Millions thoughts raced through my mind but the packed overnight calls left me with no room for sleeping, let alone blogging! Roar!
Here are some bits and pieces:
1) Perhaps being an oncologist, the first thing one should equip with is to know where to stop. Be decisive on cure, be realistic on palliation.
2) Sometimes, words of genuine care are way more comforting then offering the 3rd 4th or 5th lines of chemotherapy.
3) Never overlook suffering and pain.
4) Presentation-phobia. But the excitement after facing the fear is priceless.
5) Tough feeling: how come cancers are still that invincible regardless all those medical advances we had in this era?
6) Joy came from being treated a dinner with a nice hemato-oncologist. Inspiring chat we had.
7) Lumbar puncture, bone marrow, chest drain, pleural tap, abdominal tap, pleurodesis - all in a single week! yohoo!
2011年9月15日 星期四
Are we overdoing it? (2)
Its obvious and true that we are overinvestigating and overtreating our patients. But knowing the very fact does not change our current mode of practice, why is that?
As usual I had my overnight duty last Sunday. It had been a very miserable night and I could bearly take a breath until 3am. While still busy preparing patients for cardiac cath the other day, I received a call from nurse informing me of a old gentleman complaining of chest pain.
Attending the patient, after only a few lines of chat I know almost for sure it is not cardiac type of pain -he clearly illustrated to me the classic symptoms of gastric reflux after lying flat on bed. Then of course I gave him a tab of antacid and went back to document it on case notes.
But then the struggle came. A loud voice emerged within my brain (which was in sleep mode): could this be an atypical presentation of heart disease? I am pretty sure it isnt. Then the next bombarded: Could I bare the consequence if it's really a case of heart attack?
I hesitated.
Argued with myself for another minute, I surrendered. Walking with my heavy eyelids I carried with me the ECG machine and find the gentlemen again, added for him a few blood tests. Of course, as predicted, not a single clue of heart disease can be seen. Feeling stupid yet much relieved - I then carried on with my work.
Reading through the NEJM article as recommended by my teacher, it echoed a whole lot with the current situation we are facing here in Hong Kong. Medicine is now not only evidence-based as we proudly claimed, but also highly defensive and protective - not to patient but to ourselves. Many a time we order tests to fulfil our uncertainties, regardless of the pre-test probabilities or indications.
As in the old gentleman in the night, fear has overrided my clinical judgement. I would not say I was hundred percent sure to exclude heart attack, but as there exists such a tiny possibility (as it would always do) and that I could not afford to miss - it rationalised my decision.
To complicate, patient's wish also urged us to switch towards this very mode of practice. We are now in the age of consumerism, doctors no longer hold the authoritative power in patient care. Not uncommonly we encounter patients who demand extra and sometimes redundant investigations - having paid the bills, they insist they own the rights to request the best (percievingly) for their health. This phenomenon is particularly pathological among Hong Kongers, who consider personal benefits the utmost important asset to protect.
Lets not talk about the financial implication, and put aside the potential health hazards posed if we continue patient care of this kind.
What truly bothers me is the gradual loss of the art of clinical medicine. When our decisions are not guided by clinical deduction but fear, when we act not to protect our patient but overselves - what roles do we doctor serve?
As usual I had my overnight duty last Sunday. It had been a very miserable night and I could bearly take a breath until 3am. While still busy preparing patients for cardiac cath the other day, I received a call from nurse informing me of a old gentleman complaining of chest pain.
Attending the patient, after only a few lines of chat I know almost for sure it is not cardiac type of pain -he clearly illustrated to me the classic symptoms of gastric reflux after lying flat on bed. Then of course I gave him a tab of antacid and went back to document it on case notes.
But then the struggle came. A loud voice emerged within my brain (which was in sleep mode): could this be an atypical presentation of heart disease? I am pretty sure it isnt. Then the next bombarded: Could I bare the consequence if it's really a case of heart attack?
I hesitated.
Argued with myself for another minute, I surrendered. Walking with my heavy eyelids I carried with me the ECG machine and find the gentlemen again, added for him a few blood tests. Of course, as predicted, not a single clue of heart disease can be seen. Feeling stupid yet much relieved - I then carried on with my work.
Reading through the NEJM article as recommended by my teacher, it echoed a whole lot with the current situation we are facing here in Hong Kong. Medicine is now not only evidence-based as we proudly claimed, but also highly defensive and protective - not to patient but to ourselves. Many a time we order tests to fulfil our uncertainties, regardless of the pre-test probabilities or indications.
