A Family Doctor's Tale - MEDICAL LOCUM

 MEDICAL LOCUM

The compulsory 1 year houseman internship was over. 
I have become a fully qualified medical doctor which also means a yearly registration fee of $25. This fee of $25 per year was cheap compared to the present $600 registration for 2 years. 

My wife and I had a beautiful baby girl halfway through my houseman internship. We were married after her graduation from a teaching diploma and after she started work in a school. 

With our beautiful child at our side, I was very interested in becoming a pediatrician.( child specialist).
I have always been interested in children diseases and development having learned from one of the best Pediatric Professor in the world. 
He was not only dedicated to his work and his teaching, taking the trouble to do a teaching conference every Saturday morning. His conference notes on Saturdays alone were as large as the Britanica encyclopedia. 

He was also the Director of the postgraduate school of Medicine.
Unfortunately the limited amount of traineeships were given to the older medical officers.

I have a choice of staying in the public hospitals or leaving for private family practice.

Although my wife and I have discussed about opening a family practice, we felt that I need to have more experience in dealing with patients outside the hospital context. 
In addition we felt that we need to build up our finances before starting up a new family practice clinic.

So I applied to be a  medical locum ( a temporary replacement doctor for any private doctor who may need to go for a holiday). I was lucky to almost immediately get work in a small run down family clinic in one of the satellite town. 
The sole medical doctor had to leave to attend to a family matter for 3 months in India. 
He could not pay me a fixed salary but was willing to pay me 70% of the profits.

I was to take charge of the whole clinic including ordering of the medicines, seeing the patients, paying the single clinic assistant, keeping the medical records and accounts of the clinic. 
The clinic key will be held by the clinic assistant. 
It was a perfect experience for me. 
It was like running my own clinic without the risks and learning all about how to run a family clinic. 
Work was from 9am to 12.30pm from Mondays to Saturdays and 2pm to 5pm on Mondays to Fridays. 
Sundays and public holidays were excluded.
There was no night duty so I have some time to spend with my family.

I felt that even though it was a small practice, it was a good learning experience and if I do well I may be able to get more money than a fixed salary. I was to submit an account to the doctor every month with income and expenses signed by the clinic assistant and the doctor will send me a cheque for the 70% of the profits.
It was because of this many other locum doctors had turned down his offer as they preferred a fixed salary and also did not like his rundown little clinic.

I was not so particular as I felt that if a doctor is good he should be able to work any where. Money was not everything to me.
The best thing was that after 1 year of hectic hospital work, there was definitely more time to spend with my wife and child.


So after a rest of 2 weeks, I started work in this small run down family clinic.

A Family Doctor's Tale - MEDICAL COLLEAGUES

MEDICAL COLLEAGUES

The good , the bad and the ugly - as in any department, medical colleagues may be any of these.

However in the medical department of the Thomson Road General Hospital, most of my medical colleague are of the first category(that is) The Good.

The medical posting was a relatively slow paced easy posting with early daily ward rounds, clerking of new and old cases admitted and relatively quiet night duties. A normal duty may start at 8am in the morning and ends the next day at 1pm after night duty.

Most of the patients were
1.chronic medical conditions patients such as chronic heart diseases( A Simple Guide to Chronic Heart Diseases), uncontrolled diabetes(A Simple Guide to Diabetes Mellitus), chronic lung diseases(A Simple Guide to Chronic Obstructive Lung Disease) (mostly smokers) , chronic liver cirrhosis(A Simple Guide to Liver Cirrhosis) .(mostly drinkers)

2.acute conditions such as suicides by insecticide or barbiturate poisoning, unexplained fever(A Simple Guide to Fever), acute asthmatic attack(A Simple Guide to Asthma)

 Most of the consultants were friendly except a few who were a bit aloof and spoke to us through their trusted medical officers.

Most of the medical officers are friendly and helpful. 
One of the medical officer is my best friend to this day because we work so well together. 
There were the few medical officer who hope to further their career by sycophanting the consultants  and trying to get a traineeship which were very rare and difficult to get at that time. Sometimes you do not see them in the ward the whole day because they were too busy searching information for their consultant to write for the journals.

Illnesses which require operations were sent to the surgical wards.

