Tropical Fruit Season

Fruit season is a very much awaited time of the year in the rural areas of Malaysia. Plenty of delicious fruits are available freely (for those who have the trees) or cheaply (if you need to buy it from the mushrooming roadside fruit stalls) .

For some rural folks and the orang asli (the aboriginies) - those who kais pagi makan pagi, they don't need to go to work, they just stay home and eat. They just need to pluck the fruits and eat. So they eat and eat and eat.

Sometime you see complications... especially if they swallowed the seeds. Tropical fruits are not like apples; thick 'flesh' and small seeds. Furthermore, some fruits you have to swallow the seeds, otherwise no 'uumph'. Mangosteen and rambai are examples of this type of fruits.

Last night a senile elderly lady, was brought in to the hospital with constipation and severe anal pain. Abdominal X-ray showed dilated colon packed with hundreds of 'seeds. I spread-opened her buttock, and I could see those seeds impacting the anal canal. I had to manually evacuated the seeds. Memanglah sakit tapi lepas tu lega. They are manggosteen seeds, and that suprised me. A mangosteen usually has six fleshs; only one or the most two have seeds. That means she really ate plenty of those fruits probably more then a hundred in several days.

When I was a medical officer in Mentakab, an orang asli girl presented with abdominal colic caused by similar problems.... and I had to dig out hundreds of 'setol' seeds. She literally picked up the fruits from the floor of the jungle and ate them. I had to sedate her with Ketamine and removed the seeds with my finger till clear.

A fellow physician once told me; The most honorable thing a surgeon does is to digitally relieve a patient with an impacted rectum !

Hard objects impacted in the colon cause ulcers in the colonic mucosa by pressure necrosis. These ulcers are called stercoral ulcers. Not uncommon, the ulcers perforate through and caused peritonitis. Few years ago when I was in the university, an old lady presented with peritonitis. I took her to OT and opened her abdomen. To my astonishment; I found hundreds of rambai seed in the peritoneal cavity. What happened was she ate the rambai and swallowed the seeds; her colon was packed with the seeds resulting in the colonic perforation. I had to pick up all the seeds, washed the peritoneal cavity and exteriorised the colonic perforation as a loop colostomy. Later when she was well, I closed the colostomy.

This picture showed ripe rambai fruits. Each fruit contains three glistening, usually sweet and sour flesh with a seed in the middle. You don't need to chew them, just put in your mouth and swallow them.

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The lesson is: If you really like these fruits, eat them by all means. But please don't swallow the seeds. Otherwise someone has to stick his finger into your arse.

Tired and Betrayed

Last Thursday was a busy day for me, I had several surgeries and some endoscopies. As I was about to settle down just before midnight (malam Jumaat beb), a lady was brought in with difficulty in breathing. She was pale as a sheet, her hemoglobin was 3.2 gm/dL(normal > 11). As I was asking where and what could be the source of her chronic blood loss, I smelled something bad from her body; smell of necrotic tissues.

After much persuation and explanation including by her sister (whom I thought I've seen before)she reluctantly showed me this;

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The usual thing . . . . . . . . . . . . . . . . . . !

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Advanced ulcerating cancer of the right breast with chronic bleeding from the ulcers.

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If you observe the surrounding skin, there were multiple nodules. There are cancerous metastases called stellite nodules. The other breast were also involved, with peau d'orange (skin lymphatic infiltration)

She forewarned me not to do anything to the tumour as she was at present on treatment; homeophatic medicine and after this is going to another bomoh in Melaka. All she wanted was the treatment for the breathlessness.

The breathlessness was caused by severe anemia. So I transfused her with 4 unit of concentrated blood (packed cells). When she felt better, she insisted on going home. I asked her who was doing the dressing all the while, the answer; my sister. I turned to her sister; have we met before? Yes, I was a head-nurse in xxxxx department when you were in the university.

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Oh Tuhan, apa dah jadi ni? (O God, help me!)

