immediately follow that if your boss is good, kind and gives you money, the subject will act the same way as the boss has.

Now, by increasing the budget for dole-outs and decreasing the budget for education, health and OFWs, one can only wonder which direction this country will be heading. Even if we cannot predict the future, we can anticipate and plan for a better one instead. Why do we have to wait for money from abroad or from the loans the government keeps on getting from countries of the first world?

If President Noy-noy doesn't want to spend on health, or education, or our OFWs, or protection of the country's environment, then we must urge our honorable Congressmen (boxing or non-boxing), our honorable Senators (in hiding or not), Governors (pro-Jueteng or not) to do it instead. After all, the pork barrel will be in their hands soon. Did we vote for these officials so that they can go traipsing with their SUVs, play golf whenever they want while the seats of the House of Representatives are vacant day in and day out?

Or would you rather be interested in who President Noy-noy's new date is? You decide.

Global Hunger Index and the Philippines

2010-10-19T23:33:00.000+08:00

The recent article from the Philippine Daily Inquirer by Esplanada attempts to provide cause for celebration by citing that the Philippines has reduced its Global Hunger Index (GHI) score from 19 to 13 points. The GHI is the score derived from the assessment of the International Food Policy Research Institute which is based in Washington, D.C. USA.

However, the big question is, is the change in the score significant?

Unfortunately, it is not. The GHI score of 13 for 2010 is still considered under the "Serious Problem" category for hunger (which was the same rating given to the Philippines in 1990).

The solution? (Obtained from the International Food Policy Research Institute)

To reduce child undernutrition, governments should invest in effective nutrition interventions targeted to mothers and children during the window of opportunity. These interventions should focus on improving maternal nutrition during pregnancy and lactation, promoting sound breastfeeding and complementary feeding practices, providing essential micronutrients, and adopting salt iodization, while also ensuring appropriate immunization. Achieving high coverage of these interventions could have a rapid impact on improving early childhood nutrition. Governments should also adopt policies that deal more broadly with the underlying causes of undernutrition such as food insecurity, lack of access to health services, and poor caring and feeding practices, which are exacerbated by poverty and gender inequity.

Now, are we following the recommendations by this body of experts?

Simply refer to the results of the DOST-Food and Nutrition Research Institute 7th Nutrition Survey to answer this question, by clicking here.

The countries who obtained better scores (GHI of <5) include Malaysia, Cuba, Mexico, Serbia, Chile, Brazil and Bosnia among others. Perhaps our country's leaders could look into how these countries solved their hunger problem.

Where do we start?

One must begin to ask questions on the "school feeding programs" being implemented by the City Councilors and Mayors, such as:
1. How many students exactly benefit from these feeding programs?
2. Are these programs sustainable?
3. Who measures the outcomes of these programs? Do they present it to the media? Do they document it online where everybody can peruse the outcomes?
4. Are the feeding programs effective? What measures are being used to determine the effectiveness of these programs? Is it weight gain? Increase in height? Better school performance?

There is a lot of work to be done, and we must make sure what is being done actually solves the problem of hunger in the Philippines.

Hope for heavy burden PTB Countries!

2010-10-17T11:06:00.000+08:00

The company Seattle BioMed is developing a TB booster vaccine as an adjunct to the commonly known bacillus Calmette-Guerin (BCG) vaccine.

BCG is given to young children here in the Philippines as to prevent acquiring pulmonary tuberculosis. However, the report from Physorg, the effectiveness only lasts for 10 years. The protection isn't long lasting as we would like it to be.

As a clinician who sees PTB patients almost every week (most of these patients troop to government centers), this development is very significant in the battle against this disease which not only claims millions of lives annually but also prevents people from working or getting jobs.

Chairmanship

2010-10-15T23:02:00.000+08:00

I've been appointed to chair the Department of Medicine at the St. John the Baptist Medical Center, a secondary hospital located south of Manila.

The department is brand new, there are around 10-15 active physicians handling internal medicine cases and we will be having our first meeting next week.

Now I'm back to making powerpoints and reviewing admission logbooks and making the monthly census. Oh yes, I remember the residency days. No wonder they call it training.

This time, its the real thing.

The Thing Speaks for Itself

2010-10-11T21:58:00.000+08:00

Back to smoking. People need proof.

A friend commented on my Facebook page with regards to the Upin and Ipin Show. She didn't seem to have watched any episode with smoking in it. A commenter on this blog also shared the same sentiment. I haven't learned how to make links in this blog a few months back, but now I know. Here is the link Forward the slider to 2:08

For those with slow download times, I have taken the liberty to screen capture the topic in question.

There we go. Smoking in the Upin and Ipin Show by the character Tong. Perhaps the movie wasn't shown in Malaysia. The scenes are from the 3D animation movie, Durian Ghost.

Since Upin and Ipin is shown on Disney Channel, a little YouTube search revealed a nice surprise, click here.

Disney Channel is pretty consistent when it comes to influencing the minds of our young.

Thank you Youtube.com

Appeal to Disney Channel to Improve Upin & Ipin Show

2010-10-10T11:11:00.000+08:00

http://www.aap.org/advocacy/releases/sept2710studies.htm

In a previous post, we have revealed that smoking is a common sight in a children's television show called Upin & Ipin. In the Philippines, the hundreds of children can watch the show on Cable TV, the Disney Channel.

Recently, the American Academy of Pediatrics have released the following:

AAP CALLS FOR NEW LIMITS ON TOBACCO AND ALCOHOL ADVERTISING
Despite ongoing efforts by parents, teachers and the federal government to urge adolescents to "just say no" to tobacco, alcohol and drugs, more than $25 billion worth of advertising for these products is working to get them to "say yes." Because of these mixed messages, a new American Academy of Pediatrics (AAP) policy statement, “Children, Adolescents, Substance Abuse and the Media,” published in the October 2010 print issue of Pediatrics (published online Sept. 27), calls for a ban on tobacco advertising in all media, limitations on alcohol advertising, and no erectile dysfunction drug advertisements until 10 p.m. In addition, the AAP recommends that parents exercise extreme caution in letting their younger children view PG-13 and R-rated movies and television shows, which often feature substance abuse, and that all substance abuse prevention programs, including those in the classroom, include media education. The policy statement recommends that pediatricians actively encourage parents to limit unsupervised media use and television channels with excessive depictions of substance abuse, and that the White House Office on Drug Control Policy begin producing and airing anti-smoking and anti-drinking public service announcements.