We also have a weekly medical conference with the doctors and consultants of a nearby hospital the Tan Tock Seng General Hospital which was famous for their neurologists and the single neurosurgeon .

A consultant neurologist from Tan Tock Seng Hospital was famous for his neurology methodology. 
He used to teach me neurology when I was a medical student and is still teaching students from the major Government hospitals today.
 He was a real gentleman with perfect bedside manners and has perfected his medical examination of the neurological system to a simple step by step technique which is why the University of Singapore continue to employ him to continue teaching even after he left the public service. 
He reminds me of the need of life long learning.
He treats all the doctors consultant, trainees, medical officers and housemen as equals.
To me he was the perfect physician to emulate.
To this day I have always refer neurological cases to him .

The nursing staff at the Thomson Road General Hospital were mostly friendly although there were a few cynical nurses who have seen housemen and medical officers pass through the ward every 6 months and know who were the good, bad and ugly.
Happily most of the nursing staff were kind to me because I was willing to work and I also help them with their work when I am free.

It was on the whole one of my best posting with lots of happy memories. I have learned a lot from my medical posting and I was glad that I was able to contribute to the treatment of a few memorable cases such as the Malaria case(A Simple Guide to Malaria) and barbiturate poisoning.


Soon we will be leaving the department having finished our housemanship and hopefully try to get a good medical officer or  a traineeship posting. That, however, is another story.

A Family Doctor's Tale - INSECTICIDE POISONING

INSECTICIDE POISONING

While the rich or middle class try to kill themselves with barbiturates, on the other spectrum the very poor has only insecticide to try to kill themselves by poisoning. 

Insecticide usually contains organophosphate which can not only damage your mouth, stomach and intestine by their corrosive chemical reactions and results in symptoms of severe abdominal pain and vomiting. 

It can be rapidly absorbed into your blood to damage the brain and nerve endings causing 
1.miosis of the eyes(small pupils), 
2.convulsions (fits), 
3.paralysis of the respiratory muscles with difficulty in breathing, 
4.paralysis of the heart muscles, 
5.damage to the brain and coma and 
6.death.

It can be a very painful death unless treated early and quickly.

Usually a intravenous drip is setup and atropine given to hopefully counter the effects of the insecticide chemicals. 

A nasogastric tube is also inserted and suction of the fluids and liquids(gastric lavage) is done with the hope of removing some of the insecticide.

The chances of recovery depends on the amount of  organophosphate insecticide ingested but are generally poor.

Recovery is good if the patient made good progress during the first 4 to 6 hours with improvement of breathing and heart rate. 

More often than not the patient usually succumbs to the insecticide poisoning within 12 hours.

Those who recovered may have badly scarred gullet and stomach with difficulty in swallowing and permanent stomach damage later on.

Even in the 1970s evidence of the gap between the rich and poor can be showed in the way they tried to kill themselves by poisons. Cheap poisons like insecticides are dangerous and result in a very painful death while 'rich' poisons like barbiturates can kill the patient by making him or her sleep to a painless death.

A Family Doctor's Tale -VALLEY OF THE DOLLS

VALLEY OF THE DOLLS

Barbiturates (the dolls in the novel and movie Valley of the Dolls) used to be the most common sleeping tablets in the 1970s. They have since been replaced by the benzodiazepines. 

The danger of barbiturates was the rapidity of their action as seen by the use of thiopentone to induce sleep in anesthesia. The other danger was that in high quantities they tend to depress the respiratory function so that an overdose can kill by causing breathing to stop.

Barbiturates are mostly used by the rich and middle income who can afford to get them from their physicians.
So they were the preferred choice by the rich or middle class to commit suicides.

There was a couple who had a bad quarrel in their home and the wife ended in the hospital after being discovered by the husband to have taken an over dosage of barbiturates.
She was a patient of our deputy head of the medical department.
She was kept under observation as she was still breathing at the time of admission.

When her respiratory rate reached a low critical level, we were summoned to start her on a respirator to assist her breathing.
As usual, I was the one to do the endotracheal intubation as I was the only one in the ward able to do the intubation having learned from the Anesthetic Department.

The intubation was done and the patient was put on the respirator. An intravenous drip was also inserted and her vital signs were kept under constant observation.

After 2 days she woke up from her so called sleep and was reconciled with her deeply stressed husband.

