obstetrics and gynecology

Hello, Orthopaedics!

July 31, 2018

I just feel like writing today.

It's been a while, I know.

I have successfully completed my Obstetrics & Gynecology posting, alhamdulillah. :) Missing it the moment I am writing this post. O&G was my first in encountering almost everything. My housemanship basically started from zero, there. But, to complete these 2 years, I know I need to move on to another postings.

So, here I am, on my way to complete the very first month in Orthopaedics.

Honestly, I don't have specific postings in mind to choose what is going to be next though. So, I am gladly accepting this posting :) There are few life lessons I learned here (so far in 1 month).

1. I need to be physically fit.

Orthopaedics is more about musculoskeletal stuffs - involving fractures of bones, dislocations of joints, diabetic foot ulcers any many more. And this is a surgical based - so, expect operations every single day. Operations are almost 100% different than O&G. They took hourssssss (the longest one I have been in... was 7 hours straight - with 20 minutes break for me in the middle because I was hypoglycemic). But there was one time when there were 4 operations planned to be done that day and it was going one after another from 8am to 5.45pm and all of us there were basically standing the whole hours.

MO: "Hanis, take a break, pergi makan kat pantry. You need energy to assist me."

Full respects to all of my surgeons, who are very committed to reduce all the fractures, to debride all the wound, to explore the area etc. T___T

One day, I was helping the medical assistant to lift up a full right leg of a 150kg man to secure the best position of it so that the surgeon can have the best view and space to do operation on the leg. Once upon a time, I was a person who could lift a 30kg luggage up to 4th floor with stairs - but I assume not anymore. I don't know why but seems like I am losing most of my energy and strength.

So, back to the story of 150kg man.... my hand was literally shaking upon lifting the leg. The surgeon realized this and ended up asking a PPK to exchange with me.

MO: "Hanis, the moral of today, you need to eat more and exercise more."

Me: "Okay, doctor."

Thank you doctor for being considerate enough to a newbie like me.

2. Expect the challenging response.

There was one fine morning, raining cats and dogs at almost 6am, when I still remember the azan was berkumandang. It was time to take blood coming morning (means as an oncall person, we need to take any blood needed for the whole ward early morning that day).

I pushed the blood taking trolley towards a bed - who was known to be very hard to take the blood. But, what could I do? Blood is like an identity to us. Other than physical examinations, doctors can know what is happening in the patients' bodies via blood - how the liver functioning, how well is the kidney, is there any chronic infection going on, are the antibiotics working out yada yada.

So, the uncle said to me. "Doktor nak ambil darah ke? Muak dah tengok muka doktor-doktor asyik nak ambil darah je"

I am so sorry to have this inner thought, "Ingat doktor tak muak ke nak ambil darah?". I proceeded to do so, because this is my job. No matter how much the patient hates blood taking, I am doing my job and trying to make sure to get my job done so that I can feel satisfied for my pay. Keberkatan gaji is very important to me.

I ended my shift that day at about 2pm and later at night, my colleague told me that patient passed away towards the end of the evening. I was not in charge of him but I feel bad for my inner thought that morning... astaghfirullah T___T

3. Get my work done first and only then, help others.

In this department, we are assigned to beds - which mean we need to take care of the specific patient through out our working hours that day. The beds may be the same from the previous day or the next day, depending on how the oncall shift people distribute the beds.

I need to remember, other colleagues may help me but usually all people will focus on getting their carry outs done first.

I need to do the same.

And I need to remember my favourite MO mentioned to me a long time ago, "Hanis, I know you are very nice to help your friends. Keep that attitude but in reality, most of the time, you need to save your a** first."

Life is very subjective. There are colleagues you don't mind to spend your extra time to help them out, but there are some whom you will feel you need to get out of there as soon as you've done your job that day.

Keep being nice, Nina. You can do this.

4. Ortho ward is full of patients with infections.

Honestly, I feel bad for all babies and kids who come to the ward. I am sure that there is a big notice in front of the ward that we don't really recommend the parents to bring the small kids and babies inside. I know you want the kids to visit their grandmother, grandfather etc.

But, isn't your children's health more important?

Trust me, babies and small kids' immune systems are not that strong compared to adults. They are still literally growing, their immunity is still maturing. If the infections are strong enough for normal adults, don't you think they are extremely harmful for your little buddies?

