Wednesday, January 27, 2016

Last days in Nambour Hospital

What a ride it has been!

My past two years in Nambour have been nothing but spectacular, fun and adventure-filled. There were stressful times as well, occasions where i have made mistakes and felt terribly sorry, or got scolded by bosses or nurses. But all in all, I have had such a great time and I am bringing so much precious memories with me.

I have just finished two and a half months of night shifts. Night shifts are scary. You are the only person representing Department of Surgery and you have to be able to deal with all kinds of emergency in the hospital. Bleeding, perforation, obstruction, peritonitis, trauma were some of the common emergency we have to deal with.  I was feeling really anxious prior to starting my night shifts, worried that i might kill someone or not be able to save someone due to my incompetency.

I am glad to say I have done neither. Some of the really interesting moments were dealing with massive upper GI bleed post Whipple with Dr Aseervatham and Priscilla, massive lower GI bleeding from radiation proctitis with Thushara, a couple of open splenectomy with Dr Grieve and Dr Aseervatham, laparoscopic assisted small bowel resection for closed-loop SBO with Scott, a laparotomy and adhesiolysis with Dr Donovan, and a perforated diverticulitis with Priscilla and Peter. Every surgeon has a unique way of operating and i have learned so much from all of them. Dr Aseervatham is very particular about techniques, and always tells me to learn how to operate with both hands to the point where i forget which hand is dominant. One night, he had to come in to do laparotomy for upper GI bleed post Whipple. We started at around 10pm and finished at 2.30am. This was followed by a Hartmann procedure for a 120kg man with LBO. We started at 3.30am and ended up finishing at 6am. He had been up for 24 hours, spending his last 8 hours performing really stressful operations. Yet he never complained. He remained very calm and composed. I am so touched by his dedication and perseverance, and i hope i could emulate him when i am a practising surgeon.

I also really like Dr Donovan's minimalist approach to operating: where he does only the absolute necessary during operations, things that truly matter to patient's care. He doesn't waste time doing unnecessary manoeuvre, and he has a great sense of judgment in knowing when to and what to do when dealing with complex situations. I just wished i have done more emergency shifts with him.

Not to forget all the smaller operations I have done with the registrars. I have done about 15 laparoscopic appendicectomy with Anna, Kim, Katherine and Peter. All of them have taught me important lessons in doing a safe operation. I feel i am ready to do one on my own now.

I am going to miss all the residents i have worked with. Harrison, Bryan, Stephanie, Madeline, Isabel, Sean, Edwin, Fiona, Dave, Tahira, Chris, Karina, Ali, Stuart, Sam, Claire. All of them are awesome residents and are much better than me when i was one.

All the nurses in 1B and 1C - I can't finish naming all of you. Helen, Leanne, Jen, Ae-ran, Sheree, Roshni, Maggi,  Sarah, Nicole, Abby, Trilby, Kate, Jade, Maria, Jacki, Jenny, Raj, Bronwyn, Sharna,  Bec, Coralie, Deidra, Cadie, Trevor. You guys are amazing.

The specialist CNC - the beautiful Lauren, Erin and Caroline, you ladies are doing such a great job.

All the other doctors from other specialty. Lisa, Vinesh, Neil, Julia, Anjanee from Medicine. Graham, Karin, Nicola, Ben, Paul, Lauren, Courtney from ED (thanks for your non-stop referral during nights!). Mark from Ortho. Paul, Jonathan, Troy, Madeline, Glenna, Dan from Radiology. Chris and Andrew from Ultrasound.

Too many people to name. Thank you all of you!

Now I am off to Caboolture to begin the next chapter as a SET 2! See you again!

Running with Dr Donovan
All the awesome registrars - Manilka, Linda, Scott, Kimbeley, me and Peter
Anna, me, Peter and Manilka
Thushara (red) - the most friendly consultant who has helped me tremendously in my career
Dr Grieve - the person behind all the research projects in department of surgery in Nambour Hospital. I did both the colonoscopy and lap trainer research with him.
Operating with Dr Aseervatham - my mentor. What an honour.
The hallway to work

Sunday, November 15, 2015

Jim Pryor Begonia Prize, Provincial Surgeon Australia 2015

On October 30, I attended the Provincial Surgeon Australia conference in Lismore, NSW. 

