Life in Surgery

I just finished a stressful night shift in the surgical ward. It's my 6th night in a row and the previous nights have not been easy either. There are a few sick patients who demanded a lot of time and resources from medical and nursing staff. At the beginning of my shift last evening, I also just found out that one of the patients i saw the night before was taken back to the operating theatre for emergency surgery yesterday morning and was found to have ~2L of blood in the abdomen. She didn't look that unwell when i saw her, just some abdominal pain which was present even before i came on. Her belly was soft, stoma was working, bowel sound present, good urine output and all her vital signs were within normal limits. The only thing abnormal was she had a markedly elevated APTT (test for blood clotting) whilst on heparin infusion (blood thinner) which we responded appropriately by withholding the heparin for 2 hours and re-commenced at a slower rate according to guidelines. The only I did not check at 2am was her haemoglobin. Bad mistake. In my mind, intra-abdominal bleed was not even considered because she must be my 8th or 9th patient this week who had markedly elevated APTT. All of them were fine and the APTT normalised the day after. Well, all but this lady. 

During the morning handover, I saw how the night registrar was being fired by all the seniors for the patients that he admitted. 'Have you discussed this with Dr H?', 'What did the urine dipstix show?', 'What was the reason for MRI cervical spine?', 'Can you get a normal lactate with ischaemic bowel?' Questions after questions. I imagine that must be extremely stressful and even humiliating at times when you could not answer your superiors'  questions.  It just re-emphasises that point that surgery is such a fine art of which the treatment, be it surgical or conservative, needs to tailored specifically, timely and appropriately according to patients' presenting complaints, clinical signs and investigation results. There is an old saying which goes: a good surgeon knows when to operate, a great surgeon knows when not to operate. Whenever bowels or organ viability and haemodynamic stability are in question, there is no time for delay. Definitive action is required and that's when most junior registrars run into trouble. Knowing when is a good time to ring your boss (mind you, i am talking about waking your boss up in the middle of the night to discuss patients and risk his/her wrath), having a coherent story and all the investigative results at hand, organising and liaising with members of other department to book a patient for surgery, and finally mustering the courage to call are certainly a challenge for every junior registrars doing night shifts. I am having anxiety and goosebumps even thinking about it. 

Last Thursday I just had my interview for the Surgical Education Training (SET) programme. It's the final hurdle to enter into the ever-competitive, much-coveted surgical training programme. The entry into the surgical programme is based on three things: curriculum vitae (which is based on work experience, research experience, achievement, awards and teaching), referee reports (you need five referees who can back you up) and the surgical interview. There is probably around 500-600 people in Australia fighting for 50 slots. So only about 1 in 10 would get into the programme. The interview consists of 5 stations, each station manned by 2 experienced surgeons, 10 minutes per station. 

The interview was very stressful. The time is so limited and the surgeons all kept a straight face. Throughout the interview, they either remain silent or they ask: anything else? anything else? anything else? It just gives you a deep sense of inadequacy that you are missing something. 

I think i did average. I was feeling reasonably confident and happy in some stations and doubtful in others. This year where only 1 in 10 would get a spot, average ain't going to be enough. You have to be extraordinary in your performance to stand a chance. 

One thing i am happy with myself though, that is i did not ask for the interview questions from those who had finished the interview. I felt God had spoken to me, to put my trust in Him and to do it His way.  One day before my interview, I saw my registrar in the hospital and he was telling me i would be silly not to know the questions beforehand. The interviewers would be more strict because they expect us to already know the questions and have come prepared. But I have made my mind to do it God's way. If i want His blessing and favour in my application to the programme, I must put my trust in Him, knowing that He would open door for me which no one can shut and close door which on one can open. 

Dead gut

Missing our days in Delaneys Creek

Running at the backyard of our house

Running - compared with surgery - is a so much more relaxing and free

Love the smile on Rachel's face :D

Reflection 2 - work

Two years ago I made a decision that I was going to invest time in pursuing my hobby and passion of running. I had just finished medical school, in what many deem to be potentially the five most stressful years of one's life, of intense studying, burning late night oil, attending lectures after lectures, memorising terms, jargons and conditions which we dont use everyday etc. I thought maybe it's time to take a break from studying and spend time doing other things which I love. After all, if there is any period I can take a break from studying, right after med school is probably the right time to do it, since in specialist training years, it is pretty back the same old days of mugging and burying under books again, where we are put through countless vigorous hours of medical training.