Of course the husband was very grateful  to the consultant and insisted in taking him out for a grand dinner after the wife was well enough to go out.

We (the medical officers, housemen and nursing staff who did all the resuscitation ) were not even mentioned by the couple.

A Family Doctor's Tale - THE MILK DRIP

THE MILK DRIP

In the early 1970 one of the medical treatment of acute exacerbation or mild bleeding from gastric peptic ulcer(A Simple Guide to Gastritis) was the milk drip. 

Our ward consultant was a gastroenterologist specializing in stomach, intestinal, liver and gallbladder(A Simple Guide to Gallbladder Diseases) problems. 
Many of his patients who had a diagnosis of acute exacerbation of peptic ulcer were sent to the ward for a milk drip as treatment for the hyperacidity of the stomach.

Provided the patient is not lactulose intolerant ( not able to tolerate the lactulose in cow's milk), a nasogastric tube was inserted from the nose into the stomach of the affected patient. Milk was allowed to flow continuously into the stomach acting as an alkaline lotion to neutralize the acid in the stomach. It was first introduced as a treatment in one of the British journal in 1950 and has since been a popular way of treating peptic ulcer in Singapore hospitals in the 1960-80.  

I also incorporate a continuous use of antacid suspension every half hourly to my gastric or peptic ulcer patient nowadays until their symptoms are relieved. 
This seems to work better than giving medicines 3 or 4 times a day. 

However medicines like cimetidine (H2 antagonists) and ranitidine which are first used from 1976 in United Kingdom and 1979 in USA became the drug of choice for treatment of gastric and duodenal ulcers. This was followed by the proton pump inhibitors like omeprazole and nexium from 1986 onwards. 

However the use of these strong acid reduction medications does not mean antacids are not necessary for the countering the acid in the stomach. 

In addition a new cause of gastric ulcer was found to be a bacteria called helicobacter pylori. 
So for some of these gastric patients an 6 week course of antibiotics have to be given together with H2 antagonist or proton pump inhibitor and antacid. 

All too often many specialists just prefer to give the strongest medication like omeprazole alone without the antacid and hope the gastric disease will be cured. 

In fact the cause of gastric disease is multifactoral including irregular meals, stress, hereditary and bacterial. 

Unless the cause is also treated, the gastric problem will never go away. 

In fact the milk drip has many advantages to the treatment of gastric ulcers. A continuous flow of alkaline liquid, a good bacteria (lactobacteria) which may counter the hylobacter pylori bacteria and rest in bed all help to cure the gastric problem. The only problem are people with lactulose intolerance and the high cholesterol (A Simple Guide to Cholesterol)in the cream of the milk.

A Family Doctor's Tale - MALARIA PATIENT

MALARIA PATIENT


Coming back to my first day of posting to the Medical Department of Thomson Road General Hospital, I mentioned that there was a woman who had stayed in the ward for 1 month with a diagnosis of unexplained fever. The medical officers and housemen were asked their diagnosis of the patient. I mentioned that I suspected that it was malaria( A Simple Guide to Malaria).

The diagnosis of malaria as the cause of her fever was suspected when she was first admitted to the Hospital. However it was discarded when the blood film test for malaria parasite was found to be negative a few times.

She also had all the blood and urine tests done and X-rays taken of her chest, abdomen, brain and bones. 
She has also being examined by 
1.the kidney specialist for urinary tract infection and disease, 2.the heart specialist for any heart and lung problems,
3. the gastrointestinal specialist for any abnormal liver, gallbladder or gastrointestinal disease, 
4.an endocrinologist (specialized in hormonal diseases like thyroid diseases, diabetes, etc) for thyroid conditions which may cause fever, 
5. a neurologist to exclude any abnormal brain or nerve disease which may cause fever, and finally 
6.the gynecologist to exclude woman diseases.  
All possible diagnoses have been excluded and the consultant was still at a loss at what her illness was.


Going through her case notes, I noted there were regular daily spikes of  fever especially at night which was very suspicious of malaria. 
In addition any rigors (or shaking of the body ) will be missed especially at night when the lights were dimmed for sleep. 
Blood films for the malaria parasite were usually taken by the laboratory technician during the day when the fever was down.

