The Annoying ANAKAYUB's Blog

2012 Goals

2011-12-31T22:54:00.001+08:00

1) Professional - Decide between sports medicine vs critical care. Decide between KKM vs education.

2) Bench 100 kg for reps. Deadlift double that for reps. Keep my weight at 95 kg max. Aim for a max rep set of pullups of ten reps (a stretch but not impossible).

3) Make my son a badass. Save money. Be someone who somehow can be made proud of, with all the bullshit I bring to the table.

Ideal conditions and ideal results only happen when you're already dead. The time to get results is now.

Strength Training... As a Houseman.

2011-07-21T22:50:00.000+08:00

This post is obviously inspired by Fendi's worries of not being able to train as a houseman. After 1 year of housemanship, these are my thoughts:

1) Let's face it, the most important step to being able to train as a houseman is to be at the right hospital so that you can choose the right gym.

Rules of thumb:

You need to be near a gym with good operating hours. For example, during weekdays I train at Celebrity Fitness, Lot 10 (closes at midnight during weekdays). This is a big point as it allows me to sleep first before going to the gym, should I choose to train in between EOD's (!).
The gym must be good enough so that you don't have to wait too long to use the equipment you want.
The hospital shouldn't have EOD's as the rule. Having a hospital with stable on call schedules is best. For example, I train better during medical with 10 calls spread evenly throughout the month than during O&G with the same 10 calls but with EOD's and greater breaks between calls. If you can coordinate your calls with your leader, do so. As you'll be able to adapt calls to your liking for training.
Find out gyms near areas you'll be traveling on off weekends. A good session in a per entry gym is a good session.
The point is: getting a hospital suitable for you to train after work is doable, and the onus is on you.

2) Another issue is timing of training. Unless if you are working in surgery HKL with 3 calls a month, you are not training 4 times a week; 3 might be possible if you are single.

Since medical posting, I have maintained a fairly regular schedule of training on post-post-call days. I was very lucky in medical as I was able to negotiate a very good on call schedule; I did not have EOD's ever in medical except during the Chinese New Year (and that was a passive EOD call; oh wait I'm too Jonah).

In O&G however, I was stuck with EOD's. This requires more precise planning in advance. On some days I'd train in between the EOD's with sleep before sessions, especially if the break after the EOD was only 2 days. On some occasions I'd train post call (of the 2nd EOD) followed by an EOD session at the gym if there was a 3 day break. You need to know your schedule.

3) Seeing the 2 points above, there's a conclusion to be made: you need to choose the right program.

If you were a seriously body-building type of strength athlete you'll have serious problems: Your optimal program is always 4-a-week, which is not attainable. And forget 6-a-week body part splits. You'll have to change to a 3-a-week with an upper-lower split with high intensity during the training. Hitting one body part twice a week on 1 week, then once a week on the next week is the idea.

Another idea is to go straight to full-body routines. For a bodybuilding program, it should work well if you're still a beginner. I'm not familiar though with bodybuilding programs that aren't in the traditional body-part split model. But I think looking up Chad Waterbury/Alwyn Cosgrove for interesting full-body routines might give clues.

And if you're more into powerlifting like me, the solution is very simple: Jim Wendler's 5/3/1 is king; devised by a lifter who wants to do more in life. And you can modify it to a 2 a week schedule and make great progress. This is an example of my 2/week, 2 week per round, 6-week training cycle:

Day 1 week 1:

Deadlift - 5/3/1 week would be 154.4 kg x 5 (+4) (just deadlifted 138.6 x 8 few days ago)

Reverse lunges, front squat grip - 5 x 10 x 52 kg

Lat pulldown, supinated grip - 5 x 10 x 47 kg

Out in 1.5 hours; it's changing the plates on the deadlift that take a lot of time training alone.

Day 2 week 1:

Bench press - 5/3/1 week would be 85.9 kg x 5 (+4) (just benched 77 kg x 10 today)

Penlay rows - 1 x 8, 4 x 7 x 61 kg

Standing DB press - 1 x 10, 4 x 9 x 30 lb

Warm up till done in 1 hour.