As in the old gentleman in the night, fear has overrided my clinical judgement. I would not say I was hundred percent sure to exclude heart attack, but as there exists such a tiny possibility (as it would always do) and that I could not afford to miss - it rationalised my decision.
To complicate, patient's wish also urged us to switch towards this very mode of practice. We are now in the age of consumerism, doctors no longer hold the authoritative power in patient care. Not uncommonly we encounter patients who demand extra and sometimes redundant investigations - having paid the bills, they insist they own the rights to request the best (percievingly) for their health. This phenomenon is particularly pathological among Hong Kongers, who consider personal benefits the utmost important asset to protect.
Lets not talk about the financial implication, and put aside the potential health hazards posed if we continue patient care of this kind.
What truly bothers me is the gradual loss of the art of clinical medicine. When our decisions are not guided by clinical deduction but fear, when we act not to protect our patient but overselves - what roles do we doctor serve?
2011年9月4日 星期日
Are we overdoing it? (1)
Let me share a recent story.
Well, he is a businessman in his fifties. Living with his family he enjoys quite a good past health. Only that he found himself a lingering headache for a week, together with on and off cough and occasional sneezes. Coming to the emergency department, he met a busy doctor, diagnosing him with chest infection, X-ray taken with some bloods drawn, he was then sent to our unit.
Few minutes after entering ward, nurses found him with fever. With the headache going, he was pushed down urgently at night again to AED for urgent CT brain.
Enjoyed the radiation shower, he was then transferred again back to the ward, started on intravenous antibiotics. Sputum and urine saved for bugs screening, blood taken again for further culture and investigations.
Results back, his liver function is slightly derranged. An urgent ultrasound abdomen was done the other morning, to look for possible liver abscess. Turn out - only fatty liver.
Finally his nasopharyngeal aspirate results are back - yielded Influenza A.
Then he stayed in-hospital for 5 more days, to complete his antibiotics, together with an antiviral, and finally discharged.
============================
He is just a regular everyday normal guy.
A middle age gentleman with fatty liver and common flu.
What have we offered him?
- Blood tests >30 items
- Needle sticks >10 times
- Chest radiograph x 3
- Nasopharyngeal aspiration x 1
- CT Brain x 1 (with radiation ~200 chest X-ray)
- Intravenous antibiotic x 1
- Antiviral x 1
- Hospitialization x 5 days
- Uncertainty, fear, worry
What did he actually need?
- A good rest
- Reassurance
- Good education for diet and exercising
- Sickleave x 2 days
=============================
2011年8月7日 星期日
Horseshoe Crab
Well, Horseshoe crab (Chinese:鱟) is indeed a phenomenal creature.
While reading the latest National Geographic mazagine this month, this ancient and evolution-proof creature is written about again. By ancient, I am refering to 450 millions back then, even long before dinosauers came ruling the earth. How could we not be interested by this very organism, which has happened to survice through all the major extinction events, and presenting themselves in the form almost unchanged all these years?
But what amazes is not its age, not its alienoid appearance, not its close relationship with spider and scorpion (ITS NOT A CRAB!), but its blood.
I remember once in Cheung Chau, passing by a seafood restaurant, I encountered a chef preparing a horseshoe crab dish (probably a soup). Flashing back the memory, I didn't see any blood as he chopped the shell into half, at that time I thought: nah its like crab - bloodless.
Now with the magazine in hand, I was shocked. For God's sake, not only does it has blood running inside, it is blue in color!
The peculiar blood color is due to their copper-rich content, instead of hemoglobin in human, they had with them hemocyanin that carry oxygen for them. The blue blood not only charms with its color, but its medical value as well. Amazingly, in these bottles of blue fluid, there runs a type of cell known as amebocytes (literally means: a cell that can changes its shape), which have a special power - they react with the tiniest amount of bacteria in the surrounding and clot the blood. In vivo, these cells act as a defense mechanism for crabs, so that when there is a small leak of seawater into its blood, the breakpoint will seal immediately, stopping bacteria entering its body. Indeed, perhaps it is this unique immune power that makes this creature a living fossil.
And scientists use this very property as a bacterial screen for sterile materials, and help us detect the trival number of bugs, which is exceedingly important for immunodeficient patient. On further readup on the web, once the blue blood was also brought up to the space, to check for possible live-forms outside the earth!
Sadly though, due to recent enviromental over-exploitation, this seemingly-everlasting organisms are reducing in number drastically in recent years. Surviving previous extincting events didn't make it through this one - the human damage. Perhaps, someday later, our grandsons and daughter can only see this lovely creature on fossils, where the sky-blue blood can never and no longer be appreciated.
Its sad, but true.
