2014 retrospective Part 1

A year away in Tasmania - what a year of being blessed in so many ways! The downer is of course being apart from Penny (quite a big downer too!) but overall the year has been a good one - which I hope to recap for posterity in the next few blog posts.

Melbourne skyline from the Spirit of Tasmania












Hobart - have nothing but good things to say about the town, the food, the church, the people at work, my housemates...could go on and on...

Royal Hobart Hospital - where I started my journey into Renal medicine, poking kidneys, tweaking dialysis machines and eating countless chicken parma sandwiches 


















Scallop pie in the small town of Ross...my first meal in Tasmania

Walking down from the hospital on Argyle Street, with the flyover on top of Pilgrim Coffee (best coffee in Hobart for my money!), I could get to Constitution Dock in ten minutes, with its array of fish-n-chip shops and countless places to eat, while fending off over-inquisitive seagulls.


My housemates and I spent most of the year in a huge townhouse bordering some community housing, which made our days (and nights) interesting - the time we each thought someone had left a cloak on our front porch, which turned out to be a really thin boy stoned out of his mind....or the times we called the police to break up fights that occurred outside on the street, or the night someone ran into my housemate's car and drove off in some hurry...

One of the great things about Hobart was how one could get to amazing scenery within an hour's drive or less! Mount Wellington, the beachside cliffs of the Tasman Peninsula, or the forests of the Central Highlands are all within reach...

The view from the top of Mount Wellington on a clear day - blustery winds are worth it!

 Walking around Salamanca Market on a Saturday morning..arts and crafts, secondhand books, plants in weirdly shaped pots and the smell of roasting sausages in the air..

 The chef himself, from Masaaki's in Geeveston at Farmgate Market (on Sundays in Hobart). The queue was crazily long, so it took an early start to be able to get (finally) the finished product!

Also, the best peanut butter I've had so far is found in this market! About the only thing I carted home in bulk from Tassie..

An early morning's fishing trip with Mr Flathead - where we ended up with way too much flathead and ended up cooking them three ways!

 The weird and wonderful came together at the MONA (Museum of Old and New Art) - we had fun playing table tennis underground, rolling around in the room of joy(Which sounds dubious but is really a pink plush-lined room with los of little bumps to sit on and roll around on) and smelling the poo from the poo machine seen above.











Next up: how we severely depleted the oyster population and enjoyed the moonlit nights at the East Coast!

How I prepared for PACES

I had thought about writing this post for a while, if only to serve as a reminder to myself because I'll likely be needing to repeat the exam next year. But also I guess I'm hoping to give other first-timers to the PACES bit of the MRCP some idea of what to expect. Most of the following can actually be found on the PACES bit of the MRCP UK website as well.

First up, the format:

PACES is 5 stations of 20 mins with 5 mins break in between each station.

Station 1 is Abdo Exam (10 mins) and Respi Exam (10 mins)
Station 2 is History taking (20 mins)
Station 3 is CVS Exam (10 mins) and Neuro Exam (10 mins)
Station 4 is Comm Skills (20 mins)
Station 5 is 2 cases of either skin, eyes, locomotor or endocrine (10 mins each)

For the examination stations (1 and 3) you'll get 6 mins to examine and 4 mins to present your findings and be questioned by the invigilators (there'll be 2 in each station with one doing the talking).
For the history/comm skills station you'll get 14 mins to either take a history or resolve a comm skills situation (eg breaking bad news or calming a patient after a prescribing error), 1 min to put everything together and 5 mins to present to the examiners.
For station 5, you'll have 8 mins to take a history/examine each patient and 2 mins to present and be questioned by the examiner.

At the start of the exam you'll be ushered into a room with your other 4 candidates (5 to a stream) and have to fill out your name and examination/center number on 16 marksheets. These, togetherwith your steth, and a pencil are all you have to bring around as you go (though people have also brought their own opthalmoscope/pen torch etc - all these are provided).

You'll then be brought to your stations and have to wait for the bell to ring, signifying the start of the first 5 min break. When the bell rings again, the door opens, a friendly examiner's head pokes out and the exam begins!

In terms of preparation, the key books that I've been told about are Ryder's Aid to the MRCP PACES, Cases for Paces and Baliga's 250 Cases in Clinical Medicine. Certainly most people I've spoken tohave read through the first 2 of these. The other key is to form up a practice group with other PACES candidates and start compiling a list of patients with signs to practice on 2-3 months before the exam and testing each other(trying to get consultants/regs to supervise whenever possible).

