Dancing With Dr Death

New Straits Times: Tuesday, Feb 10, 2009

Bungling US doctor charged in Australia.

When I read this news in NST and later read the event from major Australian online newpapers - I found some similarities with what happened here about 20 years back.

In the late 80th and early 90th, there used to be many expatriate (foreign) doctors in Malaysian hospitals employed by the goverment to overcome shortage of specialists in this country. Many of these people came here from countries which were generally 'poorer' than Malaysia. You can't expect doctors from UK or Australia to come here since their income in their home country is much higher than here. Since the salary we paid them was relatively low, we couldn't expect to get first class specialists. Bak kata pepatah: You give peanuts, you get monkeys ! Jadi ramailah yang datang ke sini buat-buat pandai, ada yang datang dengan 'blown-up CVs'. Ada seorang tu, dalam CV pernah buat lebih 1000 endoscopy, tapi bila pegang OGDScope, nampak sangat tak tahu!. Every thyroid operation, blood loss would be more than a litre. I still remember very well; few medical officers 'diverting' cases to other surgeons whom they believed were more competent. I have assisted a surgeon doing esophagectomy - after the surgery I thanked him for allowing me assisting him although I was not in his team; I said "thanks sir, this is my first esophagectomy", he said "thanks to you, this is also my first, I choose you because I saw you opened a chest before". Laa, patutlah dia sungguh-sungguh suruh aku belah dada kawan tu!

I believe those era has long gone; we are now having many capable doctors. Some of our hospitals are the best in the region; for example the IJN. But recently the cycle might have come back. With prosperity, more private hospitals were opened. More specialists moved from the public to the private sector, leaving the public hospitals short of senior doctors. Again the vacancies are filled with foreigners.

Janganlah pisang berbuah dua kali...... The goverment mungkin perlu ingat .... you give peanuts, you get monkeys. Sorry !

Hirschsprung Disease

Hirschsprung disease is a disease seen in neonates where congenital absence of special nerve cells in the rectum called ganglion cells resulting in the failure of the that segment of large intestine fails to function. Newborns fail to pass meconeum, and they are diagnosed and operated by paediatric surgeon as soon as possible to save them. A very small percentage of children born with this disease might survive with chronic constipation. This is usually when the affected intestine is very short; short segment Hirschsprung disease. Rarely they live beyond that and into adulthood untreated. This is what I am highlighting today.

In the last 20 years of my practise, I have seen many such patients, 16 to be exact. These people was never brought to seek treatment by their parents when they were small kids. Some was forced by their teachers and friends to seek help because they were smelly with overflow incontinence - cursed busuk, tak tau basuh punggung ke?

This is an intra-operative picture of a segment of a large intestine (rectum) in a 33 year old policeman with Hirschsprung disease. (I once joked to a colleague; I removed a cat that accidentally went into the man's rectum while he pleasured himself with the animal ! )

He had a laparotomy and colostomy done in a nearby hospital when his colon perforated. He was then referred to me for the definitive surgery called Duhamel operation, and later closure of the colostomy.

The point is - our peoples wait till the last minute to seek treatment. If they had done so earlier; they would have led a normal life. But they rather wait and suffer the consequences; in this disease - chronic constipation, abdominal distention, overflow incontinence (ke mana pergi busuk bau taik) and if unlucky enterocolitis and death.

Ini sebut je operation, tak payah lah. Tunggu besar lah; bila besar yang senang dah jadi susah. Apa nak jadi !!!

Sorry, I need to talk to BOMOH first

This CT scan image belongs to a middle-age man who came to the hospital for prolonged fever and multiple lymphnode enlargement. He was found to have generalised lymphadenopathy involving those in the neck, abdomen, inguinals and in the chest. CT-scan diagnosis was Non-Hodgkins Lymphoma stage IV, and the managing physician advised him to have a biopsy of one of the nodes. This was when I came to the picture.

I explained to him that the biopsy will involve making a small incision in the neck or in the inguinal, and taking out a lymphnode for the pathologist to study. All he said was ..."Sorry, I need to talk to my BOMOH first". With that, he discharged himself from the hospital despite many attempts to make him understand what a lymphoma or a cancer means.

I am speechless ! Whoi !

APA NAK JADI DENGAN DOKTOR-DOKTOR KITA ?

Last week I joined my gynaecologist operating on this patient; inserting bilateral ureteric stents and assisted him in his surgery. The patient was an elderly lady with advanced ovarian cancer. She had earlier seek treatment for a progressively enlarging abdominal mass and lower abdominal pain in a nearby public hospital. She went to the gynae clinic there; saw one MO (medical Officer - ? trainee gynecologist) who did an ultrasound scanning. Detecting the mass, he requested for a CT-scan examination. During the next visit, CT was done and she was seen by another MO and was asked to come at a later date to see the gynecologist in-charge. On the given date, she came but this time she was seen by another MO and no decision was made. She was then given another date. The time interval from the first to the last visit was four and half months. Upset with the long wait, her childrens later decided to bring her to our hospital; saw our gynaecologist on one day, admitted her and got the CT-scan and IVU done on the next day, TAHBSO surgery on the day after. Now, she is awaiting her chemotherapy.