It's a decision I didn't regret.

Now that I am almost finishing my short running career, it's time to start planning my next move - one which most likely will demand more of me than running does, and carries far-reaching implications and influences than anything that I have ever done with my life. My next goal in life is to train to be a surgeon.

As with anything, I will begin with big picture. My dream is to be a highly competent and compassionate general and trauma surgeon working with the top surgeons in the field from all around the world, being actively involved in research and discovering new treatment and therapy, participating in humanitarian and missionary surgical work in the war-afflicted and poverty-stricken countries, and in training and educating the next generation of doctors.

Dream will only remain as dream if we dream with closed eyes. Those who dream with open eyes, however, are dangerous, as their eyes will have its unwavering focus on what's ahead, to see what steps to take to get nearer to the goals, and to help evaluate the present situation and circumstances one is in. Whether or not my dream will be realized, it depends on how I can allow God to guide my every step and to open my eyes to see the truly important things.

To get to where I want to be, i need to start with little steps. I need to see as many patients as possible as possible, to learn how to assess them, practice my clinical skills so I can arrive at the correct diagnosis. I need to learn how to manage their conditions, to learn how to recognize the seriously ill and distinguish those who need urgent intervention from those who just need ongoing observation. I need spend a lot of time studying - especially in the subject of anatomy, physiology and pathology - for they form the foundation of surgery. I have noticed that so many surgical residents and trainees tend to neglect the basic, and want to dive straight into operating and journal reading. I firmly believe in building a strong foundation and knowledge for which other things build on. Besides, I also need to get myself out there, to meet the different surgeons, to learn from them, from the way they take history, to the way they operate on patients. Operating skill is an art which takes a lot and a lot of practice to master and perfect, and good hand-eye coordination, three dimensional thinking and precision are needed.

Traditionally surgical training programme is one of the most competitive ones out there, and rightfully so, because patients' lives are entrusted to the hands of surgeons. Before surgeons can earn the right to cut open patients' bodies, one needs to prove he or she has superior knowledge of the human bodies, pursuing excellence in everything she does, being subject to the most vigorous and stressful training, and has outstanding track record in academic and research work. Moreover, knowing the right people and having good network and connection with other surgeons are paramount to successful entry to the programme. These older surgeons have to have the confidence in you to train you.

Running has taught me many things. Amongst them is the ability to persevere in adverse and trying environment. Surgery is one such environment, where good and bad surgeons exist together. Traditionally surgeons are notorious for having the God-like complex, being inflexible and bullying others into follow his or her way only, and sometimes being downright rude and condescending towards other staff who are not quick to learn something. I am not saying you don't have problems in other medical specialties, it's just that the kind of personality that exists in surgery (which is the reason why they choose surgery as a career in the first place) makes you have to be on your nerve at all times. A stupid mistake or a wrong first impression can be disastrous, as I have seen in the career of some of my older colleagues.

Galen (year AD 157) attends to a wounded gladiator as the crowds bay for more blood

Andreas Vesalius  (1514-1564) - the father of human anatomy

A 'muscleman' illustration from Vesalius' De Humani Corporis Fabrica (1543) - alludes to his foray into body snatching

John Hunter (1728 - 1793) - challenged the traditional teaching of medicine started by Hippocrates and advocated careful observation and scientific method in medicine. A trip to London where his brother worked as an anatomy teacher and gynaecologist when he was 21 changed the course of his life as he took on an interest in human body

Walter Lillehei performs open heart surgery using cross-circulation in 1954. 

Dr Ben Carson (neurosurgeon) - featured in the movie Gifted Hands (2009) - a must-watch! He is well known for performing controversial procedures on the brain which others would not dare to and he is one of the first neurosurgeons who successfully separated a pair of siamese twins (joined at the head) in an operation which took 22 hours. 

Modern day surgery

I will miss running. I will miss following the news of the latest ultra and seeing the development of the sport. I will miss the thrill of toeing the starting line knowing you have done your best to prepare for a race and will demand nothing short of an honest and out-all effort. I will definitely miss the post-race camaraderie with other runners, discussing our race and training strategies and future plans.