---End of AAP Message--

I would like appeal to all parents to be vigilant and protect their children from unnecessary and potentially harmful exposure to media.

I would like to appeal to Disney Channel to remove smoking in the popular children's show Upin and Ipin.

Let us support the advocacy of our health leaders, and let us regard our health as number 1 priority for ourselves and our children.

The Price of Prevention

2010-10-08T22:17:00.000+08:00

If you had Php6,780 in your wallet right now, what would you do with it?

I recently admitted Patient X, a 42 year old male, a security guard by profession, previously diagnosed with Hypertension and pre-diabetic blood sugar levels who came to the Emergency Room because of left sided body weakness. His speech was slurred and the left side of his face was also weak, creating facial asymmetry.

Patient X's wife explained that he did not take his blood pressure medications regularly even if he was aware his usual blood pressure was around 160/110. He happened to have a mild stroke last May, but even that wasn't enough to make him understand how risky his life had become. His livelihood puts his life on the line every time he is on duty, while his elevated blood pressure only increased his chances of a stroke or heart attack 24/7, on duty or not. Talk about double trouble.

Patient X's cranial CT scan revealed a small hemorrhage on the right side of his brain, the part which controls muscle strength on the left side of his body. His brain had started to swell because of the accumulated blood and thus he had to receive medications to control the swelling.

Patient X's blood pressure also proved to be a problem. My initial medications were insufficient to bring the blood pressure down to less than 150/100. I had decided to use 3 anti-hypertensive medications, however upon the recommendation of a colleague, 4 different drugs would be better.

After 2 days, his blood pressure finally decreased to 140/90. With 4 drugs.

Looking ahead, if Patient X would be able to take a look at his drug store receipt, this is what he would find (using the most reasonably priced medications available for branded & generic drugs):
1. Angiotensin Receptor Blocker + Calcium Channel Blocker, 1 tablet once a day = Php 26.00
2. Beta Blocker + Thiazide Diuretic, 1 tablet once a day = Php39.00
3. Central Agonist, 1 tablet every 6 hours =Php132.00
4. Statin, 1 tablet once a day = P32.00

Total of Php229.00 every day just to keep his blood pressure down and reduce the risk of getting another stroke.

In one month, it would cost Patient X about PhP6,780.00.
In one year, it would cost him P82,440.00.
After 5 years of drug therapy, he would have spent P412,200.00.

Not included in the costing: a. Post Stroke Physical Therapy, b. Evaluation by an Ophthalmologist, c. Evaluation by a Nephrologist.

With the meager income of a security guard, being able to take his current set of medications every single day would take a ton of miracles. He does not have PhilHealth Insurance, or any kind of insurance to offset his medical expenses. With his disability, chances are he may not be able to work as a security guard ever again.

What will his future look like? Not promising, for sure.

If he had the chance to go back to the day he found out he was hypertensive, would he change his ways? What would he give just to get such a chance, a second chance to live without paralysis?

This story is just like the thousands of Filipinos who suffer from strokes every year in the Philippines. If each and every one of us would only learn from Patient X's story, then probably we could steer away from such a difficult future. We are not invincible.

Patient X is aware of it now. When will you?

Criminals, Health and Physicians

2010-10-07T20:56:00.000+08:00

Here in the Philippines it is common practice of individuals suspected of committing a crime to rush to the nearest hospital for safety/asylum using complaints of chest pains or high blood pressure. Or, if the suspect is already in jail, he or she seeks the healing touch of the physician to appease his or her troubled spirit.

Photo from news.xinhuanet.com

Of course, the physicians do their duty to keep the "patient" out of harms way the quickest way possible.

I believe that this practice must change. People should not use hospitals or doctors as a shield from the law.

Theodore Roosevelt had this to say about our subject:

"As for ill health, it must be remembered that few people are as healthy in prison as they would be outside; and there should be no discrimination among criminals on this score, either all criminals who grow unhealthy be let out, or none."

If you do the crime, do the time.

For parents and parents-to-be...a reminder

2010-10-03T11:51:00.001+08:00

It should be your care therefore, and mine to elevate the minds of our children, & exalt their courage, to accelerate and animate their industry & activity, to excite in them an habitual contempt of meanness, abhorrence of injustice & inhumanity, & an ambition to excel in any capacity, faculty & virtue.

If we suffer their minds to grovel and creep in infancy, they will grovel and creep all their lives. But their bodies must be hardened as well as their souls exalted. Without strength & activity & vigor of body, the brightest mental excellencies will be eclipsed and obscured.

John Adams

*Photo from bicolmail.com article on Iron Kids.

Decision making by Filipino patients

2010-09-29T22:29:00.000+08:00

The Dengue season appears to be slowing down after inflicting its feverish hemodynamic related damage to thousands of Filipinos here in the country.

Many decisions are made at the doctor's clinic or at the emergency room or at the ward/room. It appears that most patients when faced with simple choices such as which pain reliever for the back pain or medicine for that bothersome productive cough, they can make the choice themselves.

The hard questions however, requires the input of the family members. Not only within the nuclear family per se, but also the distant relatives (the cousins, aunts, uncles, those living abroad).

What are the hard questions?
1. In order to make a good diagnosis we need to do a excision biopsy. Would you give your consent for the procedure?
2. In order to treat your malignancy, we need to give chemotherapy. Would you like to receive treatment?
3. Your father just had a massive heart attack and your HMO can only provide a limited coverage. Would you agree to shoulder for the rest of the expenses?
4. Your bronchial asthma is still uncontrolled. If respiratory failure occurs, would you like to receive mechanical ventilation?