I decided on my own that I would like to get a blood film from the patient when I was on night duty. 
This happened on the second night of my posting.
I observed the patient until her fever started rising in the night about 11pm. She did not have any rigors but that did not exclude malaria. Malarial parasites are usually released from its reservoir in the spleen at a certain time into the blood stream. That was the time the body reacts by raising its temperature. It was also the time when the malarial parasites were highest in the blood.


It was also the best time to do a blood film for malaria parasite. 
I did a prick on her finger and managed to get 2 thick blood films of her blood and sent it to the laboratory myself. 
A thick blood film was important as a thin film may not contain sufficient malaria parasites to show up under the microscope.

The next morning our laboratory technician called to inform the ward that in deed the blood film was positive for malaria.
The diagnosis was confirmed. The patient was treated with anti malarial drugs and after 2 days her fever had subsided and she was discharged after staying for 1 month in the ward. 
I was very happy that I could help her to be diagnosed and be cured of her condition.

It just showed how a simple change of procedure could help to effect the outcome of  a patient's illness.

Doctors should not order tests routinely for the laboratory technician to do. 
Certain tests may require the laboratory technician to come when there is a high fever(such as at night) and do a thick film instead of a thin blood film. 

It would definitely save the patient the unnecessary stay of 1 month in hospital and ease the worry of  the patient and her relatives.

A Family Doctor's Tale - EMERGENCIES AND NIGHT DUTIES

 EMERGENCIES AND NIGHT DUTIES


During an emergency or code blue, the nurses will rush out all the resuscitation trolley and respirator to the bed of the patient requiring it for you to do the resuscitation. 

If the resuscitation trolley was not ready, then we had to do mouth to mouth resuscitation until the mouth pieces arrive and you can use mouth piece to do the resuscitation.

In those days we do not think of possible HIV or H1N1 infection through the mouth to mouth resuscitation. 
We only think of how to save the patient so that after a successful resuscitation, even if you end up with a bad taste of the patient saliva in your mouth which also make you lose appetite for food, you were still happy because you have saved a life.
If you happened to be having lunch or dinner given to you while on duty when this happened, you will definitely be unable to eat your food especially with the bad taste in your mouth.

It was one of the reason I ended up with gastric problems.

Once resuscitated ( the heart rate and breathing returns), an endotracheal tube can be easily inserted into the windpipe and a respirator attached to it for the patient to breathe . 
Only a handful of doctors was able to insert the endotracheal intubation. I was one of them because of my experience in the Anesthetic department.

My medical officer and I teamed up to do most of these resuscitation efforts. 
I remember one particular old Malay man  with heart failure whom we manage to resuscitate his hear stoppage to life 5 times.
Each time the relatives who has gathered were so happy to have him back. Then one morning we came to the ward and found him gone.
It seem that the house woman who was on duty the previous night was called to the same patient. The nursing staff has prepared the resuscitation equipment all ready for the resuscitation. The house doctor instead just put her stethoscope to the heart and pronounce him dead. She then signed the death certificate and went back to sleep.
That really make us mad. All our resuscitation efforts has come to nought.


When you are on night duty, you are given a room to sleep. Normally you will be able to sleep unless there was an emergency when you will be rudely waken up by the nurse. 

Night duty means work from 8am in the morning to 1pm the next day, later if the paperwork has not being completed.
Food was provided during lunch and dinner on the same day and breakfast the next day. 
Most night duty was fairly quiet because few patients turned up at our small hospital.
The patients usually prefer the bigger Hospitals like the Singapore General Hospital or National University Hospital. 
So after dinner I was able to do a quiet round of the ward myself talking to the patients or the nurses if they are free.

Some of the nurses are a cynical lot having seen all types of doctors coming in and out of the hospital.
There was the doctor who was lazy and pushed most of the work to the nurses  or the house doctor. 
There were those sycophants who always curried favors with the consultant and do all their research in the journals for them while leaving the ward work for doctors like us.

The nurses' term for these people was "FON" or "Full of Nonsense. "

While talking to the nurses I also try to do some of their work for them especially when they were short handed.

Similarly when I was busy, some of them will just helped me out without my knowing, such was my rapport with the nursing staff.