I was there to present my research (Development and Evaluation of an Inexpensive Home-Made Laparoscopic Trainer for Surgical Training) for the Jim Pryor Begonia Prize. There were a total of 7 presentations. 

Jim Pryor was a distinguished General Surgeon in the City of Ballarat from 1963 to 2002. The Jim Pryor Begonia Prize, was a memorial to Jim's contribution to country surgery. He conceived the Begonia Prize session of the PSA annual meeting to enable surgeons to exchange views about procedures large or small, instruments they had found useful or techniques they have found worked. The presentation had to be brief (3 minutes) and he instructed the Judge to award extra points for originality. 

At the end of the session, i was announced the winner. I had such a great time at the conference meeting new friends and learning new things. The GALA dinner on Friday was especially memorable, to see all the surgeons letting their hair down and dancing like there is no tomorrow! 

Next year's PSA will be held in Albany, Western Australia, in early August and it promises to be a great one as well!

Sally Erickson (right) - finally got to meet the lady who is behind every GSA event

John Henderson - this man has a spirit of gold. In his 80s, he still contributes to every RACS event by being the photographer

Dr Graeme Campbell (right) - receiving Rural Surgeons Award for his contribution to Rural Surgery

Dr Stephenie Weidlich (left)  - Surgeon from Darwin. She was the person who suggested i should present my research idea in PSA! She also recently Supervisor of the Year award from RACS. Thanks Stephanie!

Here is my presentation

Good Afternoon ladies and gentleman.
One disadvantage of working in regional or rural hospitals is limited access to surgical simulation. If you are interested to purchase a commercial laparoscopic trainer to practise at home, a FLS (Fundamental of Laparoscopic Surgery) trainer cost $3360,
So I am here today to show you how to make one with just $84.20 in less than 30 minutes.
To construct a home-made laparoscopic trainer, firstly, we need a box. I got the IV fluids Baxter for free. The sides and the front of the box are cut.
We then fixed a white tile on the base to serve as a platform for laparoscopic tasks.
We then glued a strip of velcro onto the tile. 

We used four pieces of elastic bands each tied to a clip, and they are attached to the four corners of the box.

For light sources, we used a LED ribbon strip, and that was glued on the inside roof of the box.

We used a high definition Logitech C525 webcam with autofocus ability, and mounted on the side of the box.

We made two holes for the instruments.

This is the final product.

This is a list of materials and cost needed to construct the lap trainer.
This home-made lap trainer has been successfully validated by 30 participants in our hospital and found to be comparable to the FLS trainer, and it was extremely well-received by the participants as well. 

Now some of you may be thinking: What can i do with this home-made lap trainer? Well, sit back and enjoy.


Video: A collaborative effort between Dr Grieve and I (ps: he did the harder tasks)

Finally, the best thing about the home-made lap trainer, is even my son can play with it. 

Surgical Research Society of Australasia Meeting 2015, Sydney

I initially signed up for this research meeting without putting too much thoughts into it. I mean, I like research, I want a good platform to present a colonoscopy audit which I did last year, and I get to meet many like-minded people from all over Australia to learn from their experience and work.

I then got an email from the organisers saying that my research has been accepted for oral presentation. Yay! This is going to be fun. Then the organisers said after scoring by three independent surgeons, unfortunately my research wasn't eligible for prize. What?! My registrar presented the same research at the ASC Perth this year and won the general surgery best paper prize. Hmm.. Whatever. Maybe I was not pitching it to the right audience. Still I was going to make sure I do a good job in presenting. If anything, this would be a good practice for my own development.

On Thursday we had many speakers discussing on the topic of academic surgery, which is very fascinating topic. It seems like, to be an academic surgeon who operates, it's not quite the same as being a surgeon who happens to do research. The former has invested much of his time and energy in first getting a PhD, then building his research portfolio, and then being extensively involved in university roles of teaching, publication and mentoring, and somehow still be able to fit in some clinical work and operating. Sometimes this means taking a paycut to achieve these things, especially in his or her early days of starting the academic career. But the journey, they promise, is an extremely rewarding and satisfying one.