The most common answer to these questions are: "Hinihintay ko po yung (kamaganak) ko/I'm waiting for (name of relative) before I can make a decision."

Now that is entirely within the rights of the patient, and most doctors provide enough information for the patient to allow him or her to make an informed decision. The problem lies when the unwanted complication occurs and there is still no decision made among the family. Interventions such as intubation and emergency hemodialysis are very traumatic to the patient and relatives and these actions are often perceived to be more of a danger to life than an aid for survival. However, if there are delays in the procurement of consent, the doctor cannot perform his or her duty to save the patient. There have been many times when consent is given a moment too late.

In the first world countries, the practice of making advance directives is fairly accepted in society. Based on studies based from hospice centers and hospitals, advance directives actually improve quality of life of patients who are most likely to die from complications. Unwanted resuscitations and procedures are done away with and the patient dies with dignity and peace.

Perhaps Filipino patients are too afraid of talking about death, about disease or treatment. We probably build up walls to hide from the truth that we are vulnerable, that we can get sick and become dependent on others and that our health is not always our priority.

As patients, please communicate with your doctor(s). Ask questions if things are not clear or the explanation is inadequate. As a family oriented society, doctors can provide better service if the concerned relatives (i.e., decision makers) are present during the doctor's visit. Everyone hears the information at the same time and the important questions are answered in one sitting. It is very difficult for us if on every visit a different relative gives the same question already asked the previous day by another relative.

Life is filled with difficult choices. Make sure the options you choose matter. It is your life after all.

Philippine SWAT = Not physically fit for work

2010-09-29T08:53:00.000+08:00

The Philippine Daily Inquirer reports:

http://www.philstar.com/Article.aspx?articleId=616274&publicationSubCategoryId=63

As more and more deficiencies among Philippine government offices are being divulged (lack of rice, lack of funds, lack of classrooms, lack of teachers, etc) the deficiency now extends to the skills and physical fitness of our police forces, most notably the Special Weapons and Tactics branch of the Philippine National Police.

Thus applies the theory of use and disuse. The more you use something, the more likely your skill will be perfected by practice and the outcome will be a successful one. If you get lazy and leave things to chance, then your likelihood of failure is nearly 100%.

We are ill prepared time and again. When the next typhoon like Ondoy comes in and ravages our country, we will suffer the consequences. What more the next gun slinging hostage taker?

It is easy to pin the blame on the leaders of the PNP, the President of the Philippines etc etc. But it is also our fault as countrymen and women that the system is dysfunctional and corrupt simply because we ALLOWED it to happen. As a society we should be watchful and aware of the goings-on in our country.

If the PRC and other regulatory agencies keep professionals on their toes, so should we, as a people be watching the government closely as they do their duties. Check and balance.

Sorry Doctor, your HMO patient is not covered for your choice of treatment

2010-09-28T10:04:00.000+08:00

Last week I had a patient come in because of severe neck stiffness. The man did some hard labor the day before, placing screws into aluminum tubing for a water system. After he got home, his neck hurt so much he could not even look to either side.

He came to my clinic the next morning, clutching his HMO patient form in his hand. In pain.

"Okay", I thought to myself, "the HMO will take care of my treatment plan." After giving him instructions to take some pain relievers, muscle relaxants, application of warm compresses, I asked him to obtain a stiff neck brace to afford some relief. I sent him to the HMO coordinator.

5 minutes passed.

10 minutes.

30 minutes.

If it takes this long to get permission for a neck brace, chances are the request is denied.

After 40 minutes of waiting the patient returns forlorn because he was unable to get the neck brace we needed for his treatment. The neck brace costs around P800 per piece. This is a person who earns around P300 a day. Since he couldnt come to work, how will he earn the P800 to pay for his neck brace?

So much for Health Maintenance.

Genetically modified eggplant, lawmakers and consumers

2010-09-26T22:16:00.000+08:00

The recent hullabaloo about stopping the tests on genetically modified eggplant in the Philippines really shows how easily people are swayed by popular opinion (http://newsinfo.inquirer.net/breakingnews/nation/view/20100908-291142/Dont-touch-my-talong-lawmaker-cries).

The Philippines continues to be an agricultural-quasi industrial country that is not able to feed itself, where 2.5M Filipinos claim to be hungry most of the time according to the social weather station surveys, where 19.5% of the population is iron deficient and the statistics for Type 2 Diabetes are rising every year. We even have to import rice from Vietnam so that we can enjoy our hot cup of steaming white rice. We import SPAM and Doritos from the United States, without even thinking twice about the sodium content or the additives included in these foods.

In addition to hunger, the food supply of the country is ravaged by pests, particularly the fruit and borer insects and recently by the infestation of army worms in Batangas.

Farmers claim that about 50% of their crops are lost to these pests and the government approved control of these pests is achieved by the application of more pesticides (http://www.mb.com.ph/articles/272127/experts-tell-how-control-armyworms). More pesticides mean more expenses in the form of purchase of sprayers, safety gear, health effects of pesticides to humans and effect of pesticides to the ecosystem.

The benefit of using GMO crops is that we end up using less or no pesticides at all. It is like conferring additional defenses to the crop against the pests that reduce our farm output. However, there is an alarmist attitude among our politicians and civic leaders, despite the provision of a window of safety as deemed by our scientists in the genetics community (http://www.eating-greens.com/fruit-and-vegetable-diet/18686/on-bt-eggplant-%E2%80%98use-science-not-fiction%E2%80%99/).

So the Philippines is facing a dilemma. We need to feed ourselves.

The question now is, which is the eggplant you will choose to eat, the eggplant bathed in pesticide or the eggplant with a bacteria that will stop pests but not affect humans?