A PACES course is a good idea just because of the sheer amount of patients with signs to see - there is always some practical advice worth gleaning from these courses as well (some of which I will try to reproduce here) and to get an idea of how you stand with other candidates in terms of preparation.

Practicing comm skills and history taking with your PACES buddies is also a good idea to get an idea of time (so you have a sense of how long 14 mins is in an exam situation) and the comm skills in particular are worth working through as there are some points to be gained from practice (eg remembering to ask how a patient is going home after breaking bad news - ideally someone at home with her and not driving alone)

Paces Tips I Should Remember:
1. When presenting after each case, its a good idea to take the steth off and put my hands behind my back and to NOT look back at the patient while presenting to the examiners.
2. When presenting a CVS patient, always a good idea to mention the presence/absence of 'peripheral stigmata of infective endocarditis and/or heart failure'
3. When presenting a Respi patient, always good to mention the presence/absence of 'pulmonary hypertension'
4. When presenting a renal transplant patient (in the Abdo station) always good to mention the presence/abscence of 'modes of renal replacement therapy eg AV fistulas and whether they are working or not, signs of immunosuppression'
5. Always good to give an idea of the diagnosis of why the patient has had a renal transplant, or an enlarged liver, or pulmonary fibrosis etc
6. Always mention the key phrases 'I would like to complete my examination by...' (differs according to each system eg CVS - doing an ECG, checking the urine for haematuria and checking the BP / Respi  - checking the bedside obs incl O2 sats, looking at the sputum pot, doing peak flows and checking for signs of heart failure / Abdo - checking the hernial orifices, checking for inguinal lymphadenopathy and doing a PR / Neuro - doing a full upper/lower limb neuro exam and checking for cerebellar signs)
7. So a complete presentation might sound like 'I've examined Mr X who looks tachypnoeic at rest with a RR of 22 breaths per min. He has evidence of clubbing and central cyanosis and has a productive cough. His positive findings on his chest were coarse crepitations on both lung bases which changed in nature with coughing. He had no evidence of pulmonary hypertension or pitting oedema to suggest heartfailure. My diagnosis for this patient would be that of bronchiectasis. I would like to finish my exam by checking the sputum pot, checking his bedside obs incl O2 sats and confirm my findings by doing bld tests to exclude infection as well as a CXR to look for evidence of basal consolidation. I would also send the sputum off for culture/sensitivity.'
8.Cases for Paces should really be the baseline reading book I think - its a good springboard to more xomplex stuff however Ryder is also well worth a read, if only for the pictures and the comm skills/history taking scenarios in Book 2.
9. I also used the Pastest Online website which is not, as you might imagine, an ideal way to practice for this exam - but it does give some idea of what to expect as well as some good pictures/spot diagnoses to look at.
10. Do a mock exam - useful to get an idea of what to expect and to gauge where you stand with other candidates - its useful after you'vedone some work, but even if you're not fully prepped, its good for that figurative kick in the butt! Also those who've done one don't seem to have that fear of the unknown on the day of their actual PACES.

All the best if you're prepping forit and if you're prepping from Australia, specifically Melbourne Australia, let me know and we can buddy up!

To those who say I don't bathe for long enough.

So I was thinking in the shower:

So who among us is good, really? The long-quoted phrase 'no-one is perfect' - how many of us would challenge this? Granted, being 'good' is different to being 'perfect' - we may be considered 'good' despite making mistakes. But even so, what is the definition of 'good'?

Oxford Dictionary lists the definitions (as an adjective) thus:
1. To be desired and approved of.
2. Having the required qualities; of a high standard
3. Possessing or displaying moral values
4. Giving pleasure; enjoyable or satisfying
5. Attributive; being thorough
6. Valid
7. Used in conjunction with the name of God or related expression as an expression of extreme surprise or anger

We can discard 4,5,6,7 from this discussion.

1. To be desired and approved of - whose desires/approval are we talking about? Each individual has different desires/ppl they seek approval from - therefore what is good differs from person to person. And this is where influence of people, for good or bad, is able to change the fate of nations eg apartheid in Africa, the Dalits in India, Nazism in WW2, 9/11 etc.

2. Again, whose standards are these? We may say we 'aspire to high standards' yet to others, our standards may be woefully low. What is impressive to me on the tennis court, is peanuts to Roger Federer for example.

3. Moral values, ah. This is the crux. To go back to Oxford, moral is defined as:

a.concerned with principles of right and wrong behaviour.
b.holding or manifesting high principles for proper conduct.