Professor John Windsor, an academic hepatobiliary and upper GI surgeon from University of Auckland, Professor Peter Choong, an academic orthopaedic surgeon from St Vincent and Professor Joe Hines from UCLA were the three distinguished speakers who shared about their life work.

On Thursday night, we had the academic forum. There were three short talks and a three-course
dinner. To my pleasant surprise, the director of surgery from my hospital - Dr Ratna Aseervatham who is also my mentor, turned up for the forum. We sat in the same table with Suzie, theatre coach from my hospital, Fiona - a surgeon from Armidale (who sits in the generic surgical science exams committee) and another ENT surgeon - Dr Hamish Sillars from Auckland and his wife. Dr Sillars was there to receive supervisor of the year award for his contribution to education. We had some interesting conversation in our table about some quite controversial topics which I shall not reveal much. I also got to tell Dr Aseervatham an extremely busy, chaotic and interesting night I had 2 days ago. He is my mentor, and I value what he says about how I can further improve.

On Friday, it was the surgical research presentation day. My presentation was in the last session at around 4pm. The chair - Dr Andrew Hill started by saying that this is a premier platform to present one's work. Yes ASC is good, GSA is also good, but this is truly the best. I chuckled. I thought he meant it as a joke to make us interested.

As the presentation proceeded, it became quite clear he really meant what he said. Highly specialised research, well thought-out question, advanced methodology, equipped with sophisticated statistical analysis were the type of research that were presented. To be quite honest, I probably only understood about 50% of what was said, but I pretended I did, laughing at joke which I didn't quite get and clapping my hands in agreement when I saw everyone else doing so. 

I met Siobhan Fitzpatrick, a final year medical student from Griffith University who is also the chairman of SURGIA (students surgical association)- an extremely bright and industrious young lady who aspires to be a plastic surgeon. We both sat at the back and lamented on the lack of emphasis on research that is inherent culture in QLD. Too bad she is moving back to NSW to begin her internship in Royal Northshore Hospital. I can't believe she couldn't get her first choice hospital in QLD, and was to be sent to Townsville Hospital instead. It's a loss to QLD then. But I am really excited for her for the opportunities that lie ahead.

At the end of session 3 just before the final session, I was ready to run away. Compared to what others have presented, mine is like child's play. Why did I submit my abstract in the first place?! Everyone is going to laugh at my miserable attempt! I went to the chairman of the final session, Marc Gladman, Professor of Colorectal Surgery at Concord Hospital, and told him how I felt. He kindly reassured me and told me to never look down on my own work. He said there is a value in outcome-based research (which was what I was doing), good stuff can come out of small studies. 'This is a friendly audience' he said. 'You will be fine'. 


For the last 10-15 minutes before my presentation, i started to visualise everyone in the room as my best friends and family to help to calm my nerves. I had been in similar position before. There is no turning back now.  'Should i take along my script?' I was debating with myself. 'What if i forget what to say?' The thing is, in all my previous presentations, i always have my script with to me. But i also realised this was a crutch which was hindering my presentation. I made up my mind at that point that i wasn't going to rely on my script. If i don't step out of my comfort zone, i would not be able to improve. 

The hardest thing for me in any presentation is usually the beginning - the first sentence. You need to get the tone of voice, the enthusiasm and scene right. But the problem is, once i realised i was in front of a group audience a lot more senior and smarter than me, i usually freaked out. I would go on an autopilot mode, stared intensely at the laptop, and just fired memorised words from the script without truly communicating with the audience. 'I need to get the beginning right!'. The first 20 seconds will determine how the rest of the presentation go. 

I made a mental note to take the first 5s to just look and smile at the audience before i started talking. This is a mental checkpoint for me, to remind myself that effective communication is just as much the non-verbal as the verbal. It's more an art than a science. It's also to slow myself down psychologically so i could ease into the beginning seamlessly.  

Marc Gladman said at the beginning of the session that according to sales psychology, we only have 60s to convince people if they were going to buy the idea. I was going to use my first 60s well. 

The presentation went well. It was quite well received by the audience. I have kept my points as simple and as interesting as possible. Some remarks during the Q&A were 'this is one of the most politically correct conclusion you have made', 'your mentor must be very proud of you' etc. 

Alas, i had made a break-through. Whereas previously i would be crippled with fear before and during a presentation, i am now able to look at the audience and communicate. Wow. What  a feeling!