The Idea of becoming a doctor (and being a nutritionist at the same time)

2010-09-16T07:17:00.000+08:00

For the second time in the history of the Human Ecology Camp hosted by the College of Human Ecology at UP Los Banos, Philippines I have been asked to give a small talk about BS Nutrition and the possibilities & job opportunities of a Nutritionist-Dietitian.

As a woman dominated course, there were only 4 of us gentlemen when I took my BS Nutrition as a pre-med course. I was often told that BS Nutrition is only for women, or it was a course about cooking, or it had no relation to medicine.

I asked the group this year if the gentlemen also experienced the same kind of prejudice against their chosen course. The answer was a united "yes".

A sad fact, but truly, BS Nutrition is a highly underrated course here in the Philippines. There is so much potential with this course even if you don't plan to go into medicine. You can be a researcher, a community health leader/advocate, a hospital health care team member, or a counselor.

Despite all the potential, growth in numbers among registered nutritionist dietitians has been disappointingly low. From 2007 to 2010, less than 500 pass the Professional Regulations Commission Board Exam per every year. Compare the measly number to those who pass the Nursing Board Exams or Criminology Examinations. To think there are millions of Filipinos who need their expertise and advice, from the underweight children to the iron willed triathlete.

There is a great need to change the perception about BS Nutrition and promote it more than ever. With the results of the Food and Nutrition Research Institute 7th Nutrition Survey showing the persistence of iron deficiency anemia, and malnutrition, we need more Registered Nutritionist Dietitians in the Philippines. Now.

Perhaps the most interesting part of my talk was the pathway to becoming a physician after completing the BS Nutrition degree. I would start with the number of years it would take before one actually starts his or her own practice. The number always elicits shock and aahhs without fail. Then I follow it up with the current tuition fees per year of medical school (non-government) and more aahhs are heard from the audience.

It would seem that most college students in the life sciences have a desire to go into medicine. But the path is long, expensive and demanding. It is not for everyone. The idea of becoming a doctor is nice, being it a noble profession and all. But getting there is going to take all your determination, physical strength and the deep wallets of your parents. The first two depends on how hard you want to be a doctor and your overall health, but for the third some measures can be done to reduce the cost.

Study hard, every single day in college and aspire to get into the Dean's List. Get those 1.0s in those class cards from 1st year to 4th year, do well in the National Medical Admissions Test and there is the possibility that you can be waitlisted into the Doctor of Medicine Programs at the Philippine General Hospital or Pamantasan ng Lungsod ng Maynila.

Do you want to go into medicine?

I've sold my Cervelo.

2010-09-09T22:23:00.000+08:00

Goodbyes are always difficult.

This month significant changes have occurred and a change in workplace and residence will be in order. That means leaving behind some of the most cherished and treasured items in my possession.

One of them is my 2008 Cervelo Soloist team, the one I'm using in the picture above. I've sold it to my triathlete friend, Eric. The sale brought back a memory when I was in the United States during my summer vacation while I was still in Medical School. I saw a grey old Volvo parked on the side of a street, with a for sale sign taped to the window. The sign said, "I'd love to keep this, but it has to go."

What does a triathlete do when he doesn't have a bike?

Thank you for punctuality

2010-09-04T11:55:00.000+08:00

I went to the Philippine College of Physicians Office in Ortigas, Pasig City last Wednesday. Coming from Los Banos Laguna, it was certainly a long drive, and that meant leaving at 6:00AM to avoid the rush hour.

Business hours usually mean 8AM to 5PM. I got to the PCP office at 7:40AM. They let me in and finished my business in less than 10 minutes. I thanked Marita for opening early and making save precious time as I had to go across Pasig to get to my alma mater in Quezon City.

Yesterday, I had my Ford Focus undergo its 20,000km preventive maintenance examination. My appointment was at 7:05AM. The service adviser, Jay, told me the car would be ready after lunch. However, it was not even 11AM when he came in with good news. My car was ready for pickup.

Thank you Marita and Jay. It is great to see people who value your time.

Rainy days = less chances for work outs

2010-08-29T21:43:00.000+08:00

September is coming up and the rains continue to pour. The typhoons are passing through the Philippines one after the other, bringing rainshowers in the morning, gone by mid-day only to return just after sundown.

Yep, so much for riding the bike or grabbing my shoes for a quick workout before or after work.

The only thing getting the miles into the books is my car. I'm nearing my 20,000km and its due for the preventive maintenance check up this coming Friday.

Of course, I'm optimistic. I think I can squeeze in a ride or two this week.

Here goes.

Dengue Hemorrhagic Fever Incidence Almost Doubles in first half of 2010

2010-08-21T06:42:00.000+08:00

http://www.doh.gov.ph/node/2753.html

The Department of Health reports in its official website that the cases of Dengue Hemorrhagic Fever (DHF) have nearly doubled as compared to the same period last year.

Usually affecting young children and adults, cases of 95 year old citizens with DHF have been documented. Most of the cases are male (52%).

The report however also has a piece of good news. The Case Fatality Rate decreased from from 1.1% of last year to 0.8% despite the increased number of cases for January to July 2010.

As always, there are questions why this is happening to us.

1. Is the increase in incidence of DHF really due to the El Nino phenomenon? Apparently the Health Secretary Dr. Enrique Ona believes so. I can give another possible reason (and an easy one to prove): continued littering in the streets. Just take a drive through any major road in the country and observe the people riding buses, jeepneys and tricycles. Then count the number of times litter is thrown out of the windows or the sides of these vehicles.

Where the does the litter go? Straight to the drainage networks of the municipality or city to cause obstruction and water retention. Once this happens, the mosquitoes responsible for transmission of DHF are now free to proliferate and spread disease.

2. Are our information dissemination facilities effective enough to increase awareness (AND UNDERSTANDING) of DHF? The TV networks have been doing their usual sensationalized reporting about DHF. TV reaching millions of people all at the same time appear not to reduce the Filipino's foolhardiness/sense of invincibility.