I believe running has prepared me very well mentally and psychologically for what's ahead. To do well in anything, be it running, studying, playing a musical instrument, or being a salesman, one needs an incredible amount of inner motivation, a strong and fierce dedication toward excellence, lots and lots of hard work, and a good dose of wisdom in maintaining healthy work-life balance.

Reflection

As the year comes to a close, I thought I should reflect upon the year which has passed, and then prayerfully seek for directions and guidance for the new year.

So many things happened this year: I married the girl of my life, we set up a family of our own, we went to Europe for the first time for our honeymoon, I participated in a lot more races and widened my experience in trail ultra-racing, there were setbacks at work, there were valuable lesions that I have learned at work, a dear friend passed away in a waterfall accident, my love for God and interest for spiritual matters fluctuated a lot this year, one of my best friends broke up after a stable relationship of four years, I took a break from running after northface singapore etc. As much as I have tried to plan my life a certain way to avoid disappointment and keep things under control, unexpected things happen which swung me out of balance and my comfort zone.

Bachelor's Party with the 2 Js. 

Marrying the girl of my life

Caleb (middle) - one of my best friends got married this year

Honeymoon in Sweden

Northcape - watching midnight sun

My brothers in Christ

Bringing my in-laws for a walk around our house

The two horses who live with us

Fraser Island

Kevin (right) - a man who has such a big heart for people, passed away in a tragic waterfall accident while trying to rescue someone 

Adelene Williams - a friend in my hometown, who is both beautiful and godly, passed away in a tender age of 28 from SLE

No matter what the events are, it seems like the objects of my reflection always revolve around these five themes: God/spirituality, marriage, running, work/medicine, and friendship. Each of the above subjects deserves a proper look into as they are things which i hold very special in my heart. My walk with God has been very shaky and sometimes almost non-existent, especially toward the later part of the year, mainly because i have wilfully chosen not to place Him first. As for marriage, it has its ups and downs. The joy of having a companion who shares the same bed and roof as you is so very real, which on the flip side, also drives each other mad sometimes. I will talk about these some other time.

For this post, i will share what I have learned from running this year. I have learned that if you put your heart and soul into something, be willing to work extremely hard and suffer, you will most certainly achieve what you set out to do. I have surprised myself in many ways in my running journey this year. I would say from the outset that I have never been a great runner. I only really picked up running when I was 16 and I have been inconsistent in my training, hence producing only very average results. Prior to 2012, I have never officially ran a sub-40 min 10km or sub-3hr marathon. I never thought there were possible for me. It's only in 2012 when I started training high mileage(~100-140km/week) and throwing in some high intensity work-up that I began to see that maybe I have been wrong all these while. What i had done subconsciously is setting limitation on myself such that I never even dared to dream of doing something faster.

Look, no one taught me how to train before. I never had a coach, or a training manual which tells me the purpose of each type of training run: long run, tempo run, fartlek, speed intervals, uphill sprints, downhill sprints etc. After reading Born to Run in 2011 when I was in South Africa, I got infected with the running bug and started running long distance as I wanted to see how far and how long i can go. After finishing first in TMBT 50km 2011 (my first win in a major race), I started to believe that maybe I do have what it takes to run fast, especially in ultra-distances. 2012 was a year of alternating intensive high mileage weeks and injuries for me. Even though I did not have any outstanding performance leading up to TMBT, I managed to - with God's strength - win TMBT 100km. Thinking back, it was definitely a miracle because I completely buggered both my knees up three weeks from the race. That was the turning point for me. It was then that I started to believe that you can achieve anything you put your heart and soul into.

TMBT 50km 2011

TMBT 100km 2012

How I love the ice bath!

During the lay-off period between 2012 and 2013 racing season, I started to research more into running techniques, forms, training programmes etc. I bought a number of books to understand more about the sport. Some notable great books I have read are: The greatest: The Haile Gebrselassie Story, Hansons Marathon Method, Running with joy by Ryan Hall, and More Fire: How to train the Kenyan Way, Eat and Run by Scott Jurek. Then I extracted their training programmes and created something which suited my time and style. I started alternating my easy-moderate runs with intensive speed work-out. The easy-moderate run is to build a superior aerobic base, whereas the speed and tempo sessions are meant to add extra space into my lungs and build explosive strength in my legs. As a result, I finished second in Mt Mee Marathon in a time of 3:13, with ~1000m of elevation gain. Were it be flat, I think I could have gone 2:45-2:50. Three weeks later, I won my first solo race in Australia in the Cook's Tour 50km. After that, my confidence increased and I continued to plan my training strategically and specifically for the race that I was doing. The result? A podium finish in all the other races that I participated (except a DNF in Northface Singapore).