Day 1 week 2:

Low bar back squat - 5/3/1 week would be 131.1 kg x 5 (+4) (last cycle ended with 129 kg x 6)

Romanian deadlifts - 5 x 10 x 63 kg

Face pulls - 5 x 10 x 7 lb each side (pitiful, I know)

Warm up till done in 1 hour 15 minutes.

Day 2 week 2:

Military press - 5/3/1 week would be 59.1 kg x 5 (+4) (last cycle ended with 59 kg x 6)

Pullups - 2 x 3, 5 x 2, 3 x 1 (not awesome, but I'm 94 kg with a 34 BMI)

Pushups - 3 x 10

All are done in superset fashion. Warm up till done in about 1 hour, depending on how crowed the pullup station is.

As I'm still a beginner, such a program is sufficient for me to get stronger, with getting bigger as an interesting bonus.

3) Exercise selection is extremely important.

This is why body part splits are not so smart; too little bang for your buck. What builds more muscle: lying leg curls vs deadlifts? Pullups vs (stupid) pullovers?

But you can't choose exercises that are too challenging for your soft tissue nor your brain. A previous problem I had was that my deadlift days are too CNS heavy: deadlifts followed by squats followed by good mornings. It was common that I'd skip good mornings, or end up vomiting on the way out of the gym, and feel like a piece of shit at work the next day.

Not that I did not include isolated core work in my routines. The sole reason is that I want to save time. Hence why I do no supported work other than the lat pulldowns; all exercises are to involve the core when possible. Maybe I'll add them one day on bench days; assuming that my free time increases as an MO/specialist (I doubt it).

4) How about supplements?

Frankly, the supplement you'll most need is caffeine! I do not use protein power, stopped creatine after noticing that it actually had some not-so-nice effect for men with hormones, and never tried anything else than fish oil (which I tend to forget to take, but you should take it regularly even if you don't train). Eat a shit ton of real food and save some cash. If you weigh 100 kg's with 10% body fat, or a powerlifter with lifts of say, 200 kg/150 kg/230 kg, pretend I'm not talking to you.

5) Recovery will be an issue.

You are a doctor. Recovery will always be an issue. Hence a few rules you need to accept:

Your training schedule is never optimal.
You might train post-call
You'll feel like shit even on good days of rest (but feeling shitty is relative)

This is why you need to accept that going to a gym for fat loss during HO days is probably not a good idea. Just focus on overall mass/performance and you might make yourself happy with small progress. I actually halve the progressions for my squat and press for subsequent cycles to deal with long term fatigue and slow strength progress.

Notice how I did not mention cardio yet. It's because of this: sleep is more important than cardio for fat loss as a medical professional. Lower your overall stress hormones by getting enough sleep, whatever that is for a medical professional with on calls. Train for the stimulus to increase mass/strength.

I might amend this further down the end. When HKL goes into shift work for HO's, a lot in this post might be irrelevant. But if you've questions, I'll answer and probably edit/add some points I've forgotten in the main post.

In the meantime, here's some inspiration:

And what you can do as a houseman:

Heh. Some Random Thoughts.

2011-06-07T01:11:00.000+08:00

1) WWDC starts in an hour. It's now 12.30 am. Damn it.

2) For good or bad, the fact that my wife and newly born kid are both in Melaka means that I'm able to train with a much higher frequency. I'm currently training every other day in between EOD calls. It might eventually be a stupid idea in retrospect but life is boring alone otherwise. And spending RM140 for training only at most 8 times per month (usually ends up at only 4 times per week there) is fucking expensive compared to when I was in Kuantan. Hell, if I trained at Bangi exclusively with the per entry rates it would be only RM80 per month!