The meeting concluded with prize presentation. The young investigator award went to an orthopaedic surgeon from Victoria, Dr R Mittal on his topic of CROSSBAR (combined randomized and observational study of surgery for type B ankle fracture treatment): Results of a multi-centre RCT who, at the time of the prize presentation, had left. The chairman of the meeting immediately announced that he was disqualified from the prize because the rules had clearly stated that prize winners must stay till the end. Another surgeon from NZ - Dr Mohammed Amer, won the prize on his topic - Preoperative carbohydrates for enhancing recovery after elective surgery: A multiple-treatments meta-analysis. I was especially impressed with a presentation by a medical student - Chen Bi Yi from NSW on Radiation-induced gene expression of Tissue Factor, Thrombomodulin, Cadherin 5 and Catherine 13 in cerebral mouse endothelial cells. I later asked her if she was also a phD student, since there were many of them in Sydney. She told me no, that she was doing her MBBS in Albury - a regional area in NSW, and travelling to Sydney during her holiday to complete her honours in research. Amazing! 

I spoke to Professor John Windsor at the end of the meeting and told him my interest in Academic Surgery. Professor Windsor is one of the most well-regarded academic surgeons in Australasia, and the thing that attracted me is not so much his achievement (although it was massive), but his ease with people. His humble nature makes it easy for anyone to approach him. 

'Do you want to be an academic surgeon?' He asked me. 'It's a little too early for me to be absolutely certain if this is the path for me though i really enjoy attending meetings like this and i will continue to attend future meetings to be inspired by people around.' I said. 

'Well, i can see that you are being infected by the research bug now. The best advice i can give you, now that you are in the surgical training programme, is to work for a year, and then take 3 years off your training to do a PhD, and then resume your training again. Time and time again i see people making the mistake of leaving their PhD till after they complete the surgical training, and they lose out of the benefit of being equipped with these skills early in their career. Doing a PhD during your fellowship will also mean that you won't enjoy your fellowship and you can't fully focus on the subspecialty training. Besides, a lot of the fellowship programmes out there are very competitive, and having a PhD will certainly help you when applying to these programmes.'

'It's risky business i know, to interrupt your training, take a pay cut to do your PhD. But in the long run, this will be extremely beneficial. Trust me, i know.' He said. 

'Well, i don't know what your family circumstances are, but if you are interested, i would be more than happy for you to come to Auckland to work with me. Currently I have 46 PhD students in my department. I would be happy to mentor you in this process. Here is my name card. Just email me if you have any questions.' These were his parting words. 

This is a very difficult decision to make. Is this the path God has set for me? Whilst i love research, i don't want research to take me away from patients, who are the reasons i set out to be a doctor in the first place.

Taking three years off work and formal surgical training also means i have to take a significant pay cut to do this. Would I still be able to feed my family? Three years seem like a really long time. I would surely forget a lot of my surgical knowledge and operating skills. Will i struggle when i resume surgical training?

Anyway I am glad I don't have to decide now. 

All in all I had a really great time at the surgical research society meeting. I came home being inspired by the people that i have met and the high quality research that were presented. I am more determined than ever to produce a stunning piece of work too in the near future!

Friday, November 13, 2015

The story behind Blackall 100

I have always wanted to run a fast road marathon in home soil, Malaysia.  

In 2013, I was in the best shape (fitness-wise) of my life and was ready to give Standard Chartered KL Marathon a crack. Unfortunately the race was postponed due to haze. We were notified of news just 3 days out from the race. I was deeply disappointed.  

In 2014, I took a break from running to focus on family and work. We had Jonas in July and it was a great joy having him in our lives. At the same time, I was working hard to complete my surgical exams and trying to work hard to get on the surgical training programme. 

In June 2015, I decided to start training for a road marathon again. I thought this is probably my last chance to have any reasonable amount of quality training prior to commencing surgical training in 2016. 