This is contentious; on one hand, everyone's right or wrong code is different. Someone may agree with cheating to get ahead as long as no one's hurt however others feel this is wrong. However we do consider some things that definitely are bad. eg. rape/murder/incest/abuse. Surely there can be no question of that? So, surely if we do not perform these 'morally condemnable' actions, we must be good, or at least, good-er than people who DID perform these actions.

But then again, is there a scale of goodness? Where we are ranked 6 above Hitler who is probably a minus something? And who decides this scale? Santa Claus?


Where am I going with this?

I put it to you, that the term 'good' is something relative, not absolute. And that all of us who compare ourselves to others do so on an individual code of morality (that is, unless you are of a faith that says differently, in whatever way).

And so the conclusion is, none of us are really 'good' or 'bad'. The closest we can come to deciding that (without outside help) is by judging each other, rather pointlessly in fact when we think about it (but which we are really, really good at). For good people do bad things, and vice-versa, despite the labels we give each other.

And I also put it to you, that this often-quoted question 'Why do bad things happen to good people?' is thus rendered inaccurate.

As in, bad things happen, there's no denying that. But the people that they happen to, are neither good, nor bad. Indeed (if I may be allowed to use an expression from what I believe), we are all sinners in need of grace.

What do you think?

The bulb has burst

I'm sure there's a more technical term to it, but then I'm only a medical student.

Someone asked me some good questions today. Among them was 'I am unsure about your intentions.' Which in itself isn't a question, as the more astute among you would have noticed. Nevertheless it gave me an opportunity to sit back and take stock. For all of half a minute, as she was still waiting for an answer.

I'd better explain.

Somewhere along the way, I managed to get coerced into leading in some capacity, the university students who come to Liverpool Chinese Gospel Church every Friday. A student leader, if you will. And the hows and whys have yet to be fully understood, never mind revealed. Actually to be fair, it wasn't a coercion, more of a quick decision, something I'll probably live to regret.

Hence the question. By one of the former leaders no less. Which sort of put me on the spot. And as all clinical examiners/consultants in Liverpool who've ever examined me before know, JLEH is not at his best when being put on the spot.

I'll save my answer for another post, my mind being bothered at the moment by the intermittent collapse of my corkboard. Apparently 9 slabs of blu-tack is not sufficient to hold a corkboard slightly over twice the width of my laptop on my wall without falling at least once a fortnight.


Had the manchester people over for the weekend. House cleaning was therefore postponed to monday and late sunday night. A slow start to the week.


I'm really going to have to start thinking seriously about where I'll be applying for house jobs next year. An open day in hospital tmrw, and a lecture on CV-writing in the afternoon...My CV is as yet, non-existent. Which just goes to show how unprepared I am for anything.

How in the wide world are 6 people going to go for a road trip in Wales exactly 1 week from now without having prepared in the slightest will be probably the subject of a couple of posts from this. When you look at the photos, in fact, all the photos from now on, will be taken by a Samsung E900 2MP mobile phone. Any complaints about how pixelated/grainy/underexposed/shaky the photos look, will hopefully reach the ears of the person(s) in possession of a stolen Pentax Optio somewhere in Msia (or maybe even abroad, with the wonder that is eBay).


Would upload photos of the past few days, but its a late night as it is.

There and back

Had a great summer month at home, now back in cloud-cast Liverpool and found out:

That I could have had a free lunch during my stopover in Dubai

That I've gained 6kg over 4 weeks

That I've far too many books that I'm loathe to throw or give away

That I'm not comfortable sleeping with just one pillow under my head

How hard cleaning a carpet actually is

How much my medical brain has slipped since finals

How much work 5th year actually entails


Baptism Sunday in church today. Packed to the brim like sardines, we watched as youth and adults alike were dunked into the heated pool, symbolizing death to sin, washed and made clean, rising up and out of the pool like Jesus - defeating death forever. Mandarin, Cantonese and English alike rejoiced at the sight.
More or less got my room in the shape its going to be for the coming year. The rest of the house is coming together as well. With any luck, we'll be able to have the juniors over soon for a meal.
Am thinking of getting more board games. Stack 'Em has been popular on 2 occasions when people have been over so far.
Am glad some of us met up to talk about where we see the student fellowship driving towards this year. With the student welcome coming up soon, we'll be well and truly started on the journey!