3. Do we have enough supplies of blood products to support such an alarming incidence rate? Treatment of severe cases of DHF require blood transfusions, specifically platelet concentrate. Once more the Philippine National Red Cross will have a massive headache in collecting blood donors, and regulating the release of platelet concentrate bags to the needy Filipino public.

Preventive medicine. Public Health. These two concepts have been ignored time and again. The domino effect repeats itself every year, killing loved ones, placing strain on health services and government resources...simply because many a thoughtless passenger throws his empty soda plastic bag into the gutter of the National Highway.

Old habits die hard

2010-08-19T20:23:00.000+08:00

My work schedule has been quite busy lately (Yey!). Everytime I leave for work in the morning I see my bike in the corner of the hallway, it was as if it was asking me when the next ride would be.

Then, whenever I get home, its either too dark for a bike ride or I'm tired.

The solution?

Waking up at the crack of dawn and heading out for short but intense rides around the campus. Air is cold and clean, no bothersome cars or motorcyles, and the occasional chasing/barking dog at your heels.

Feels great!

Tolerance or avoidance: knowing the risks & choosing

2010-08-14T08:48:00.000+08:00

Medical news have been interesting lately.

Research from UK now recommend giving stating (drugs used to lower cholesterol) for free when a customer goes to his or her favorite fast food chain for a quick fatty and salty meal. So even if the customer knows such burger and fries are harmful to one's health, he or she will still have said meal because it tastes really good. So the experts say, take the drug so that you can enjoy your meal AND still be protected from the harmful cardiovascular effects of that burger and fries.

One prominent blogger recommends that doctors ask their patients during the history taking if the patient texts while driving. 28% of US road accidents involve this distracting activity. I raised this issue in Facebook to get some thoughts from my friends, and a healthy debate started between two of them. Of course, texting and driving IS NOT advisable.

Preventive medicine will never be popular in our culture. We are so used to instant gratification, never mind the risks to oneself or to others. The question is, are we really wired to destroy ourselves?

Research from Texas, USA revealed that people who have a strong connection to their country or a group of people are expected to be very protective, so much that a person will be willing to die for his or her country/cause. That explains the suicide bombings in Afghanistan/USA/Great Britain/Iraq/Iran/Russia....

In my daily clinics, many choices are being made when it comes to treatment programs. Doctors offer solutions, preventive and therapeutic and when the patient goes out my clinic door, they decide their course of action. A doctor can only explain, warn and encourage so much.

So what is it going to be? Throw caution to the wind or understand the facts and get the most our of your life?

Peculiar way of reporting in Cycling/Triathlon

2010-08-10T00:51:00.000+08:00

The 7-Eleven Charity ride was featured in the Sunday edition of the Philippine Star. Come Monday morning, the paper was silent about the success or failure of the event.

The same thing happens in triathlon events, especially that of the Triathlon Association of the Philippines. You will see in the paper a feature of a race and then don't hear much about it afterwards. Save for the Ironman Camsur last year and the recently completed Tri-King, that is the only time you will read a follow-thru article.

Why?

Losing

2010-08-08T23:44:00.000+08:00

At the end of the day, what really matters the most?

A brave woman physician by the name Karen Woo is murdered along with other medical personnel by Afghan rebels on the premise she was teaching Christianity. Despite being broke and asking for money for health supplies and equipment on her blog Bridge Afghanistan, walking over rocky terrain, Dr. Woo savored every minute doing what she loved best, taking care of the less fortunate.

A friend loses her first born child to viral myocarditis despite aggressive attempts by pediatric cardiologists at an esteemed health facility in Quezon City. This young boy was the brightest moon in the universe of everyone he touched. He excelled in math, karate, and music.

Its what you have given to the world, not to yourself, that matters.

So, how do you want to be remembered after you die?

Results of a motorcycle accident: Fever day in, day out

2010-08-07T18:49:00.000+08:00

A patient of mine is still feverish despite 12 days of antibiotics (changed antibiotics twice). She sustained degloving injuries of the thigh and buttock after being involved in a vehicular accident. Debridement is being done religiously and pockets of infection have been removed however fever persists....She cannot eat due to segmental ileus, complains of severe pain almost daily (despite adequate analgesia), and has difficulty sleeping due to post traumatic anxiety.

This is why people who ride motorcycles should be extra-careful at all times. No more drunk driving, counterflowing, overtaking buses at high speed, improper wearing of helmets (or not wearing one at all), texting while riding, etc.

Please put a stop to this brand of insanity on the streets.

Rain, squeaks, and a bike ride

2010-08-06T10:39:00.000+08:00

I set out to ride around the campus this Friday morning, with overcast skies and a high possibility of rain. Since the downpours usually occur in the afternoon due to an approaching Low Pressure area from the east of the country, I gambled to get my bike ride this morning.

I haven't gone a kilometer into my ride when I made the an amateur mistake. I had forgotten to re-lube my chain. Thus the squeaks. Oh well. Since it was just going to be a moderate perceived exertion ride I pressed on. As I entered the Biotech loop, the sun came out suddenly and I regret the choice of eyewear I had on, a pair of clear lens Rudy projects.

The bad thing about going around an area where practice driving is done every day is that there are bits of broken glass everywhere. Hi pressure tires and broken glass are not very good friends and often the tires are in the losing end, get punctured and the rider is placed in a world of frustration.

As I entered the Pili drive the clouds once again covered the harsh midmorning sunlight. I settled into a good pace and travelled towards the UP Gate. As usual the jeepneys were doing their best average speed of 20kph in the campus.

I went straight towards the Economics buildings and turned left into BioSci. In my college days, those hallways were usually packed with students. Not so much these days. To put a little effort into my ride I climbed up to the Library and went around the rotunda and headed towards Forestry.

It was in the Forestry campus when the rain started to go down, drizzles at first and then a steady light shower. A welcome respite for my leg muscles doing all the hard work going up the climbs.