A Family Doctor's Tale - THE THOMSON ROAD GENERAL HOSPITAL

 THE THOMSON ROAD GENERAL HOSPITAL

After my 2 short postings in the ENT Department and Anesthetic Department, I now have a long posting of 6 months in the medical Department of the Thomson Rd General Hospital, a small hospital catering to the satellite town of Toa Payoh and surrounding area.
It was later named Toa Payoh General Hospital and is relocated later in  the East as the Changi General Hospital.


The Head of the Medical Hospital is Prof Lee who was also the personal physician to our Prime Minister Mr Lee Kuan Yew. 
He was also the first doctor with a law degree.
He was usually quite busy and left most of the work to his deputy.

Our posting here consist of 3 months in the woman's ward and 3 months in the man's ward.

As usual the day starts at 8pm with a ward round where the medical officer will go through the previous day problems of all the patients staying the ward for the Consultant in charge of the ward to suggest better investigations or treatments. 

There was a woman in the ward who has staying in the ward for unexplained fever for 1 month for which the diagnosis could not be found in spite of  all the laboratory tests and x-rays. We the new doctors were asked for a possible diagnosis to the woman. My guess was malaria but the blood film for malaria has been done and was negative so malaria has been ruled out.


Then there were cases of 
1.chronic heart valvular disease admitted for heart failure, 2.chronic obstructive lung disease admitted for breathlessness, 3.chronic liver cirrhosis admitted for liver failure and loss of appetite, 
4.acute asthmatic cases ,
5.severe food poisoning, 
6.severe gastric ulcer, 
7.uncontrolled diabetes, 
8.kidney disease and 
9.attempted suicides.

Night duties were 3 days apart, not too bad compared to my last postings. The hospital was small , patient load was not too heavy, and there were 8 house doctors 2 for each ward and 4 medical officers. The present batch of medical officers had just completed 1 year of posting there and a new batch of medical officers will be coming in a fortnight.

Ward work includes taking blood for testing, registration and clerking of new patients who were just admitted through the Emergency Department and the outpatient specialist clinics.   

Clerking of patients was just a term for writing in the complaints of the patient, your examination of the patients, writing the findings and suggesting the investigation and symptomatic medication for the patient.

We have to do the paperwork in order to prepare for the next day ward round. 

Of course if there were any patient or their relative in the ward who have questions and needs answers we have to attend to them.

There was also paperwork to be done for those who will be discharged on that day. 

Once I have finished the paperwork , I normally go round the ward one more time to talk to the patients. 

Then you are free to do what you wish until the next patient comes or there is an emergency such as the stoppage of heart of a heart patient.

A Family Doctor's Tale - ANESTHESIA, SURGEONS & SLEEP

ANESTHESIA, SURGEONS AND SLEEP

Being in the Anesthetic Department gave me access to the operation table and the surgeons working inside.
I also has an inside view of the surgery and the the techniques used for the surgery.

Most of the surgeons were friendly and gave tips on how their operation was done.
There a few surgeons who would vent their displeasure on the assisting operation nurse .
I have seen surgeons who threw the instrument on the floor when given the wrong instrument.
There was also a neurosurgeon who was the first neurosurgeon in Singapore in the 1970.
He was so careful with his operations that most of his operations last 6 to 12 hours.
There are also surgeons who leave the initial cutting of the operation wound to his trainee and once they finish the main part of the operation again leave the closure and stitching of the wound to his trainee or assistant.

Sometimes when the surgeon lack a assistant , they will ask you the anesthetist to pull open the operation wound for them. That was okay by me because I can learn better by helping out.

One major operation occurred one night when there was a major alert that there were 2 kidneys available for transplant to 2 kidney patients. All less important operations were cancelled and the theater was prepared for the transplants. Organ transplants were rare at that time.
The team of surgeons were summoned and 2 anesthetists were assigned to help in the operations. Since I was one of the anesthetists available, I was glad to help out in the transplant.
The set of 2 kidneys were removed by one of the surgeon in another theater and the kidneys were rushed to the 2 other teams of surgeons waiting to do the transplants.Blood transfusions were set up. In the meantime the recipients were put under general anesthesia by me and the other anesthetist.
The Head of the Anesthetic Department also arrived to help out in this rare operation.
It was a well organized team effort .
Although the 2 kidneys were successfully transplanted into the 2 patients, one of them died due to rejection of the kidney. It was quite sad for one patient and joy for the surviving patient.