3) 5/3/1 by Jim Wendler is probably the best training program ever for a general strength enthusiast. You can train 4 a week, 3 a week, and even 2 a week and still make progress. Let's just run the numbers:
Mid 2009 - My 1 rep maxes were:
Deadlift - 120 kg
Squat - never tested. 3RM front squat was 85-ish kg
Bench - 60 kg
Military press - 40 or 50 kg. I think. I didn't log my original 1RM.

Let's run the numbers now. Do note that I've not tested my 1RM's in more than a year. My best lifts are:
Deadlift - 145 kg for 6 reps
Bench - 75 kg for 10 reps. No spotters for racking/unracking.
Squat - 115 kg for 10 reps. No spotters for racking/unracking.
Military press - 57 kg for 6 reps.

And this progress is made even with on calls and real life stuff that make me lift only 2 times a week for the most part. Get the program here.

He doesn't even use the spotters in "just for fun" competition!

4) This is an extremely good read. From a man who's an accomplished powerlifter, head athletics coach, physical therapist, and a well of knowledge.

5) June 6 was the birthday of late Abah. Too bad he isn't around to see his grandson. Shit, not being able to see your father's last breath as you're stuck in your first on call as a junior doctor is a big blow. Sigh. No abuse from a consultant/specialist/medical officer can break my resolve in continuing as a doctor more than the circumstances and implications of Abah's death. Nothing can make you feel more like a failure. Al-Fatihah.

Things to Aim for in 2011

2010-12-31T23:25:00.000+08:00

Training:
1) I want to reach that theoretical 100 kg bench. And since I already can and have deadlifted 140 kg for a single, I'm now aiming for at least 180 estimated 1RM. Since I'm not training to compete, I'll stick with the basic Jim Wendler 5/3/1 "2 a week" template without focusing on singles; as long as the estimated 1RM reaches the goals, I'm happy. I've already recovered from the temporary hiatus from training due to starting housemanship and training at full speed (considering the circumstances). Here's where I'm at now, with the estimated 1RM and previous best (right before starting housemanship):
Deadlift - 123 kg x 9 (159 kg, best 166)
Bench - 68 kg x 10 (90 kg, best 94)
Squat - 117 kg x 5 (136 kg, best 140)
Press - 52 kg x 6 (62 kg, best 63)

2) Keep the weight down, without the expense of losing strength. This is a bit difficult as I'm training 2/week. If I've more time, I'll do more resistance-type of cardio. Dietary restriction will only be secondary. As long as I'm not bloated up I'm happy. But...

3) Being heavy inhibits my pullups. I want to get stronger at pullups again. Currently I'm training my back in every lifting session. But that won't do much if my weight remains at 90. Last session, I could only 2 7 sets of 2. Pitiful. But hey, that's at a BMI of what, 34?

Career:
I want to further set my sights on the path that suits me. In general, this is how I am as a doctor:
1) I hate history taking
2) I don't hate examinations
3) I love difficult procedures, and am relatively good at them. I always get "referrals" from colleagues for difficult lines, difficult ABG's or blood taking. I'll do those over boring reviews. If you can memorize your cases, and monitor them well enough, writing everything down again and again with small changes is dead boring.
4) I love resuscitations, making sense of investigations results stat, and tense moments.

So far the 2 career paths I'm keen for are surgery and anesthesiology/critical care. Mr Zainal (HOD) has already said (via MO's I know) that I'd be welcome back once I finish my housemanship. Prof Faisal (UPM) has also said that I'd have his full support to enter UPM as a trainee lecturer in surgery. But I want to taste the anaesth posting first if I can.

Another issue is whether I want to stay in KL/return to IIUM Kuantan. My first choice would be Kuantan; but since my wife has a good career development path by staying in HKL, the obvious choice would be to stay within the Klang Valley.

Exams? I'm seriously considering to take the MRCS part 1 this year, and maybe even the MRCP part 1 even thought I hate medical; after all, a strong medical background is needed regardless of your clinical specialty later on.