One of the problems with rain is that it does tricks with your brakes and wheel rims. You hear sand grating on the rims, the brakes fade quite a bit and a sense of uncertainty looms whenever you make your turns at the smooth asphalt roads in campus.

Better safe than sorry, I used my brakes gingerly and managed to get back down without any incident.

From Forestry I headed towards the Mens and Womens Dorms, then to Baker Hall and Agronomy. The clouds were getting darker and thus I went home, happy to have taken a ride on my bike and getting some exercise in for the week.

Doctors and Exercise

2010-08-04T23:42:00.000+08:00

I started this blog because I wanted to be an example, that it is possible for doctors to walk the walk and actually do what they advise their patients about exercise and physical activity.

These past few months, it has been getting quite difficult to meet my quota of 30 minutes of exercise daily. Of course, the most common excuse is work.

One colleague of mine, a gastroenterologist, also happens to share my to-and-fro journeys from hospital to hospital in doing what every other doctor has been doing here in the Philippines: Rounds.

I no longer get to do my 5k runs in the morning, because I'm too tired. I couldn't do my 2hour bike rides because its already dark when I get home. I get referrals at 2AM, and have difficulty getting back to sleep because you're all worked up trying to analyze the patient's condition and planning a course of action.

Of course it's difficult. However, getting that exercise in your schedule is not impossible.

I continue to take the stairs. I park my car far from the entrance of the hotel to get some walking in these legs. I wash my car myself. I try to monitor the amount of food I eat.

But whenever I get that rare opportunity to suit up and ride my Cervelo, the excitement is always there. When I do get to run my 5k, it feels so good because I know I can still do what I have done years before and I can easily get back that fitness triathlon has given me.

Long live Tri!

Philippine Board Examination Results

2010-07-30T20:07:00.000+08:00

The Professional Regulation Commission or the PRC has released the results of the following for the year 2010 (data available from the PRC Website):

1. 972 new board certified agriculturists (out of the 2,689 examinees). Passing rate 36%.
2. 434 new board certified Physical Therapists (out of 938 examinees). Passing rate 46%.
3. 476 new board certified Nutritionist Dietitians (out of 676 examinees). Passing rate 70%.
4. 1,787 new board certified Marine Deck Officers (out of 3,445 examinees). Passing rate 51%.
5. 770 new board certified Social Workers (out of 1,321 examinees). Passing rate 58%.
6. 869 new board certified Pharmacists (out of 1,261 examinees). Passing rate 68%.
7. 993 new board certified Architects (out of 2,004 examinees). Passing rate 49%.
8. 509 new board certified X-ray technologists (out of 982 examinees). Passing rate 51%.
9. 1,886 new board certified public accountants (out of 4,772 examinees). Passing rate 39%.
10. 151 new board certified Chemical Engineers (out of 329 examinees). Passing rate 45%.
11. 631 new board certified Physicians (out of 1,344 examinees). Passing rate 46%.

Of course, the Philippine Government is known for sending its citizens all around the world so that it can collect the billions of pesos in remittances to pay off its debt (and also hopefully some of the money can go into healthcare, education and national security).

But the big question is, are we producing enough qualified professionals? The results speak for themselves.

Take note also of the more "popular" career choices among the Filipinos. With increasing malnutrition in the country, we only produce less than a thousand Nutritionists. The same goes for the Physical therapists. With more and more cases of stroke survivors in the Philippines, who will help our patients recover from this crippling complication of hypertension and cardiovascular disease?

So ask yourself, is the government really looking out for the interests of its constituents?

So while the government officials are pondering on which committees they will hold a chairmanship position, or how to deal with the disgraceful congressman-elect incarcerated in Hong Kong, or which Party List Representative really represents the Security Guards and Drivers, we continue to supply the world's demand of our talented and hard working fellow Filipinos with LESS THAN IDEAL NUMBERS.

Also, since we are talking about the PRC, have you been there lately? I went there with my wife to have her license renewed a week ago. Certainly, I did not feel like I was a professional for this country. The place still looks like a public market. You couldn't even park your car without going around the block twice.

The PRC officials should really follow the footsteps of the people from the Department of Foreign Affairs. The new DFA building near Mall of Asia and the efficiency of the personnel impressed me when I had my passport renewed. Take note PRC officials, please.

Pussyfooting and sex education

2010-07-29T22:02:00.000+08:00

http://newsinfo.inquirer.net/breakingnews/nation/view/20100729-283818/Sex-ed-critics-withdraw-class-suit

Dear Secretary Armin Luistro, the complainants have withdrawn their class suit. Please do initiate the Adolescent Reproductive Health program in ALL SCHOOLS.

The next time I get to diagnose a 4th year high school student with chronic Hepatitis B, I will ask him or her to come see you personally, so you can explain to the student why he or she cannot get a career in Hotel & Restaurant Management or Culinary Arts or Nursing or Physical Therapy or Care Giver.

Sincerely yours,
Dr. George

Iron Fortified Rice-- Pinoys don't like it

2010-07-29T21:50:00.000+08:00

The Manila Bulletin reports that the fortification of rice with iron (as mandated by Republic Act 8976) is now put on hold, because the distributors of IFR are complaining that Filipinos want their polished rice. The report goes on to describe that Filipino consumers remove the iron from the rice.

Filipinos often complain that their government simply makes laws but don't enforce them.

This is one of the exceptions. The government is trying to reduce iron deficiency among its constituents by this method of food fortification. Simply because Filipinos are so used to eating white rice.

Vitamins and minerals are better absorbed if they come with the food we eat. For example, Vitamin C works better with the carotenoids in fruits and vegetables. This is the reason why we fortify our food.

But for Filipinos, they want their white rice. The iron that they need would simply come from the multivitamins prescriptions they request from their doctors. This behavior is simply not cost effective for the government and the Filipinos.