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All in all, the posting is honestly full of dramas. Belum masuk kisah-kisah patients yang nak masuk wad tapi taknak masuk wad, nak operation tapi taknak operation. Hahaha. Adoi laaa.

Embrace them, Nina.

Absorb the best parts and let go of the bad ones.

Nina,

You are still learning, try hard to avoid doing mistakes. But, if you do any, acknowledge and analyse the mistakes and try not to do them ever again. If other people blamed you for something not your fault, back yourself up with valid reasons so that they can't fire back at you. But, if they still blamed you for no reasons, then it is their problem, not yours.

I love the working hours in Orthopaedics anyway. :)

One of the best things here other than very helpful senior housemen and MOs who are willing to guide and teach.

M, Perak, Malaysia

180731

My Different Version of Eid

June 24, 2018

To be honest, 2018 is my very first year to celebrate the first day of Eid Fitri away from my family. I had expected this to happen this year, so, my heart was well prepared for that. 6 years staying abroad, alhamdulillah I managed to go home every single Eid Fitri :)

But, life changed. I have new responsibilities, new environment and I look forward for more changes in my life, insyAllah with an open heart.

Night of 1st Eid, I was on call at the labor room. It was uneventful, I mean the oncall was bearable with few admission - tolerable much. Well, who wants to get sick on the night of Eid, you tell me. -_-'

I had something I could not forget, two different cases that really caught my heart on how people perceive the hospital admissions.

1st case.

There was a lady, primigravida (first pregnancy) who came to Labour Room (LR) at 0200H (2am) with complaints of contraction pain and show. Upon further examination, the CTG (reflect baby's condition in the womb) looked reactive (means normal), the os was already 2cm and time contraction was 2x in 10 minutes that last about 30 seconds.

Based on my previous experiences, we will admit this patient to the ward for further observation - in view of:

- she came at 2am

- her house is quite far away from the hospital.

Even though she was just primigravida (the labour process is usually longer for primigravida), she could still deliver the baby ANY time!

But, she was really keen to go home instead of being admitted.

Well, I do understand she did not want to celebrate Raya at the hospital, but this was out of her control. If it is fated that her baby to be delivered on 1st Syawal, let s/he be. So, my MO allowed her to go home and asked her to come immediately to the hospital if the contraction pain becomes stronger or if there is any leaking liquor (air ketuban pecah) or if she feels any reduction of fetal movement.

2nd case.

After the previous lady left the LR, another lady, G7P6 (means she is currently pregnant of the 7th baby and already delivered 6 babies) referred from the Emergency Department for PV bleeding (per vaginal) with diagnosis of incomplete miscarriage.

Incomplete miscarriage means:

- the 'baby' or better to be called as product of conception - POC (hasil persenyawaan) is already out

- but some of the POC still remain in the womb

We need to evacuate the POC otherwise patient will continue have a lot of PV bleeding and abdominal pain.

Upon per speculum with the MO, we managed to remove the POC at the os and upon TAS (transabdominal ultrasound), the endometrium thickness (ET) was <10mm. Usually, we need to proceed with ERPOC procedure (evacuation of retained product of conception) if the POC cannot be removed from the os and if the ET >15mm.

In this patient's case, our final impression was complete miscarriage - she did not have to undergo the ERPOC. However, we admitted the patient for observation and told her if her bleeding is minimal, we can allow her home that morning. She agreed with that - 'saya ikut apa yang doktor rasa terbaik'.

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Here we can see how patients perceive admissions to the ward. Trust me, no doctors want to admit patients to the ward without reason. Most doctors care about the patients even though admissions will increase the workload. But, that are for patients' sake and our responsibility.

And to make the night more interesting, the first lady delivered her baby just few hours after she left. Luckily she managed to return to the hospital T___T.

Birth before arrival (BBA) to the hospital is another issue.

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On the day of Eid, I was in charge of post natal ward and guess what, the ward round ended at plus minus 7am! And the housemen managed to settle all documents for discharged patients as early as 10am! Wahaaaaa. The MOs were considerate enough to allow patients home very early so that patients can celebrate Eid with family. :)

My shift ended at 1pm and I decided to drive home immediately after that. Arrived my aunt's house at almost 4pm and I ended up sleeping for the rest of evening. T_T

Went to my uncle's house that night and I ended up with sleeping on the sofa.