I thought i needed a structure in my training, instead of just running by feel. So i used the Hanson Brooks training programme, one which Sage Canaday was a part of. What i like about the training programme, is that there is a good variety of work-out, with intensive work-out sandwiched between easy days. Also the weekly mileage is usually around 60-85km, which was something i could handle, given how busy and tiring family and work are. Yes ideally i would prefer to run 100km per week, run twice a day and on a variety of surface including trails, but i know my timetable would not allow that. So i would wake up at ~5am most days, put on jacket, gloves, head torch, and disappear into the dark cold winter dawn. I would run for ~50-70 minutes and return home. Some days were extremely challenging, and some days i just felt like sleeping in and skipping the run altogether. 

After 2 weeks of training, I ran 1:29 for Gold Coast Half Marathon. Surprisingly Ryan Hall (America record holder in half marathon, 59:43) was the pacer for the 1:30 group so I enjoyed his company most of the way.  We chatted about his life and the Big Bear Lake (where he first felt the calling to be a runner). I was awestruck by how humble and simple he is. Whenever we reached an aid station, he would always reach out for water and pass them to the runners in his group.           

After 2 months of training, I ran 2:56 for the Sunshine Coast Marathon. This became my first official sub-3 marathon. 

My ultimate aim was to run the BSN Putrajaya Night Marathon on 24 October.  I was aiming for the podium in the national category.  However, my worst nightmare was once again realised. The race was canceled due to to haze.

Just when i was overwhelmed with disappointment, my boss Dr Donovan asked me to consider doing Blackall 50km instead, which is taking place just 15 mins from my house in Mapleton forest.  Thinking i had nothing to lose, i signed up for the race.  I hadn't done any trail running prior to this and was quite anxious about my ability to run a 50km trail race since all my training was on the road. I did a 40min test run in Parklands forest the day before the race and my leg muscles quickly decided they weren't happy with the rocks, uneven terrain, climbing and pounding. 

On race day, I was struggling in the first half, almost tripping over the rocks or tree roots in a number of occasions, and barely holding on to second place. Scott - who was in first place, continued to increase his lead on the rest of the field. At one point, i sort of just gave up any hope of catching up with him. There were a lot of negative thoughts, voices which told me I had made a mistake signing up for this race. The trail also became quite  technical and challenging as i ran along, and i struggled to find any sort of rhythm. I knew this was going to be a long day. 

What happened subsequently would be a major turning point in this race. 

I found that as I learned to ignore those voices and focused on placing one foot over the another, i could almost visualise layers after layers of cynism, disbelief, fear (of pain and suffering) being stripped away. It's hard to explain this process. The feeling is like: I have hit the rock bottom, and i am still alive. Why not just persevere and see how the body feels. Moreover, my dormant trail muscles must still retain memory of my past training. They slowly become activated, and i became to feel at home running on trail. My spirit also began to feel lighter and freer. I have arrived at a mental state I have never been before, and I started to feel stronger. 

At about 44km mark, to my surprise, i caught Scott. He must have been shocked to see me, and like a hunted animal, he quickly responded by running faster. I was determined not to lose him again this time. We ran stride for stride for the next 2-3km. Finally we reached a long section of road. This is the last stretch of road leading to the finish line. My undertrained legs eventually decided they have had enough and I finished in 2nd place in 4:39, about 40s behind the winner. We were both under the previous course record of 4:45.

Here is the newspaper article on the race, which briefly described the final 7km battle between Scott and I.

Gun off
Crossing the creek
Oh how i miss trail running
Crossing the finish line
Ringing the bell!
Prize presentation
Jonas clapping his hands :D
Top three men. Scott (winner), Matt Eckhard (2nd runner up)

Sunday, June 21, 2015

(T - 2) days

I went for a run this evening. I felt much better and refreshed after the run. It wasn't that I was able to straighten my thinking or come to some sort of enlightenment about the interview during the run. In fact I achieved neither. It was just simply being able to get out there, getting my mind off the interview, and doing something that I love that helped me feel better.

Why am I so worried about the interview?  My colleague made a casual comment this week saying: 'Ah jimmy, don't be so stressed. I am sure you will do fine.' I thought to myself. Of course I will be fine. But the point is not about being fine. The point is about having a perfect interview. Only a perfect interview would give us a reasonable chance of getting into the programme.

I am sure i am not the only person thinking of it this way. And here lies the source of all stress and anxiety.