Why?
1. The Philippine government has already stocks of iron (already paid for) ready for incorporation into the rice. With the halt of fortification, will we let it go to waste?
2. The white rice is nutritionally inferior to brown or unpolished rice. The incidence of malnutrition is just increasing every year. Consumption of white rice is now linked to the development of type 2 diabetes. More illnesses, more drugs to buy.
3. The purchase of vitamins and mineral supplements adds to the cost of living, making Unilab and Kirkland very happy and rich.

Filipinos just want to spend more. Only to complain about not having money later when they need to go to the hospital for malnutrition related diseases.

Sweltering heat and more Philippine tragedies

2010-07-28T18:33:00.000+08:00

Even if the internet thermometer says its 88 degrees Farenheit, I did my 5k run as if I was in an oven. There was very little wind this afternoon and the radiant heat from the asphalt seemed to squeeze every drop of sweat out of me.

Run time is alone time, and I had time to ponder over the tragedies that continue to plague the Philippines. A newly elected congressman with a very prominent surname was jailed in Hong Kong recently for drug trafficking. The Philippines was placed in the blacklist of the US Physical Therapy Board examination because the review centers were leaking questions to Pinoy exam takers. A Senator wanted for murder and currently in hiding has the gall to request not one but TWO committee chairmanships from the senate president. Then you have the shocking revelations by the president about the MWSS board members giving themselves all the bonuses they can think of, the rotting rice in the NFA storage facilities, and the numerous government agencies going into debt while Pampanga gets all the aid it can get its hands on. All this is going on while every year thousands of orphaned children are born into a society that doesnt even have the ability to control its population growth.

It sure looks to me that our society is all about going after the money, to be richer than everybody else never mind the ill effects it may have to the country. This pursuit of riches is so rampant and impairs all reason from one's head it gets one imprisoned in another country.

Now it blatantly appears that it is up to the foreigners to clean up after our stupidity. We cant even catch our own crooks/drug pushers/gluttons. Thats how bad the state of the Philippines is. We arent even ashamed of this fact.

All this just made me push harder as I ran home, forgetting the heat for even just a moment.

Keeping at it...

2010-07-21T21:40:00.000+08:00

It was around 2:30PM this rainy-cloudy afternoon, coming back to Los Banos, Laguna after doing some business in Sta. Cruz, Laguna when I saw a triathlete zipping by on the opposite side of the National Highway on his time trial bike (it looked like an Argon), with deep dish rims and unbelievable white rimmed tires.

Ironman 70.3 Camsur is next month, August 22, 2010. Good luck boys and girls!

Police Fitness and Diet

2010-07-18T21:49:00.000+08:00

http://newsinfo.inquirer.net/breakingnews/nation/view/20100718-281852/Pagcors-P21-M-purchase-of-cheeseburgers-fried-chicken-for-cops-probed

The Philippine Daily Inquirer reports that the Philippine Gaming Corporation (PAGCOR) had spent some P21Million to feed Manila's finest, notably food from McDonalds. PAGCOR paid for their meals once in January and March, twice in April, three times in May and once again in June of this year.

A number of questions come to mind.
1. Why is PAGCOR feeding the police force?
2. Is PAGCOR responsible for feeding the police force?
3. Who chose McDonalds as the sole food source for the police force?
4. Isn't the food from McDonalds so chock-full of fat it is against the maintenance of physical fitness and health of our police force?

The image of the Philippine police has often been cast in negative light, as some officers having beer bellies and being unable to pass the physical fitness tests in camp.

It seems that life in the Philippines is full of contradictions. We want cops to be alert, to have the endurance to go after criminals during their tours of duty. But the reality is that our police officers go through the day starving, and hunger is enough to distract one from his duties. What happened to the drive of the Philippine National Police to trim down the waistlines of our police officers? All forgotten it seems.

The solution applied in this situation was less than ideal. Give them McDonalds. Whoever decided to get food from the American franchise will only make the police force spend more in the coming years.

Soon, the ranks of our police force will swell with members that are overweight, with increased waist circumference (more cloth for the uniforms), with decreased exercise capacity (can't go run after the robbers), decreased lung capacity and higher risks of cardiovascular disease (more will develop hypertension, strokes and heart attacks, increasing the burden for healthcare and medications).

Its high time we should think about the decisions of the leaders of our country and the effects of these decisions on our countrymen, not only the farmers, the malnourished children, the underpaid laborers, doctors and nurses. Now even the health of the officers who are responsible for our safety, peace and order are being jeopardized right under our own noses.

...and then there was a flat tire....

2010-07-09T20:12:00.000+08:00

I usually have Friday mornings free, and this morning I had planned to go for an hour's ride around campus. Lo and behold, I saw my rear tire completely deflated. Just great. More bad luck followed as I checked my bike box for spare inner tubes (yup, I'm still using clinchers), and there was none.

Bike ride cancelled.

Of all the things about bicycles, its flat tire changing I do not like the most. I wish I could be like those pro riders in the Tour de France, where the mechanic just runs to your aid and replaces your tire with a new one in less than 10 seconds.

I took out my rear wheel, grabbed my tire levers and evaluated the cause of the flat tire. No punctures on the tire, no broken glass stuck either. I inflated the inner tube and listened and felt for the hiss from a probable leak. Feeling and hearing none, the ultimate test for a leaking tire was to submerge the tire in a pail of water. Sure enough, there was a leak, and it was in the weakest part of the inner tube, the connection of the presta valve to the rubber tube. Small bubbles were coming out of the invisible hole.

No patch can ever repair that kind of leak. That meant a trip to the bike shop. After work, I went to the Top Gear bicycle store near the crossing of the National Highway and got my inner tubes. They were about to close shop for the day. Inner tubes can cost from P150 to P350 per piece, depending on the brand. Of course, American brands command higher prices than their Taiwanese counterparts, however I have not yet seen any benefit from buying the more expensive inner tubes.

I purchased 3 inner tubes to replenish my stocks, and to make sure I won't be cancelling a bike ride ever again.

Ride safe everyone!