The end of my first day of Eid. :D

2nd day was better. :D

Selamat Hari Raya everyone!

Although this maybe quite late, but I wish you have the memorable Eid :)

If you are reading this, please pray for my success for tomorrow's assessments. I will be leaving for another department very soon and hopefully I pass this O&G - Obstetric and Gynecology with good achievement. Ameen.

M, Perak, Malaysia

180624

Detour by Raudhatul Hifza | Book Review

March 27, 2018

Despite the busy working days, I decided to have a goal of reading at least one book per month. It was a bit hard to keep in track as I don't have the luxury to read the book in the hospital and upon reaching home, I am already tired to even hold a book.

Memang bila pegang buku nak baca, the next moment I wake up... it is already 5am plus and I need to get ready for another working day.

So, after analyzing the trend, I got the pattern; to read few pages for 5-10 minutes in the morning while having my breakfast before leaving the house for work.

And finally I finished reading a book! :D

Title: Detour
Author: Raudhatul Hifza
Pages: 268
Publisher: Iman Publication
Publication Date: Jan 2018

There is no specific synopsis of this book unless you haven't read Hiatus. Oh, this book is kind of a sequel of Hiatus, just it is not written by Budak Tomato (I think?) and to be honest I imagine Muharikah is the one who wrote this piece. WAllahualam.

In this book, you can get a better understanding of Hiatus, from Raudhah's point of views.

A good, simple book to be honest, with not much cliffhanging parts but I am a bit disappointed with another open-ending book. Tapi, dah tu penulis nak buat, I can do nothing but to read, observe and apply the lessons I've learned from it.

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1. Be the person who can bring someone closer to Allah (together with us).

I believe I can relate well to the verse as Raudhah and I share the same career. Alhamdulillah I haven't deal with dying patients yet in this department, hopefully not but I believe it is something unavoidable in the hospital. Patients can die every day.

In O&G, it is more towards happiness of welcoming a newborn into this world. But, there are tears as well. Some women who really want a baby but unable to have one. Some women who got pregnant and really treasure their pregnancies suddenly came to the hospital because of per vaginal bleeding and upon examinations, they are diagnosed to have miscarriages T_T

'Bukan rezeki saya, kan doktor?' while shedding her tears.

Only Allah knows how sad I am to deal with this. But, I need to be professional as well even though quite a few times, I got carried away with this empathy emotion. What I can do is to calm them (in a rush, I need to help with other patients too) and reassured that 'Allah nak bagi yang lebih baik untuk akak. Akak pun muda lagi, insyAllah nanti akak cuba lagi ya.'

2. Rejection is another part of learning.

Well, rejection is my daily meal in the hospital. Well, it is for my own good anyway. Rejections really help me to improve on how to present cases, how to decide on the plans and the most importantly, why I need to perform such examinations and how to persuade patients.

Like, in O&G, not all cases we need to do vaginal examination (known as check jalan). In fact, there is another way to check the vagina - per speculum (orang panggil masuk mulut itik kat bawah) which is usually done if pregnant women complained of leaking liquor (rasa macam ada air mengalir lah doktor)

Same goes to abdominal ultrasound. In some cases, we need to do trans-vaginal ultrasound (masuk probe ultrasound melalui vagina untuk nampak organ peranakan lebih jelas) instead of trans-abdominally. But, we still need to respect the patients if they refuse any.

'Dah dia taknak, kita tak boleh paksa, Hanis. Yang penting, kita dah bagitahu baik buruk sesuatu prosedur tu dan make sure tulis dalam fail dia yang dia refuse.'

3. This too shall pass.

Every time I feel down with my own achievement, I always pat myself, "You have done the best for now, there are always rooms for improvement. And this too shall pass."

I hope my ability to work will be more efficient and fast with time. Ameen.

4. Dealing with depressed person.

I love how the author described this part well.

It is not that easy to deal with these people in real life. Theory and words are totally different than in reality. People are too different from each other. But, I think that I can use this as a guideline.