Night duties have always been a problem for a house doctor in the Anesthetic Department.There was always a room for the anesthetist but not for the house doctor. So I just have to made do with whatever is available for sleeping including the sofa of the operation theater's surgeon tea room. It was cold but you need your sleep so just squeeze yourself in a corner with cushions and sleep. 


Once in a while a kind nurse will call me that there is a bed available in the ward from the unfortunate death of a patient. They have cleared the bed and put a clean bed sheet on it.
That was good enough for me. At last a bed to sleep in. Who cares if some dead patient has just occupied it.?
A bed was a bed. I have no qualms about sleeping in the bed, with a ghost of a patient who has just departed.




The Anesthetic Department may have been a short stint of work for me. But I learn to deal with different anesthetists and different surgeons.

I learn to be competent in endotracheal intubation and intravenous injections and drips.
I was able to make use of some regional and local anesthesia to relieve pain later on in my own family practice.
All in all I felt I have learned a lot from my work in the Anesthetic Department.

A Family Doctor's Tale - A TALE OF 2 ANESTHETISTS

A TALE OF 2 ANESTHETISTS

There are 2 types of anesthetists:
1.confident and hardworking
2.relaxed and too easy going


The first group is
1.conscientious,
2.do a proper  pre-operation examination of the patient the day before,
3.check that he is the correct patient.
4.make sure that he is not taking medications which may clash with the anesthesia
5.check that he has not taken any food or fluid at least 6 hours before the operation
6.reassure the patient before putting under general or regional anesthesia
7.continue to check his vital signs(blood pressure, heart beat, respiratory rate) during his surgery
8.make sure that the levels of oxygen and nitrous oxide are correct
9.check the intravenous drip does not run dry
10.make sure the patient was safe during the surgery(there are times when patients wake up during the operation because the anesthesia was not deep enough)
11.reverse the anesthesia carefully
12.make sure that the patient was well after waking up


The second type of anesthetist is very easy going:
1.ask the patient a few questions just before the operation
2.induce the general anesthesia
3.leave the patient in the hands of his nurse during the operation to monitor the vital signs, gases and drip
while he goes for a break in the surgical tea room
4.when the operation is over, he will turn off the anesthetic gases and reverse the anesthesia
5.Once the patient is awake he will go for another break until the next operation


I was taught by both types of anesthetists. 
I learn to be the first type of anesthetist because I want to be good doctor who takes care of his patient and not just do his work routinely.
Besides I do not wish any of my patients ends up as one of the fatality from anesthesia.
So I was constantly with the patient from induction of anesthesia to reversing the anesthesia.
The danger of general anesthesia has been greatly exaggerated.
There is always a risk of 3 fatalities in a million due to anesthesia not 1 per cent as sometimes stated.
It is very important that a proper examination is done before the general anesthesia as medication such as Viagra may clash with some anesthetic. 
If the patient is not fit for general anesthesia, he should undergo some other form of anesthesia for the surgery instead of general anesthesia.
It is also important to have an empty stomach for at least 6 hours before general anesthesia because of the risk of vomiting or regurgitation of fluid or food entering the windpipe.
There is also the danger of muscle relaxant reversal where the patient's anticholinesterase enzyme were insufficient to help reverse the muscle relaxant.


I remember a surgery where the anesthetist was a new trainee anesthetist. It was his first general anesthesia done under the instruction of the Head of the Anesthetic Department. Everything went well until after the surgery. When he tried to reverse the muscle relaxant, he was horrified to find that the patient was unable to wake up. She was one of the patient who had this enzyme insufficiency.She had to be put on a respirator and intravenous drip for 2 days in the ward until the muscle relaxant was flushed out of her body.

It was one of the complications of general anesthesia.


General anesthesia can be administered with endotracheal intubation or without intubation. For short operations of less than 30 minutes or diagnostic operations such as biopsy, general anesthesia may be given after sedation with a short dose of thiopentone using nitrous oxide and oxygen gases. 
An oropharyngeal air way is inserted to prevent the tongue from falling back and blocking the passage.