Look, I am neither comparing (the efficiency or what) nor advertising; but to highlight the attitude of some of our doctors in dealing with cancer patients. When you suspected a cancer, you should put high priority in the case, deal with it 'urgently' . You are not dealing with a reducible inguinal hernia or a lipoma where you can take your sweet time and schedule the surgery electively at the end of your long elective surgery list.

No wonder we are seeing advanced diseases with poor prognosis !

Kalaulah orang lain buat benda macam ini pada kita atau orang kesayangan kita, tentu kita marah. Jadi rawatlah pesakit kita sebagaimana kita mahu dilayani atau dirawati.

TB Peritoneum

A man (one of the many foreign workers in Malaysia) was referred to me with ascites (fluid in the peritoneal cavity) and weight loss. The working diagnosis was tuberculosis. Mantoux test was negative, PCR and ESR were not suggestive. Chest X-ray was clear. The peritoneal fluid was tapped but the cytology was negative. I did a laparoscopy recently; and this is what I saw. Thousands of small 'soft' nodules (which I prefer to call tubercles) studded the surface of the peritoneum, intestines and other intraperitoneal organs. These were biopsied and the diagnosis of tuberculosis confirmed. He was sent back to the referring physician to recieve anti-tuberculosis treatment.

The prevalence of tuberculosis mainly PTB was high in Malaysia previously. With good public health programme and vaccination, it was brought under control. Unfortunately, lately it has resurged. One of the reasons given was HIV; low immunity. But I believe the influx of immigrant workers from countries which don't have efficient anti-TB programme is the main reason.

The authority should look seriously into this. Now, we have new diseases that we never heard about before: Chikungunya, Yellow Fever, Kala Azar and what not !!!!

Globalisation doesn't come without a price .....

Sebaceous Cyst

A sebaceous cyst is a closed sac below the surface of the skin that has a lining that resembles the uppermost part of a hair follicle and fills with a fatty white, semi-solid material called sebum. Sebum is produced by sebaceous glands of the epidermis. Usually patients present with a lump (most often painless) on the body or limb. Not unusual, the cyst gets infected and patients present with and abscess, and this is painful.

This is one of the few huge sebaceous cysts that I have removed. The patient was a man who had kept the lump for more than 10 years, and he came only when he couldn't sit properly.

He was lucky; this is a benign disease, not a cancer. If this were cancerous, then he would be in deep trouble !

SUSAH SANGATKAH NAK DATANG AWAL ???(Is it difficult to come for treatment early ??)

3 in 1

Three cancers in one patient

Last year, a woman came to me with progressive jaundice (deepening yellowish discoloration of the skin). Initial investigations showed that it was an obstructive jaundice; meaning, the bile flow was obstructed resulting in bile seeping into the skin and sclera. In this lady, the obstruction was caused by a cancer in the head of pancreas, as shown in the CT-scan picture below.

However, she was also noted to have a fungating
tumour in her left breast. (picture below)

Biopsy (core-needle biopsy) showed that it was an infiltrating ductal carcinoma; meaning this was a confirmed breast cancer.


The CT-scan film showing the primary cancer of the left breast









Further examination also revealed a tumour in her right thyroid lobe.

Biopsy (Fine needle aspiration cytology - FNAC) showed that it was a follicular lesion.

A follicular thyroid swelling can be either benign or cancerous, but looking at the tumour clinically and on CT-scan, I was almost certain that it was a follicular cancer.



She underwent a surgery for the breast cancer (left mastectomy with axillary clearance ), a palliative by-pass of the pancreatic head cancer (gastro-jejunostomy, hepatico-jejunostomy - biopsy confirmed adenocarcinoma of the pancreas)

So, what am I trying to say ?

I am saying that this lady had three (3) primary cancers. This is extremely rare (I am waiting for my report to be published in a peer journal). But this is not my point to you. What I want to highlight here is how 'fantastic' our patient can be. Should she presented much earlier, she could have been saved. She succumbed to her diseases not long after the surgery.

By the way, it was reported in most news today, that the country is in need of more oncologists (cancer specialists) - "We need more than 200 oncologists but the country has only 39" - say the Health Minister. But with this attitude of not seeking treatment until it is too late, I dont see the urgency. The ministry of health has to come out with a policy / campaign / or what so ever to get cancer patients to the hospital, and to do so early !