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I put much efforts to make Malaysian ladies seeking proper treatment for their cancers, to avoid unnecessary deaths and morbidity. I gave lectures to nurses and women groups. Promoting breast-self-examination and mammogram screening. But now I have a senior nurse who I knew personally, yet is 'encouraging' her own sister to go to the bomoh. No wonder, there are bomoh bragging that doctors and nurses are among their patients. Once I had a patient (hernia surgery) who is a bomoh patah(he treats fractures) himself, he boasted that many doctors went to him for their fractures.

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Common chaps, if you don't believe in what you practice (modern medicine), then stop practising. Don' t misled others. Go out and do something else !

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As for the lady, she chooses to end her life in a miserable way with other people avoiding her due to the foul-smelling cancer on her body.

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As for me, I am tired and feel betrayed by my own colleagues . . . .

PILES, So What .......?

Buasir je, tak payah susah-susah lah.....

Not everything that comes out of the anus is faeces

Not everything that protrudes out of it is hemorrhoids

An old man came to the hospital with severe anal pain and faecal incontinence (tak boleh kontrol berak le tu). He was dehydrated and emaciated and this thing (picture) was seen in the anus.

It was a fungating anal cancer which was later confirmed by a biopsy. So I told him the diagnosis. Buasir je... saya telah jumpa doktor panel banyak tahun, dia kata buasir, tak bahaya pun!

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So this is the problem; "patients come with rectal bleeding and prolapsing anal mass - hemorrhoids until proven otherwise" No examination done, given some medications and sent home. Subsequent visits - same medications. No reassessment or referral to the appropriate specialists.

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This is what happened to this unfortunate old man. Deadly cancer treated as a common disease; piles. The biopsy was reported as malignant melanoma; a rare but deadly cancer. On top of that, his chest X-ray revealed multiple metastases (cancer spread) . . . . . . . . . . . . . . . . . and the old man's days now are numbered .... KKM-DKP.

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Ironically, this is not just 'a case I saw', I have seen many cases including referrals treated for months as hemorrhoids / piles / buasir / ti cheng / zhi chang or what ever you like to call it - but actually are anal or rectal cancers. Once I attended an surgical workshop on PPH (new technique of treating hemorrhoids); the patient was already put to sleep and when the legs were lifted, poop.. out came an anal cancer. That case was pre-selected by a surgeon for the demonstration! . See, hemorrhoids are probably not just a simple disease to diagnose.

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If you are primary care doctors, think of a differential diagnosis beside your provisionals.

And if you are a patient, always ask for an explanation especially when things are not as expected.

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and TABIB BUASIR is not part of the solution.

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Any way, KKM-DKP stands for kubur kata mari, dunia kata pergi ..............

CARCINOGEN

Today, my PA put five Cancer Notification forms on my table. The MOH requires medical practitioners to notify The National Cancer Registry all new cases of cancer they diagnosed. 5 new cases a week is common in a big goverment hospital surgical depatment. But for a single surgeon like me in a 100-bed private hospital, this is a record. In the last one week I encountered 2 breast cancers, one skin cancer (BCC), one stomach cancer and an occult cancer with liver metastases.

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This is unfortunately not a suprise. The incidence of cancer generally is on the rise. Although different cancers have different causes, the upward trend is usually associated with the rampant use of chemicals that induce normal cells to change to cancer cells. These chemicals are called carcinogens.

Carcinogens are found in industries, drugs/medicines, clothings and most disturbing our foodstuff. Almost all factory-made food items contained some sorts of carcinogen. Some in traces, others full of them.

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One day, my young son bought a coloured, flavoured drink in a plastic container in the shape of 'ultraman'. There was a small note: Ingredients: Air, Pemanis, Pewarna, Perisa dan Penstabil yang dibenarkan. Basically it contains water, and four chemicals to change it colour and taste. In another words, it contains water and most probably four carcinogens to shorten our lives. In Kelantan, if you look for the traditional nasi kerabu hitam which is stained purple by daun mengkudu, you would never find it. Insteads you will get a nasi kerabu stained blue by a dye usually used to colour tikar mengkuang and this is highly carcinogenic. Your mee goreng or mee latna are usually added a big spoonful of Thailand's ajinomoto (which is also used as additive to farmer's racun lalang to make sure the lalang dies sampai ke akar).