While reading the latest National Geographic mazagine this month, this ancient and evolution-proof creature is written about again. By ancient, I am refering to 450 millions back then, even long before dinosauers came ruling the earth. How could we not be interested by this very organism, which has happened to survice through all the major extinction events, and presenting themselves in the form almost unchanged all these years?
But what amazes is not its age, not its alienoid appearance, not its close relationship with spider and scorpion (ITS NOT A CRAB!), but its blood.
I remember once in Cheung Chau, passing by a seafood restaurant, I encountered a chef preparing a horseshoe crab dish (probably a soup). Flashing back the memory, I didn't see any blood as he chopped the shell into half, at that time I thought: nah its like crab - bloodless.
Now with the magazine in hand, I was shocked. For God's sake, not only does it has blood running inside, it is blue in color!
The peculiar blood color is due to their copper-rich content, instead of hemoglobin in human, they had with them hemocyanin that carry oxygen for them. The blue blood not only charms with its color, but its medical value as well. Amazingly, in these bottles of blue fluid, there runs a type of cell known as amebocytes (literally means: a cell that can changes its shape), which have a special power - they react with the tiniest amount of bacteria in the surrounding and clot the blood. In vivo, these cells act as a defense mechanism for crabs, so that when there is a small leak of seawater into its blood, the breakpoint will seal immediately, stopping bacteria entering its body. Indeed, perhaps it is this unique immune power that makes this creature a living fossil.
And scientists use this very property as a bacterial screen for sterile materials, and help us detect the trival number of bugs, which is exceedingly important for immunodeficient patient. On further readup on the web, once the blue blood was also brought up to the space, to check for possible live-forms outside the earth!
Sadly though, due to recent enviromental over-exploitation, this seemingly-everlasting organisms are reducing in number drastically in recent years. Surviving previous extincting events didn't make it through this one - the human damage. Perhaps, someday later, our grandsons and daughter can only see this lovely creature on fossils, where the sky-blue blood can never and no longer be appreciated.
Its sad, but true.
2011年7月23日 星期六
Harry Potter and the Deathly Hallows Part 2
Aha, the 10-year combat with the Darklord finally comes to an end!
In actual fact, I ain't particularly urged to watch this one, but afterall the Harry Potter series grew as I grew, it feels like a more or less routine activity. With a lucky off-work Sunday, lets go finish Voldemort with the ultimate strike!
As with the last one, two hours was simply too short for a complete smooth-flowing story to be told. When we cannot ask too much for completeness of plot, shifting our focus on the visual and sound effects should put us at ease. In this very last episode indeed involves much more wand-battles, sseing the bright lights shooting around, in the background of the giants approaching Horwart Castle, it appeared to me a fusion of Starwar and Lord of the Rings. But afterall, somehow the picture synchronised quite well with my imagination while reading the novel - equally tense and catchy.
The part touches both Landico and I is the scene when Snape finally told the hidden story. I guess you should agree with me Alan Rickman has been playing Snape so well in the older productions, that we all want to give him a punch right on his face when he killed Dumbodore. But when the turth revealed itself, everything putting together yielded a loving intention, the halfblood prince finally became the greatest hero among all characters. And that's probably why as he tears, the lovely girl besides me sobbed as well.
When I stepped out the theatre, a strong sense of emptiness emerges - afterall Harry, Ron and Hermione grew with me since my junior high. But perhaps, when time allows, I shall pick up the set of novels on my shelf, and starts the journey all over again!
2011年7月11日 星期一
Houseman
The first week of houseman ship passed, starting in oncology ward is simply wonderful.
Some may reckon oncology as a team full of tears and sadness, yes I agree most of the in-patient care centres on palliative (aim not for cure) work, but still most of the patients here are still striving to live, coping quite well with their cancer cells - firm and strong.
For all these years, I was once stereotyped that a doctor's job was to CURE. But soon I finally realise, in fact, most of the time cure is never an option (even for simple disease like hypertension and diabetes, let alone cancer). On the other hand, when a patient's heart can be HEALED despite dying with an incurable disease.
Seriously speaking being an intern I am more a clerk than a doctor engaging in in-depth patient management. Most of my time was spent in clerical work, sitting in front of the comp, collect the printout, setting drips, taking blood, and walking here and there to book radiological investigations.
Still so, the edge of an houseman is that I am the man-in-the-house. Busy am I, but I spent most of my time in a single ward, it gave us plenty opportunities to talk and chitchat with my patients. Soon after a week, when I got to know more about them, doctor-patient relationship gradually turns less authoratative. We start to chat on hospital's food, our hobbies and even girlfriends. Its a pretty amazing experience - something the doctor-patient communication skill modules can never materialize. Haha.