Update your Vaccination Status

2010-07-06T08:15:00.000+08:00

Get your shots
The Centers of Disease Control in the United States regularly release their Recommended Adult Immunization Schedule to the general public.

Immunization is not new to Filipinos, & often the memories (if they remember at all) are not as fond as getting their first bicycle for their 5th birthday. Pinoys get their vaccinations during childhood & they leave it at that. Hence, immunization is & continues to belong in the domain of the pediatrician. You can't buy vaccines from your local pharmacy or popular drugstore even if you have a prescription.

However, these vaccinations, as the CDC points out, must be repeated during adulthood, especially those who have co-morbid illnesses such as diabetes & emphysema.

Rare is the adult patient who has a complete set of vaccinations. Rarer still are the grandfathers & grandmothers who have the latest pneumococcal immunization.

Therefore we have a few problems.

1. Adults dont get vaccinated because they dont know they need them. Or they know they need them but cannot afford to seek consultation & pay for the vaccine.

2. Adults dont get vaccinated because drugstores dont stock them.

3. Adults simply catch & ultimately suffer the diseases that could be prevented by vaccines.

Preventive Medicine
Preventive medicine is never the popular aspect of medical care. Fluoridation of drinking water, eating the proper foods, getting adequate exercise, & moderation of alcohol intake are the common examples that comes to mind when one is asked to think about PrevMed. However, the benefits are not seen instantaneously & often require significant work & dedication.

The adage "If it aint broke, why fix it?" comes to mind. The New England Journal of Medicine came up with an eye opening article about how preventive medicine will never ever be appreciated & it is always the big shot surgeons, magical pharmaceutical formulations & hi-tech hospitals who will come to the rescue to the ailing patient.

Vaccines & OFWs
The Philippines, being one of the major exporters of skilled labor around the world, needs to make sure the people it sends out to work be screened & vaccinated for Hepatitis B, Hepatitis A, Meningococcus, etc simply for the protection of the worker & the people he or she works for.

Many an applicant for overseas work has come to my clinic with a positive HbsAg result, their hopes for greener pastures dashed because of the diagnosis of Hepatitis B. They think a vaccination will cure them. One can only attempt to cushion their disappointment at such bad news.

Of course, chronic Hepatitis B can be suppressed with potent antiviral cocktails. For those who can afford, of course. The testing & re-testing for HBV DNA, the antivirals, such expenses easily reach P20,000 a month.

Compare that with a complete course of Hepatitis B vaccination which will cost you ~P1,500.

Immunization for overseas work must be done at least a month before departure. It must be realized that to become effective, vaccines injected into the body must identify the antigens of the virus/bacteria & DEVELOP antibodies to these antigens within a specified period of time. This process doesnt take overnight, and some vaccines (such as Hepatitis B) may not induce immunity despite the complete course.

Despite these facts, immunization confers protection among the majority of Filipinos. Get your vaccine status updated. Until modern medicine comes up with a cure, a diagnosis of chronic Hepatitis B stays with you forever.

2010-07-06T08:13:00.001+08:00

Get your shots
The Centers of Disease Control in the United States regularly release their Recommended Adult Immunization Schedule to the general public.

Immunization is not new to Filipinos, & often the memories (if they remember at all) are not as fond as getting their first bicycle for their 5th birthday. Pinoys get their vaccinations during childhood & they leave it at that. Hence, immunization is & continues to belong in the domain of the pediatrician. You can't buy vaccines from your local pharmacy or popular drugstore even if you have a prescription.

However, these vaccinations, as the CDC points out, must be repeated during adulthood, especially those who have co-morbid illnesses such as diabetes & emphysema.

Rare is the adult patient who has a complete set of vaccinations. Rarer still are the grandfathers & grandmothers who have the latest pneumococcal immunization.

Therefore we have a few problems.

1. Adults dont get vaccinated because they dont know they need them. Or they know they need them but cannot afford to seek consultation & pay for the vaccine.

2. Adults dont get vaccinated because drugstores dont stock them.

3. Adults simply catch & ultimately suffer the diseases that could be prevented by vaccines.

Preventive Medicine
Preventive medicine is never the popular aspect of medical care. Fluoridation of drinking water, eating the proper foods, getting adequate exercise, & moderation of alcohol intake are the common examples that comes to mind when one is asked to think about PrevMed. However, the benefits are not seen instantaneously & often require significant work & dedication.

The adage "If it aint broke, why fix it?" comes to mind. The New England Journal of Medicine came up with an eye opening article about how preventive medicine will never ever be appreciated & it is always the big shot surgeons, magical pharmaceutical formulations & hi-tech hospitals who will come to the rescue to the ailing patient.

Vaccines & OFWs
The Philippines, being one of the major exporters of skilled labor around the world, needs to make sure the people it sends out to work be screened & vaccinated for Hepatitis B, Hepatitis A, Meningococcus, etc simply for the protection of the worker & the people he or she works for.

Many an applicant for overseas work has come to my clinic with a positive HbsAg result, their hopes for greener pastures dashed because of the diagnosis of Hepatitis B. They think a vaccination will cure them. One can only attempt to cushion their disappointment at such bad news.

Of course, chronic Hepatitis B can be suppressed with potent antiviral cocktails. For those who can afford, of course. The testing & re-testing for HBV DNA, the antivirals, such expenses easily reach P20,000 a month.

Compare that with a complete course of Hepatitis B vaccination which will cost you ~P1,500.

Immunization for overseas work must be done at least a month before departure. It must be realized that to become effective, vaccines injected into the body must identify the antigens of the virus/bacteria & DEVELOP antibodies to these antigens within a specified period of time. This process doesnt take overnight, and some vaccines (such as Hepatitis B) may not induce immunity despite the complete course.

Despite these facts, immunization confers protection among the majority of Filipinos. Get your vaccine status updated. Until modern medicine comes up with a cure, a diagnosis of chronic Hepatitis B stays with you forever.