See my point: Nak makan sedap, you may risk shortening your life.

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That is my bad news for the week. BUT the good thing is : Hari ini every junction from Kota Bharu to Kubang Kerian along Jalan Bayam is beautified with bunga manggar. Maklumlah, cuti umum Agong' Birthday bertindih dengan cuti sekolah. Ramai ambil kesempatan buat kenduri kahwin. Baguslah tu, kurang peluang syaitan nak suruh orang buat maksiat. Yang sebelumnya haram dah jadi halal, dapat pahala pulak tu!. Dalam pada tu, malam tadi ada yang datang ke hospital melahirkan anak dengan jari yang masih penuh berinai. Bila kahwin dik?. dua hari lepas doktor....

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AstaghfirLah hal azim...apa nak jadi dengan orang mim lamalif ya waw................................

Young Malay Ladies

Forget about this picture, I am not writing about it. I am using it only to beautify my posting.

(Anyway it is a picture of a myomectomy operation - removing a uterine fibroid - done by a gynecologist friend of mine; Dr. Ang Koh Seng)

Last week I attended our Annual Scientific Meeting & AGM, College of Surgeon, Academy of Medicine of Malaysia in Langkawi.

College of Surgeon bukannya sebuah kolej tetapi lebih kepada kesatuan profesional (seperti Bar Council) yang dianggotai oleh pakar-pakar bedah seluruh Malaysia.

A lot of important things presented and discussed; new technologies demonstrated and things that had happened reviewed and learned.

One thing that is relevent to this blog is a presentation from University Malaya Medical Centre (UMMC) on breast cancer survival. They presented a paper: The Impact of Defaulting Breast Cancer Treatment; Halving The Survival Time For 1466 Breast Cancer Patients.

They studied the outcome of all their breast cancer patients from 1993 to 2002. Out of those, about 100 defaulted treatment. What they found was;

1. These defaulters succumbed to their cancers much earlier; their 5-year survival rate was only 47 %. Maknanya selepas 5 tahun hanya tinggal 47%, yang lainnya telah berpindah ke alam barzakh

2. Majority of the defaulters were Malays

3. Many of these poeples were younger than 40 years old.

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Their findings and the messages are easy to understand. Pertama: You ada kanser payudara, tak rawat you mati (of-course semua orang mati, tapi you mati menderita kanser). Kedua: Orang Melayu, kita ada bomoh yang memang kita tak percaya pun, tapi bila kita kena kanser bomoh inilah yang kita cari. Ketiga: Yang ini yang saya tak faham; kenapa yang muda banyak yang jadi defaulter.

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I have seen young, well educated, some are extremely rich and of course yang berpangkat ladies when told about about the cancer, they say thank you, I am off to my bomoh. In my personal experience, teachers are the worst. If you have a Malay teacher with breast cancer; I can bet; she presents early (kena paksa oleh kawan-kawan), when I told her it is cancer, she disappears, and a months or two before she dies, she comes back to you crying as if you are the Archangel Izrael. I tak cakaplah off you go, but at that stage nothing much could I do.

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I hope my message is loud and clear .................................

Hanya Jauhari Yang Kenal Maknikam

Yesterday, a lady with advanced breast cancer came to me requesting breast cancer surgery. All the while she didn't bother to see a doctor because there was no pain, but lately the cancer became painful (usually indicating the cancer is penetrating through the skin, soon it is going to ulcerate). She and her family knew very well that it was cancer, and the chance to have a proper curative treatment was wide open to her right from the begining. One of her anakbuah is a doctor working in a hospital designated for breast cancer treatment; the Putrajaya Hospital. Instead she opted for the mercy of a bomoh .

Bomoh bukan sebarang bomoh
Bomoh bergelar dari Keraton

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Barah dirawat dengan surgeri
Sakit tidak berdarah pun tidak
Bahkan dirakam kamera VCD
RM 7000 dibayar pengeras diberi

The bomoh 'operated' on her. He 'performed surgery' to treat her cancer !