Stressful times like bring me closer to God, as it always does. When i have come to the end of myself, the only person i can go to is God. Obviously there is a hypocritical component to this, in that i only go to God when i am in deep need. Other times, i just lead my own life the way i wanted to. It feels like i am only 'using' God to help to advance my career. But this is, of course, not entirely true. I also go to God for comfort, for guidance, and to find rest when i am heavy-laden. Like a little child who has lost his way, or has nowhere else to go, I run to God.

I think the thing i need to be most concerned now is not the final outcome, neither should i be worried about things like: Will God bless me? Am i holy enough for God to bless me? Or should i spend more time with Him so He would bless me? These questions, while valid and are very human, focus on me utilising God for my own purpose rather God using us for His purpose.

I need to focus on a few truths instead.

First, God loves me and has given His Son to die for me. (John 3:16)

Second, God has a plan and purpose for my life, plans to prosper me and not to harm me. (Jeremiah 29:11)

Third, God's timing is perfect (Ecclesiastes 3). If i don't get on, it will only be because i am not ready, and that there are things God wants me to learn and experience He wants me to have before getting into the programme.

Fourth, I can go in His confidence and do my best for His glory (Philippians 4:13 & 1 Corinthians 10:31).

I surrender it to Him.

They keep me going

Thursday, June 18, 2015

SET interview (T - 4 days)

Next Tuesday I am attending an interview for the surgical education training (SET) programme. This is the final hurdle, after curriculum vitae scoring (15%) and referee report scoring (60%). This is where trainees are subjected to a series of questions in a broad range of topics to decide suitability and aptitude for the programme. During the interview, you come face to face with very experienced surgeons, where you can't hide your defects in knowledge, nervousness and lack in experience. 5 stations. 10 minutes in each station.

Last year, around ~500 people across Australia applied,  ~400 people were short-listed for interview, and 54 people were selected into the programme. This year, approximately ~300 plus applicants across Australia applied, 150 were short-listed for interview, and eventually only 50 people will be selected for the programme.

It's been an extremely difficult week for me. Somehow I just felt I am not in a good mental shape to attend the interview. I have been doing some reading and practice with friends, and my answers always come short. I am not able to think of an intelligent answer on time, much less structure my answer properly in a concise and clear manner. What comes out is usually just a random ball of mess.

I just don't believe I belong there. I felt like I don't deserve the interview. I felt others who have worked hard deserved more than me. I am frightened. I am frightened by the fact that i will be staring at the interviewers with my mind go blank on the interview day.

Time is running out. I have 4 days to get my shit together. 4 more days to D day. I am still in a mess. I need a breakthrough in my mind and spirit. Lord, I desperately need You to come through for me.

Monday, March 30, 2015

Devotional run

I just came up with a tentative race calendar for this year. Part of the reason for planning ahead is to give myself motivation to train. I was scrubbing with my boss one day (who also happens to be my running buddy) and commenting to him that I struggle to wake up in the morning to run. He said just sign up for one race and you will find yourself getting up when the alarm clock goes off.

For this year I have intentionally chosen to stick with the shorter races. Nothing more than a marathon. With increasing responsibility at work and home, I just don't have the time to train for the longer stuff. So I hope to run more shorter races and participate in cross country series or park run to get my leg speed up. This all accumulates till the end where I am hoping to run a fast marathon in Malaysia (either KL marathon, Putrajaya Marathon or Penang Bridge Marathon).

For the past week or so, I have been able to establish a routine for morning devotion and running - two of the most important activities in my life to keep my spirit nourished. I usually get up at 5am and head up for run, I would also put on my iPod and listen to sermons/short messages at the same time, I just find it really refreshing to listen to God's Word while running. Whereas in the past, my mind would be blank or thinking random thoughts when I was running, now I find my mind more active and alert to take in and meditate on God's Word.

I am not sure how long this will last. I may one day find that family and work get so busy that I don't have time to head out for a devotional run in the morning. I hope this won't happen of course. But i don't know what the future holds.

Already God has spoken so much to me in the past week during my devotional runs. I have been listening to Rick Warren's sermons on building financial fitness and realised that I really have not been very prudent with my money. So this week I have put up my new Salomon sense pro and inov-8 race ultra 290 (which I purchased last year bcoz I really liked them) up for sales in eBay. I don't need them really. I just thought it will be cool to 'have' them.

I am looking to hearing more from God in the coming days and weeks.