Thinking back on my summer, I'm happy that I managed to meet so many ppl, many of whom I didn't expect to see for some time. From secondary school friends to former pastors and mentors to IMU people, its been worthwhile seeing a brief glimpse of how everyone's been living. Although there was the odd moment when that weird feeling of not knowing what to talk about, not having seen one another for so long, at least i didnt forget anyones name this time around.

Hey

From 4 days in KL and Seremban, I'm feeling tired but content.

Seemed to be 4 days of non-stop meeting people. From chatting in malls to catching up after church services, to surprise birthdays and Starbucks till closing-time, it seemed to be one whole big eat-chat session.

Caught up with the IMU Seremban people with Jack and HP. Gracious enough to house us though major exams were looming up this week, and caring enough to help us look for our stolen bags in Jusco carpark. Met up with Sieh Jin and the WIFE as he calls her. In fact, marriage seemed to be the in-thing as I met up friends who are now happily married...there must have been at least 3 couples and one soon-to-be couple I met this last 4 days!

ECF was filled with more foreign people than I'd previously remembered, and best of all, more IMU students. Watching Ian trying to get the IMU-ers going after the service, I was reminded of Shawn (now Pastor Shawn) and Kevin trying their level best to rally us when we were in IMU. Everyday, the food court in Puchong still had their beef noodles but the fried chicken stall was nowhere to be found.

Too many people to meet, in way too little time. Talking with Ian the night before coming back, I was trying to process why is it I like coming back to Malaysia so much. Why do I feel so much more at home here despite being away for 2 years and counting? And somewhat sadly, I think its because of the memories I've left behind here. UK just doesn't seem to, I dont know...be that memorable yet?

In the meantime, I need to work through when I'm planning to fly back (if ever) to Malaysia and find out about visa details for work after 5th year. This weeks one-hour episode of Naruto takes first priority though.

Looking around my room

There's a lot of stuff to clean up. My cupboard is full of IMU notes, which surprise, surprise, I did end up needing at different times throughout the year. Books take up most of the remaining cupboard space, of these, the most dusty are the anatomy and pathology books, both rejected in lieu of oxford clinical handbook and a bit of paediatrics and obsgyn here and there.

Vikram Chandra's Sacred Games has taken the main book spot on my desk, previously filled by Pretty Girl in Crimson Rose(8) , Jesus MD, Ian Rankin's A Good Hanging, Coughlin's No More Christian Nice Guy and Strobel's The Case for a Creator. Yes, I like reading. The latest Harry Potter installment will be next on the list, can't wait till Saturday.

Then there's my laptop, behind which is squidged all the other paraphernalia necessary to ensure my multimedia needs are satisfied. Speaking of which, my laptop is close to 3 years old and still running sound as a bell! HP Compaq isn't too bad a company to trust.

Clothes have never been a big part of me, though I admit to feeling a warm glow inside whenever someone says 'You don't look too bad yourself.' And I realised; I DO have a comb. Found it the other day wrapped up in a plastic bag along with other stuff that I didn't unpack for the year. So there, Jack. Now I just need to learn how to use it.

This blog is becoming more inward looking by the day.

Wimbledon 2007

Wimbledon 2007 was an impulse decision on my part, to escape the long recriminating thoughts about how badly I'd done in my prior exams. A day of fun on the grass lawns of SW19 was in order. By a minor miracle, I managed to get cheap travel tickets, and found an unlikely hostel to stay in, and Tues morning found me at the back end of this:

The queue, I found, would wind in and out of Wimbledon Park and was close to, if not more than a km long. And they were serious affairs, these queues. Each of us was given a queue card noting our place in the queue and if we didn't empty our bladders before arriving, woe betide us, because it took us the better part of 4 hours before actually reaching the gate.

800 yards to go!

Wii....mbledon

After being cajoled into trying for Court 2 tickets, (Centre Court and Court 1 seemingly being snapped up by the brave folks who'd stayed overnight under and on top of newspapers and tents) I stepped into Wimbledon, the first thing I saw being:

V. Spadea and I. Ljubicic ( a name I still can't pronounce with a straight face) were scheduled to play first on Court 2, so that was something to look forward to. Meanwhile I met up with Jane and Jan Hoong, who had skipped audit and classes respectively to come.

We walked around the grounds. Housing 18 courts and two separate buildings housing Centre Court and Court 1 respectively, it had its own bank and 4 or 5 different places to eat. Strawberries and cream, champagne and Pimms' being out of our budget however, we trudged around, picking spots to return to later.