Life:
Aim for a nice balance between training/work/family/personal stuff. Duh? I still want to read my comics, and I wonder if Rhye will produce a Rhye's and Fall of Civilization version for Civ V...

I know that resuming life as a Wesnoth online player is more or less impossible. But watching the developments as a silent_obs (hint to the MP community) is fun, especially as regards to the tremendous art development going on.

When my late father asked me to enter boarding school, I initially refused on the grounds that I don't want to become a robot living with a fixed schedule. As a doctor, I refuse to be limited by my long hours.

Valedictory Speech, Full Version

2010-09-27T13:20:00.003+08:00

I've just finished my training session for the upcoming convocation with the IIUM Senate Committee. They said that it had good content and a good flow, but was far too long for the 10 minute limit. I'm posting it up, as I feel that the summarized version will never be as good. Note that I've not yet finished it, as the Arabicized stuff wasn't done yet, and the BM needs a lot of corrections. Done in like 2 hours before the training session, haha (!). We doctors do lack time you know (you know the typical doctor excuses).

Assalamualaikum and good afternoon to all.

It is a great pleasure and honor for me to speak in front of an accomplished audience. For today I am speaking not to an ordinary group of graduates; today I am speaking to a group whom can now be called professionals. I must take this opportunity to first thank my parents, my other family members and friends, my teachers of past and present, and as a doctor, my patients. Without all of them, I would not be as successful as I am today, nor selected to speak to address such a special group of graduates. For who I am today is a product of all those I mentioned above.

For you are a special kind of audience. You are an audience of whom standards are not just set by your teachers; the standards of your proficiency of practice is also set by your senior professionals, who have set high standards upon themselves. To graduate as a doctor, an allied health professional, or a lawyer means that there is no question regarding your qualification.

I still remember 7 years ago, when all of us were a group of students who had just finished the SPM examination, and were just about to begin a new phase as students in the Matriculation Center. At that moment many of the faces I saw were a mixture of excitement and anxiousness. We thought that SPM was hard. Would we survive the next 5-7 years of education? An education that is more specialized, yet harder. Nevertheless at the time there was always those moments of youthfulness. Late nights, last-minute studies, and of course the obligatory sleeping in class. This was the same regardless of the course undertaken by the students. Even Medicine.

Now fast forward to the moments right before the graduation. At that time you can also see the same mixture of excitement and anxiousness. But now it was for a different reason: We were preparing for the professional exams. An exam where you are judged not just by your regular teachers; but judged by professionals who are going to see you for the first time, and probably the last time. And this is what I mean to speak to a special group of graduates. You are graduates who are trusted not just by your own lecturers, but also by other professionals who have never met you before; who are convinced by your knowledge and skills the only time they saw you. You have achieved success, surely to be envied by others.

Kejayaan itu adalah sesuatu yang patut diraikan. Ini adalah kerana sesuatu kejayaan akan membawa kepada kejayaan yang seterusnya. Akan tetapi kejayaan kamu pada hari ini adalah hasil campuran pelbagai elemen. Ia bukan sahaja hasil daripada titik peluh usaha tuan-tuan dan puan-puan graduan. Kejayaan kamu pada hari ini juga adalah hasil daripada pengorbanan tenaga dan wang ibu bapa dan ahli keluarga kamu, daripada pengorbanan guru-guru, dorongan dan kerjasama rakan-rakan, sama ada rakan sepelajaran mahupun yang bukan, dan yang penting untuk diingati, para pesakit, pelanggan, dan sejarah atau pengalaman orang lain seperti kes-kes mahkamah yang terdahulu. Oleh itu, adalah penting buat diri saya bagi mengambil kesempatan ini bagi mengucapkan penghargaan terbesar bagi mendiang bapa saya sendiri di atas pentas ini, bagi Allahyharham Prof Madya Ayub bin Mohd Yatim yang meninggal ketika bulan Ramadhan al-Mubarak yang lepas.