Regional anesthesia is preferred to general anesthesia because of less risks of complications associated with general anesthesia.
Spinal anesthesia is given by a needle into the epidural space below the spinal cord for operations requiring paralysis of the lower half of the body such as appendicectomy, operation of lower intestine, ovaries and womb.
Epidural anesthesia is given to relieve pain during delivery of babies, caesarean section.


Caudal  anesthesia is given to paralyse the lower perineal region for operation of the cervix, womb, hemorrhoid and anal operations. It last for 1-2 hours. 
In the Obstretic and gynecological hospital (KKMH)of Singapore, I had to do caudal anesthesia for almost 20 patients over a period of 3 hours straight in order for them to undergo dilation and curettage of their wombs.


Regional anesthesia of a particular limb allows the surgeon to operate in cases where general anesthesia is dangerous or unnecessary (in elderly people or uncontrolled diabetic patients who needs amputations or treatment of fractures of the hips, legs and feet).



All told, the Anesthetic department was a short stint of 3 months which I enjoyed and learned.
I also found out all I can about the operations done, the conduct of some surgeons in the operation theater and the use of the surgical tea room for sleep.

A Family Doctor's Tale -THE ANESTHETIC DEPARTMENT

THE ANESTHETIC DEPARTMENT
---------------------------------------------


My next posting was with the Anesthetic Department.
Although the Anesthetic Department is in the Singapore General Hospital, the group of 20 Anesthetic Consultants catered for all the 5 public hospitals in Singapore.

It was only a office with a meeting room for the briefing of the anesthetists and duty roster for the week.
There was an hour for discussion and networking before starting work. 
There was no wards. 
The anesthetist work in the operation theater of the hospital he is assigned to. 
As I was new, I was assigned to a different anesthetist every week.
The Head of the Anesthetic Department was friendly and easy going. 
So were the rest of the Anesthetists. 

As usual there was a shortage of staff. 
So work was from 8am to 8am the next day with 1 day rest followed by work on the 3rd day.(in other words work alternate days).
Here there is no paperwork unlike the working in the ward. 
All the paperwork was done in the operation theater.

My learning journey starts in the Operation theater of the Singapore General hospital with the Head of the Anesthetic department. 
The patient has already being examined the night before to exclude any severe heart or lung disease or drug allergy which may affect his general anesthesia.
Outside the operation theater the patient was again examined to make sure that he is the correct patient and that he was fit for surgery. All dentures must be removed because they post an obstruction to the wind passages.
The patient was also asked whether he has taken any food or fluids at least 6 hours before the operation because of the danger of regurgitation of food or fluid into his windpipe.


Before entering the operation theater, the patient had an intravenous drip inserted into a vein of his hand.


This was in case blood transfusion may be needed during the operation. Besides injection of medicines can be done easily through the drip.


Once inside the operation theater, I was given the honor to give the intravenous thiopentone (25mg/kgm). 
As the patient was asked to count to twenty, the injection was given .By the count of 7-8, the patient was already asleep.
A dose of succinylcholine injected was again given intravenously. 
This was a muscle paralysis drug like curare (used by Amazons Indians to paralyze enemies or animals through their blowpipe).
The muscle paralysis is necessary so that there is no muscle movement during the operation.


A Laryngoscope was inserted into his throat to help the proper insertion of the endotracheal tube ( a tube that leads from the mouth to the inside of the windpipe). 
When done properly, the vocal cords or other parts of the windpipe will not be injured. 
The endotracheal tube is then inflated to keep it in place. 
Then the respiratory tube from the anesthetic trolley is attached to the endotracheal tube for the right mixture of oxygen and nitrous oxide(the infamous laughing gas or anesthetic gas) entered the patient's lung. 
The lungs must be checked to be sure that the gases are entering correctly. 
Once the patient is fully anesthesized, he is handed  to the surgeon to start operating.


During the operation , the patient will have his blood pressure, pulse and respiratory rate checked as well as the level of nitrous oxide and oxygen gases and the flow of the intravenous drip.
If there is any movement during the operation the surgeon will inform the anesthetist who will have to increase the dosage of nitrous oxide to improve the level of muscle paralysis.
Once the operation was over, the patient was handed back to the anesthetist to reverse the anesthesia.


A dose of neostigmine was injected intravenously to reverse the muscle paralysis and the nitrous oxide was stopped with oxygen still being given. 
Once the anesthetist feel that the patient muscle paralysis has passed and he is able to breathe on his own, the endotracheal tube is removed. 