Centre Court - the south end

Around noon, I snuck away to Court 2, where I was fortunate enough to get a seat 3 rows away from the court.

Arriving early, I chatted with a friendly Indian chap sitting in front who had come yesterday, but was driven away by rain. Looking upwards, we convinced ourselves the good weather would last the day out.

After watching the ballboys/girls march out to take their positions, and seeing the net being measured and erected, Ljubicic marched out from the opposite side to great applause. Vince followed after, affably waving back to the crowd, a stark difference to Ljubicic, who, it seemed, was of a particularly stony disposition. Or perhaps he was getting ready for the match.

Ballgirls at attention

A tight match followed. Vince seemed a bit taken aback by the raw power of Ljubicic's serve and single-handed backhand, while not being able to fire himself up enough. After losing the first set 6-4, he tried to perk up a bit, with increasing crowd support, but still ended up losing the second set. Ljubicic, sensing victory, was on form and hitting winners past Vince every time the latter charged the net.

Spadea in action

The tide turned as Vince started to step into his shots, forcing himself to return Ljubicic's topspin serves on the rise. This saved him enough points to force a fourth set. Fired up, he came out firing and started holding his serve while attempting to break Ljubicic's almost-invincible service game. However, he was denied a few line calls by the umpire, whom he later suggested of being against him throughout the game. This break in concentration seemed to distract him just enough for Ljubicic to close out the final set after a nearly losing it at 4-6.

A comeback

Ljubicic after victory

Having wandered around to stretch my legs, I stayed for a set of David Nalbandian's game. My sister being more of a Nalbandian fan than I am, I decided it would make interesting storytelling. However, Venus William's match against Alla Kudryavtseva was coming up, so that took precedence.

Nalbandian in action

Court 2 was again full, with a crowd seeming to expect Williams to take apart her opponent. However the crowd was shushed by a first set loss by Williams against a girl who matched her stroke for stroke, and who made far fewer errors. Cries of "Go, V!" were heard as she took the second set. Line calls seemed again to decide the outcome of this match, when, as Alla led by 6-5 in the decider, she challenged the umpires and linesmen, shrugging her shoulders in the direction of her supporters. Venus managed a dodgy 7-6 win in the end.

Venus Williams getting ready

Wimbledon was my first time seeing scores of British get behind their countrymen and cher them on. The hill outside Centre Court was packed with people watching Tim Henman's marathon with Carlos Moya. More than one ferocious "Go it, Timbo!" was heard from an otherwise looking sweet-looking granny and the collective sigh when he lost a point was very well choreographed indeed. You can imagine the chaos that erupted when Moya double-faulted on match point.England unites to support Henman

When I have more money, more time and maybe someone else to go with (it gets boring standing in a queue alone), I'd like to return and see Centre Court for myself. All in all, Wimbledon 2007 will be one of the things I'll remember about the UK when I've left.

I'm going hiking!

Woohoo!

***

In a final bid to escape exam pressure 1 month before finals, a group of medical students decided to attempt the dangerous and death-defying ascent of one of the Western Lake District's most notorious heights: Blackcombe. At a terrifying 600 metres above sea-level, for many of us, this would test us physically as well as mentally.

Leaving a bright and early 830, we were joined by our GP and another, older GP who apparently did climbing just for fun despite being weighed down with rheumatoid arthritis (a joint disease). The first part went well, with a rocky path to the first hill.

The walk in the valley with a stream at the bottom was fairly easy, even for someone like me whose main exercise was the walk up 3 flights of stairs to Ward 6 daily.


Things took a turn for the worse as the climb became steeper. The group dwindled slowly, finally leaving this sad bunch of stragglers trailing behind.

With promises of a break 'after we reach the next ridge', only to be confronted by yet another hill, we trudged on. The views reminded us of how far we'd come, however.

And with a bit of hard work, we trudged onto the peak, where the others were there waiting. Besides the views, the sun was out and a breeze was blowing. Nice.

(From left: Dan, Adie, Ruth, Beth, Becky, Sharon, Rebecca, Steve and Rob behind. Matt in the jersey in front, Alex, Sarah and Natasha on the right)

(From left: Faz, Kofo, Chris, Hsupheen, Dr Richard and Dr Pogrell in front)

The view from the top..pity its a bit misty on the camera.

We'd made it. Now to the pub downhill for lunch and a pint.

Where we decided which dessert to have

And where others nursed their sunburns.

I wonder if I'm going to get any work done tonight... And I bet I'll have cramps first thing waking up tmrw morning.