Strive on, houseman!
Some may reckon oncology as a team full of tears and sadness, yes I agree most of the in-patient care centres on palliative (aim not for cure) work, but still most of the patients here are still striving to live, coping quite well with their cancer cells - firm and strong.
For all these years, I was once stereotyped that a doctor's job was to CURE. But soon I finally realise, in fact, most of the time cure is never an option (even for simple disease like hypertension and diabetes, let alone cancer). On the other hand, when a patient's heart can be HEALED despite dying with an incurable disease.
Seriously speaking being an intern I am more a clerk than a doctor engaging in in-depth patient management. Most of my time was spent in clerical work, sitting in front of the comp, collect the printout, setting drips, taking blood, and walking here and there to book radiological investigations.
Still so, the edge of an houseman is that I am the man-in-the-house. Busy am I, but I spent most of my time in a single ward, it gave us plenty opportunities to talk and chitchat with my patients. Soon after a week, when I got to know more about them, doctor-patient relationship gradually turns less authoratative. We start to chat on hospital's food, our hobbies and even girlfriends. Its a pretty amazing experience - something the doctor-patient communication skill modules can never materialize. Haha.
Strive on, houseman!
2011年6月28日 星期二
Does God cure (4)
When it comes to accessing the effacacy of prayer, it amazes me how serious people can take this as an issue.
Searching on the web, it's not difficult to see scholars (mostly in the west) try and perform well-structured studies and trials to examine the "prayer effect". To us, as taught in Bible, praying is not merely asking for interventions, we praise, we confess we communicate.
Even among intervention, it would be hard for us to even falsify the very statement "God intevenes." But afterall, the easiest part of it to be quantitatively and objectively accessed by scientific methods, will be praying for cure.
As my friend Andrew has pointed out in my last post, we need to seperate the morale-uplifting (or placebo) effect in prayer from the result of divine intervention. With this, scientists underwent randomised-controlled-trials. Putting a number of patients randomly into 2 groups, one with interaccessory prayer (prayed by someone with the individual not knowing). The process of randomisation and blinding will thus, theoretically, eliminate the placebo effect and the problem of background differences.
Starting from the 80s, numerous studies were performed. The results were deemed highly variable, some claim benefits, some concluded harm, while most of them remained statistically insignificant.
Here comes the follow-up questions.
1) With God (a freewill-possessing being) involved, are prayers assessable by RCTs, and are the results repeatable?
2) Does effacacy of prayer have a dose-response relatationship - ie. will the effacacy improves as we pray more, either by frequency or number of prayers?
3) Let's say we proved God's action on cardiac diseases, do we have the confidence that we arrived a positive finding in all other diseases - if not, why on earth an almighty God has such a particular taste on healing?
4) If we compare prayers effacacy to antibiotics on patients with infections, is it justifiable to conclude in this way: Penicillin is superior/inferior to prayer as therapeutic means, doesn't it sound weird?
Searching on the web, it's not difficult to see scholars (mostly in the west) try and perform well-structured studies and trials to examine the "prayer effect". To us, as taught in Bible, praying is not merely asking for interventions, we praise, we confess we communicate.
Even among intervention, it would be hard for us to even falsify the very statement "God intevenes." But afterall, the easiest part of it to be quantitatively and objectively accessed by scientific methods, will be praying for cure.
As my friend Andrew has pointed out in my last post, we need to seperate the morale-uplifting (or placebo) effect in prayer from the result of divine intervention. With this, scientists underwent randomised-controlled-trials. Putting a number of patients randomly into 2 groups, one with interaccessory prayer (prayed by someone with the individual not knowing). The process of randomisation and blinding will thus, theoretically, eliminate the placebo effect and the problem of background differences.
Starting from the 80s, numerous studies were performed. The results were deemed highly variable, some claim benefits, some concluded harm, while most of them remained statistically insignificant.
Here comes the follow-up questions.
1) With God (a freewill-possessing being) involved, are prayers assessable by RCTs, and are the results repeatable?
2) Does effacacy of prayer have a dose-response relatationship - ie. will the effacacy improves as we pray more, either by frequency or number of prayers?
3) Let's say we proved God's action on cardiac diseases, do we have the confidence that we arrived a positive finding in all other diseases - if not, why on earth an almighty God has such a particular taste on healing?
4) If we compare prayers effacacy to antibiotics on patients with infections, is it justifiable to conclude in this way: Penicillin is superior/inferior to prayer as therapeutic means, doesn't it sound weird?
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