It is only fitting to pay tribute to my father, who has given unlimited support in my endeavors to achieve excellence in IIUM. It was a rarity for him to ever say no to giving financial support for my efforts in buying all of However, my late father fell ill during my final year of studies with stroke, making life extremely hard for my family as a whole. He then was afflicted with a heart infection, which required heart surgery - on the day of my final professional exams. And yet my family and I persevered, and I passed my exams which I personally viewed as with flying colors considering the circumstances surrounding the end of my undergraduate life. But 1 month ago, ironically on the first day I was on call, my father passed away due to complications of his illnesses. It instantly had made the hardship of work, and the rigors of studying before that, pale in its emotional stress. The scolding of senior doctors and specialists, and the fatigue of long hours at work, felt tolerable with the death of my father.

The emotional burden of personal family illness, yet with the coincidence of becoming a successful graduate has taught me one thing, something that I wish to impress on you today: your success as a graduate today is to be cherished, but its elements are never to be forgotten. The success you achieve will thus protect you from arrogance, and keep you humbled.

And your humbleness in remembering your roots will keep our parents safe once they leave us, which they will. It is with this humbleness that we will remember to pray for them. To pray that they will be rewarded with Paradise, and saved from Hell. As the prophet once said, “One does not bring but 3 things to the Hereafter: beneficial knowledge, charity, and prayers of a good son.” But before we go further, I would like to remind everyone of a verse in the Qur’an”... I want to create a khalifah on earth...” To fulfill the principles mentioned in the above verse, we muslims must rediscover what it takes to become political and professional leaders. And the effort must be exemplified by none other than the IIUM graduates themselves.

It is important for IIUM graduates to not only be humble as I have mentioned above. IIUM graduates are bred in its system to be more than mere certification holders. We have to, and are educated to, to be more than followers. We have to be leaders. And the leadership displayed by IIUM graduates is not limited to our muslim ummah only, but also to the general public, or in terms of lofty standards befitting an IIUM graduate, leadership of present mankind itself. And better yet, the principles required to lead the ummah in the 21st century are easily derived from the Triple I-CE vision introduced by IIUM, that is internationalization, integration, islamicization and comprehensive excellence. By living the principles above, doctors, allied health professionals, and lawyers from IIUM will not be mere professionals; we will be professionals with leadership, who will unite the muslim populace and lead the world via the various avenues, whether it be academics, practice, or politics.

Internationalization is an important principle to be upheld if we are to achieve our ambition of being khalifah on earth. Muslims in the modern era are now segregated by nationalities and race. In the political sense, muslims are characterized by divisions, infighting, selfishness. And in the professional sense, muslim professionals are slow to not only develop, but to adapt new revised and better standards as regards to our professional development. Instead, we have left it to our Western colleagues, of whom the majority are non-muslim, to develop new ideas, practices, and guidelines which have increased the quality of the work of their profession.

In a different aspect, muslims now still stuck by sometimes questionable traditions. We have refused to see outside of our bubble, thinking that we are superior simply because of our religious faith as being muslim, or by misguided notions that some aspects of culture and tradition have their roots in religion when they are not.

Muslim professionals must be the spearhead of efforts to finally bring muslims to the forefront of the international arena. Muslim doctors, allied health professionals, and even lawyers must learn to be at the forefront of research and development, and to quickly explore new avenues of ideas that may help us improve the standard of healthcare care and legal systems. We should not hesitate to seek knowledge from non-muslims if it means improving ourselves. After all, best practice is best practice. And we must make example of muslim professionals who are among the leaders in their fields, but ply their trade in the western world, and thriving in it.

Muslims professionals from IIUM must also be at the forefront of efforts to educate the general public and modernize its thinking. The muslim professionals should make effort to educate the general public, to teach them than modern development does not have to, and should not lead astray from religious principles. Muslim professionals must teach the public to differentiate culture and religion; the latter is permanent, the former can and must change according to its suitability in modern practice. Muslim professionals from IIUM should be exactly that: excellent professionals, and faithful muslims. We must equal the accomplishments of the various muslim professionals of whom their names we keep on hearing as regards to the Islamic Golden Era.