Finishing 2nd in Flinder's Tour 50km after taking two wrong turns and ended running 2km extra

TMBT 100km 2013

I was not saying the above in an arrogant or self-centred manner. The point I was making is: If you really believe you could do something, and are willing to pay the price and suffer for it, you will achieve what you set out to do. However, it's important to note that, hard work is one side of the coin. Success also requires a tremendous amount of drive and self-motivation, with a considerable dosage of smart and intelligence in understanding the science of running and your own body. If you are running the same distance, same time, same pace, and the same terrain every day, you are likely not to improve. It's by varying the terrain and the pace which help to broaden your running capability.

My biggest regret this year is not being able to run a road marathon. I scored ~76-78 for my VO2 max this year. The reason I don't have a precise reading is because the nose piece fell out in the last minute of the trial, causing my breath to escape. Hugo told me I could have even reached 80 if I had continued with the nose piece intact - the highest he has ever measured in an athlete (For comparison, Kilian Jornet scored 89 during the summit of my life project). Yes you can argue that VO2 max is just another reading which has no predictive value whatsoever in how fast a person can run. Running time also rests on another important factor: the running economy (which measures your running efficiency). I would add that a person's mental strength, pain tolerance, motivating factor also play an equally important role in determining the success of his/her career. With a reasonably high VO2 max and relatively good running economy, I am excited to see how fast i can go in a road marathon. I am predicting something in the range of 2:35-2:45. If i really train my butt off (and have all the essential checklist of a successful running reason ticked off), I think i may even be able to go under 2:35.

VO2 max test

My next biggest regrets are: not being able to join the Tour de Malaysia run and not being able to traverse Titiwangsa Range (in Malaysia) in the fastest time possible. My schedules this year have been stretched to the limit such that I could not fork out any extra time to join them in the quest. Allan Lee and Seow Kong (the core runners in Tour de Malaysia run) are good friends and folks whom i admire a lot. What they have done in Malaysia and in their own running career are simply phenomenal. I can only wish I could emulate half of what they have achieved.

Two legendary runners in Malaysia - Seow Kong and Allan Lee

Actually, saying the above means nothing now. Because there is no way I would be able to do them, at least not in the next four years. I am announcing this because I have completely different priorities in life now. One of them is - without a question - my work. I have been spending most of my time in the past two years running that I have spared little time to improve my medical knowledge and skill. It is a deliberate decision that I had made in the beginning of my internship that I wanted to invest more time in running, because hey, If i really wanted to pursue my passion, this is the time to do it right? Especially in the first two years of work when people don't demand so much from you. After this, people started to expect more from you. So I am making plans now to seriously discipline myself to study and read widely. Sometimes I have to remind myself of the following: Running is my passion; but medicine is my calling. I have an even stronger responsibility toward the sick, and my number one aim is to help relieve them of their suffering. So after messing around for two years, now is time to work hard.

I will share the other priority some time in the future, when the time is right. :D

I have two more races to do in 2014, and after that, no more. First race is Burden run on 26 Jan in University Malaysia. I have been intrigued to run this race because the idea of running with a 10kg sand bag sounds fun to me. The next race is Titi 50km/100km on 14 Feb, a race organised by a great friend Allan Lee and friends. I am only doing the shorter distance which is 50km, because i don't have the time and energy to train for another 100km. I am looking forward to racing in home soil.

So i will be saying goodbye to competitive running pretty soon. While I do so with a heavy heart, I can only say that this would only lead to a greater good. Human can only do that much. I believe that God has His plan and I have to be obedient in following His ways.

I went for a run with Bruce Cook this evening and I was listening to his stories. This man is a running legend, who has PRed in every distance from 3km - 100km back in the 80s and 90s. He ran 8:24 for 3km, 30:14 for 10km, 1:08 for 21km, 2:28 for 42km, 3:10 for 50km, 5:56 for 80km and 7:31 for 100km. While listening to his secrets for success, I can't help but to be in awe of what he has achieved. At the end of the run i asked him: 'Bruce, do you think i would still be able to run my personal best when i make a come-back in my 30s?' Without any hesitation, he said: Hell ya!