When I saw her, the cancer was huge, axillary nodes are massive and fixed, there chest wall was involved. Basically it was non-operable. There was no evidence of any surgery or intervention what so ever. The bomoh had done nothing but had taken her for a ride. What she needs now are chemotherapy and radiotherapy. Surgery can be considered later if the cancer managed to be down-sized by the chemo.

Back to the bomoh thing, out of inquisitiveness I searched the web for the center. They have a nice homepage, even daringly posted few of their 'surgeries' for us to see.

One thing I believe; you should know your limits. Once your cross the line, you are exposed. There was a bogus doc way back in 1985 in HKL. A failed year 3 medical student impersonating a doctor (teringin sangat lah tu!). He managed to work 'undetected' for more than a month in a medical ward. But on the day he went to OT to assist a surgery (he crossed the line), his identity was exposed.

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I tell you a story. A friend of mine sent his Mercedes to a mechanic. The next day the mechanic told him that he had changed the alternator and showed him the one that he had 'removed'. This friend took the rosak alternator home. Another mechanic saw the thing and said; ini bukan mercedes punya, ini Wira punya dah !

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You need a mechanic to know what a mechanic does .......... !

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I saw a video of a 'bare-hand' surgery from Philipines, the 'bomoh' put his hand on the victim's tummy and pulled out a 30 cm of intestine (claimed colon cancer). That thing was so small for a human intestine. That must be usus ayam (chicken intestine). I know exactly how colon or intestine look like. Any medical student or doctor knows it. To some non-medical peoples; wow, hebatnya, boleh bawak keluar usus dengan tangan kosong..... memanglah kalau usus ayam !

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You need a surgeon to know what a surgeon does ........... !

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I am going to blow up the cover of this bloody con man with big tittles hiding behind verses of quran and Islamic medicine.

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So back to this bomoh Keraton; he put his hand into a patient chest, pulled out a very small heart, too small for a human heart. My bet is that was jantung kambing! Maklumlah susah nak cari jantung yang sama saiznya dengan jantung manusia. Jantung lembu terlalu besar.But sir, if you want a jantung that of the size of a human heart, ambillah jantung BABI. Jangan kena influenza H1N1 sudahlah.

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That's not all. What about the technical aspects of the surgery, physiology, infection, blood and etc. My adviced to this bomoh, if you want to help, do what a bomoh does. If you decide to operate, then you have crossed the line. Your wickedness would be uncovered. Kalau nak tipu pun biarlah orang tak tahu. Dahlah menipu orang yang susah, yang sakit dan yang amat mengharapkan, guna pula nama Islam. Memalukan ugama dan bangsa.

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Malangnya bilakah orang kita nak sedar....

Yang nak kaya, ambil jalan mudah; skim cepat kaya,

Yang nak nama, bayar ejen untuk dapat Dato'

Yang nak jawatan, bayar rasuah

Yang nak rebut DUN pun , panggil bomoh, puh sana, puh sini

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Alahai .

RENTOKIL

Rent To Kill

Yesterday was a historical day for me. I was hired to remove pests; unfortunately a 'friendly' ones. At 3.00 am in the morning, a lady came screaming to the A & E unit; '......takutnya, tolonglah takutnya........' jumping up and down. Some creatures creaping out of her breast !

This is what the breast looks like

And these are the scarry chaps.....

Friendly larvae trying to clean the necrotic cancer tissues away.

Berbuih mulut trying to explain to her and her family about proper cancer treatments. Although already a locally advanced disease, her quality of life might improved with palliative 'toilet' mastectomy, radiotherapy or even chemotherapy. But she insisted on getting rid of the good little fellas and went home to continue with her own treatment using some expensive 'DNA milk' or what ever.

By the way, live maggots are flushed out of the dead tissues using turpentine (minyak gas). Get some turpentine from a hardware shop (not pharmacy), and pour it onto the tissues. The maggots would crawl out of the necrotic tissues. If you use some other chemicals, they might get killed and left rotting in the tissues.

Anyway... just before she left for home, I told her....."You don't need a surgeon to do this, next time just call RENTOKIL .

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..............................................................RENTOKIL provides pest-control service in Malaysia