To become a leader in the modern era, it is not enough to simply be a doctor, an allied health specialist, or a lawyer. The certificate that we have received today, despite of its significance, is not enough to allow us to lead the muslim world and the general ummah as a whole. We must seek out further knowledge, more than the knowledge of our practicing field. And all of this various knowledge needs to be united into one. Muslim professionals from IIUM must live the principle of integration.

A good example of this is seen in medical education. For clinicians of the modern era, it is not enough for them to simply be a highly qualified clinician in practice, or to simply be a Masters holder in a specialist field. Clinicians must now be proficient at research to become leaders of their field, that is to become research clinicians, to search for better practices and develop better technologies. To do so the clinicians must not just deepen the depth of their knowledge; these clinicians now have to broaden the scope of knowledge to the basic sciences of mathematics, the truly basic medical sciences: biology, chemistry and physics. But mastery of these fields is not sufficient; the knowledge must be turned into one, that is integrated.

Integration can also be seen in another light: that is integration of the general ummah. Muslims, exemplified by muslim professionals from IIUM, must be the example of integrating the ummah as a whole. In IIUM, we are blessed with a mixture of muslims originating from various countries. We even have non-muslims studying in this garden of knowledge and virtue. Our experiences and abilities to integrate with various peoples must be extrapolated to leading the muslim professionals and muslim populace as a whole, and then on to becoming political leaders of integration for the general mankind. Muslims professionals from IIUM must be at the forefront of education and goodwill to peoples of other faiths.

Muslim professionals from IIUM must not shun themselves and segregate into their own group. Instead, we must reach out to peoples of other faiths. We should provide service and education to muslims and non-muslims alike. And the responsibility is double-fold for us: to provide as a professional, and to provide as a muslim. During our practice is an excellent opportunity to preach regarding Islam to our clients and patients. And this preaching may not be direct; the character that we portray may sometimes be enough preaching in itself.

Integration and internationalization are interrelated with the next principle of Islamicization. IIUM graduates are ingrained with the principle that all worldly and religious knowledge is interrelated with each other. Secularization is the exact opposite of the what is taught in IIUM. Muslim professionals must change the current practice of their fields to reflect on basic Islamic principles. A good example of this is the field of shariah law, which combines the principles of modern law with basic Islamic rules and regulations into one field, which is already established by lawyers and led by IIUM. Other good examples are the halal food business and Islamic banking. And there are many avenues for muslim health care professionals to contribute to health care. The most obvious of this is medical ethics which I want to talk about.

Medical ethics is currently led by the Western world, based on mostly ethics based on human thinking, which can be wrong. And the western world is itself segmented, with those who believe and those who do not believe in divine concepts. This is where muslims have a great avenue to contribute. This is because Islamic principles of the world and law are based on permanent concepts: the revelation via the Holy Qur’an and teachings based on the Hadith of our beloved prophet Muhammad s.a.w. Because of this, medical ethics based on Islamic teachings would thus have more permanence and acceptance, as basic Islamic principles are true regardless of the passage of time. By improving our practice by integrating fields of professional practice with religious teachings, we will be following in the footsteps of the Golden Era researchers who pursued knowledge of Graeco-Roman origin and related it with Islamic principles to develop new fields of knowledge for which the muslims were the leaders and not mere followers.

To live by the previous 3 principles stated earlier, muslim professionals from IIUM would be living by another principle of IIUM needed to lead the muslim ummah and mankind in general for 21st century and beyond: comprehensive excellence. For to be leaders in an age with increasing populace, increasing political dynamics, increasing numbers of specialized academical and professional fields, and increasing technological advances, there is no other way other than to make effort to be the best: to be the best doctor, the best husband, the best father, the best son, the best neighbor and the best leader. This is because your deficiency in one area may ultimately hinder your role in another. And if you are deficient even slightly in a very competitive era, your leadership role will be taken by another. It sounds hard; no mission ever is easy.