The patient is then pushed outside the operation theater on the bed trolley and usually kept to one side with his face facing down.   
In rare cases there may be vomiting in spite of the empty stomach. This way the vomitus will not enter the windpipe.


The danger of general anesthesia is generally exaggerated. There is only a risk of 3 fatality in a million cases and not 1 per cent as some doctors has claimed.


This was my first case of general anesthesia.
Once you have done a few cases, it becomes easy and almost automatic.

A Family Doctor's Tale - A TALE OF 2 CANCERS

A TALE OF 2 CANCERS
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NASOPHAYNGEAL CANCER (A Simple Guide to Nasophayngeal Cancer)


The Ear Nose and Throat Department treats all cancers of the ear nose and throat.
Some of the throat and mouth cancers are treated together with the Dental Surgery Department.
In the 1970s one of the most common and deadly cancer was the Nasopharyngeal Cancer which  now is known to be linked with Epstein-Barr virus.
Treatment was difficult because of the closeness of the nose cancer to the brain and the frequently late diagnosis.
Surgical treatment is usually not considered unless it was at an early stage.
The treatment of choice was deep X-ray radiation to the affected area followed by chemotherapy in all cases spread of the cancer to other organs.
The mortality rate was high compared to the present modern treatment today of gamma knife treatment.
At the time of my assignment, there was a woman patient in the ward who was in the advanced stage of nasopharyngeal cancer and undergoing chemotherapy.
She was a teacher of 32 years of age who was mostly sick during the time there.
She was emaciated with vomiting during her chemotherapy and loss of appetite. 
She was always in pain because the cancer has spread to the brain.
We had to give painkillers and anti-vomiting injections every now and then in order to relieve her symptoms.
Because of the injections, she was also in a sleepy state most of the time.
She has quite a few visitors including her family and her students, most of whom were dejected at the state of her condition.
I tried talking to her on several occasions but she was most too tired to answer except in short sentences.
One morning her bed was cleared and we know that she has succumbed to her illness in the night.


It was sad but quite a lot of nasopharyngeal cancer patients had succumbed in this way including my father-in-law during my medical student days.


LARYNGEAL CANCER (A Simple Guide to Laryngeal Cancer)


In contrast to the dangerous nasopharyngeal cancer (which was usually detected late), the Laryngeal Cancer is usually detected much earlier . 
The symptom of hoarseness of voice was one of the easily symptom which prompts the patient to see a doctor. 
Even then, some patient then to delay their checkup by a ENT surgeon preferring to see Chinese Sinsehs (Traditional Chinese healers) for treatment hoping to be cured of their condition. 
We had a elderly female patient of 70 years who had an advanced stage of Laryngeal cancer which fortunately grow very much slower than the nasophayngeal cancer. 
Although it had spread just outside of her larynx or vocal box, surgical removal of her cancer was successful. 
A tracheostomy(hole in her windpipe) was done in order that she could breathe through the hole.
Her vocal box was completely removed and closed so her only way of breathing was through the hole.
By covering the hole partially ,she was able to utter some gutterial sounds which required a speech therapist to teach her to talk again. 
Nowadays there are mechanical and electronic devices which can placed in the vocal box area to help the patient to talk
In the meantime she was recovering from her surgery in the ward.
Strict instructions was given to made sure the tracheostomy hole was not blocked and free of infection.
 In the meantime I used to communicate with her through hand gestures and some written words.
She was cheerful in spite of her illness and I used to try to 'talk' to her with hand gestures and written words to keep her in good spirits. 
Her relatives were also helpful and kind to her.
Once her condition was well enough to return home, she was discharged. 


She even send me a thank you card for taking good care of her. 
This was the one of the satisfying things about being a doctor. 
It is always important to treat a patient well as another human being rather than a medical case. 
When you treat a patient well and kindly , even other patients, nursing staff ,and hospital 'amahs'(helpers or assistants) also know about it and treat you just as well.

In all, the ENT department was one of the satisfying department to work in and very essential to learn about managing a patient in the family practice.

Not many family doctors know how to remove a fish bone from the throat, a small marble from the nose of a child, remove wax from the ears, bleeding from the nose or treat peritonsillar abscess