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All in all, this book is a bit monotonous but I believe that if we read this book for the sake of just to finish it, we will reach to higher disappointment. Anyway, if you have read Hiatus, I would highly recommend this one to continue reading after Hiatus :)

My rating: ★★★☆☆

M, Perak, Malaysia

180327

Sharing about Hypertension in Pregnancy

March 25, 2018

Normal people usually have normal blood pressure (BP). But, actually most people have hypertension nowadays. T_T However, pregnancy can also induce hypertension - due to hormones, the placenta (uri) and the struggle of pregnancy itself. Hypertension in pregnancy is not something to take for granted, in fact it is in the top 5 disorders in pregnancy that can harm mothers (lead to death).

For people who have family's background for hypertension, we need to be extra careful on our lifestyle and diet.

1. Hypertension - different terms in pregnancy.

There are quite a number terms and definitions I need to understand and remember in order to get the proper diagnosis and plans for specific patients.

2. Why hypertension can be harmful in pregnancy?

Well, hypertension is dangerous no matter someone is pregnant or not. In this post, I would love to share why and how hypertension in pregnancy is not an easy matter.

Hypertension in general can reduce blood flow to many organs like:

brain (can lead to coma etc),
heart (heart failure / attack etc),
kidney (renal failure etc),
eyes (blurring of vision etc),
etc

So, can we imagine what can happen to the baby if the mother herself is not in good condition?
In O&G, mothers always come first to be rescued, only then the baby.

Effects - premature birth, stillbirth, complications to babies afterwards (learning disability, seizure etc)

3. How will be the routine for pregnant women with hypertension?

I am still learning and observing this situation.

But, from my knowledge, once a pregnant woman is diagnosed with hypertension or have BP ≥ 140/90 in any check-ups in Klinik Kesihatan and written in their pink books, she need to get her BP measured every other day (EOD). This means, day 1 - day 3 - day 5 and continuously until her next check up or even until delivery of baby. Even after labor, her BP need to be monitored to make sure it is in a safe range.

4. What are the signs & symptoms of impending eclampsia?

Patients usually complain of headache, dizziness (rasa pinar-pinar), blurring of vision, epigastric pain (pedih ulu hati), nausea (mual), vomiting, edema (kaki bengkak). These are the things need to be watched out every time we meet patients with hypertension.

Believe me, in unfortunate events, some patients can skip all these and go direct to seizure T_____T

5. Who is at risk of pre-eclampsia / eclampsia?

Pregnant women who are / have:

Previous history of pre-eclampsia
Other diseases - kidney, diabetes etc
Multiple pregnancy - twins / triplets etc
Obesity
Primigravida (first pregnancy)
Family history of pre-eclampsia

6. How a hypertensive pregnant woman can be admitted to the hospital?

As someone who have been clerking patients coming to EPAU (Early Pregnancy Assessment Unit) or in some place this unit is called PAC (Pregnancy Assessment Center), most pregnant women who came for high BP is diagnosed with 'TRO IE'.

These five alphabets are scary to me. It actually means - To Rule Out Impending Eclampsia

They have high BP
80-90% of them have proteinuria (protein in urine).
Some of them have signs and symptoms of Impending Eclampsia.
Some even ended up with seizure.
Most of them need to have induction of labor (IOL) / emergency C-sec (EMLSCS) as they can't exceed 38weeks! to deliver the baby - delivery is the best way to avoid the worst scenario.

The havoc to manage a fitting pregnant woman is not a joke. At least few people need to take part in this especially to:

Prepare Magnesium Sulphate bolus and infusion (to fight the seizure),
To check all vital signs (BP. pulse rate, respiratory rate, temperature)
To recheck Pre-Eclampsia profile (full blood count, liver function test, renal profile, urine full examination and microscopy examination, coagulation profile)

7. How to avoid these?

Hmm.. first, let's pray hard to all pregnant women to have a smooth and uneventful pregnancy. Live a good and healthy lifestyle, control our diet, don't ever skip any antenatal check-ups.

And if you are diagnosed with hypertension in pregnancy, please and please make sure you follow what your doctors have told you. If you need to take medications, please don't skip. If you need to get your BP measured every other day, please do so even though it can be a hassle.

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"Seizure in pregnancy is eclampsia until proven otherwise."

M, Perak, Malaysia

180323

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HANIS AMANINA

Hello, Orthopaedics!

July 31, 2018

My Different Version of Eid

June 24, 2018

Detour by Raudhatul Hifza | Book Review

March 27, 2018

Sharing about Hypertension in Pregnancy

March 25, 2018

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