But IIUM has taught you well. You have been taught to become excellent professionals in your field. You have been taught to become excellent muslims, who integrate knowledge of the islamic teachings and modern fields to develop knowledge more than the sum of its parts. You are taught to become one who integrates with the populace and others of your profession. You are taught to become one who seeks to be excellent in all aspects of life. You are a professional, an IIUM graduate.

Now go and make us proud.

Thank you. Assalamualaikum wbt.

The Last Day I Saw Him Was When I Showed Him the Wedding Pics...

2010-08-25T02:29:00.001+08:00

Thanks all. But when a patient is under cardiology care, and no serial ECG/cardiac enzymes were taken after seeing new development of ST dep and T inv in V3-V4, and the patient ends up dead in a state of episodic SOB for hours on end and eventual cardiorespiratory arrest, despite "patient is for active cardiac intervention"... I wish you the "best". As said by Arif Shahar (whom I coincidentally met at the ward), my first on call was spent on call somewhere else. Al-Fatihah for my father who passed away last Monday due to "sepsis secondary to HAP with a background of AVR (aortic valve replacement".

Thoughts (July 24 2010)

2010-07-24T10:38:00.003+08:00

1. It's back to reality pretty soon. But then again, the post exams was never a holiday for me. No honeymoon, no traveling, none of the stuff people do before starting work as a houseman. Every day, it was 4-7 hours of driving. If you think driving is not tiring by itself even though it burns no calories and chronically breaks people's backs, I'd love to have you as a personal driver.

I had to survive on pretty high doses of caffeine. There were several times when I had to just sleep in the car because of severe fatigue. Once my wife and I had dinner at 1.30 AM with work on the next day (I cooked of course, she was already fried from work and slept until food was ready). The day was spent helping my mother with errands/Abah's health issues. The only thing keeping me sane was the progress in the gym, which I could only go at night and ended up with coming home late, exacerbating my caffeine super-dependence. For references, to survive the induction I drank almost 6 cups/day of coffee/tea. That equaled 2 strong cups of coffee from Dunkin Donuts every day. I also kept my typically high levels of reading during the holidays, which at least kept my mind a little bit sharp. No studying though.

The recently ended induction program for housemen was supposed to be a holiday. But then I ended up as the participant leader. Luckily, other than an incident of a "lost" laptop and handling money-collecting duties, it wasn't too hard. But the chance for a mental break was lost. And housemanship starts next week.

I really envy the people who have been having fun during the holidays.

2. Next week I'll start work at HKL. Will it be that hard? I'm really not sure, after feeling exhausted already before starting work. Maybe it'll be the same level of tiring life as now, but in different ways. After all, I did say that the medical exams were harder and more stressful than the akad nikah (wedding vows).

What's really getting into me is the need to find a house. It's no longer feasible to go to KL every day from Bangi, especially if the aim is to reach there by 7 AM. The preferred places are Sentul/Ampang/Cheras as there are LRT stations there. A sleepy houseman is a dangerous houseman. But Sentul is super expensive, and the other two are jam centers on days that we drive. Other choices are Keramat & Gombak, but those options mean that driving is the only option to work. But as it stands, going to work from Bangi has been hell for both of us.

3. Will need to find another gym when I move. I'll make sure I get a lift, even during housemanship. But nothing will be as cheap as Kaki Gym/TLS/Try My Gym in KL. And it's utopian to get as many sessions as I could before, even during the peak of Abah's ills, when I did two a week, combing days into long sessions, sparing the weekends. Being strong has been quite useful and I don't want it to go away.

4. I'm a bit torn as regards to my future. My plan has been to go to a government clinic after housemanship, followed by pursuing studies in sports medicine. But there are several issues. With whom do I want to work? KKM, MSN, or MoHE? Do I want to be attached to a sport, or in a clinic setting? When the time comes, do I want to open what I have in mind: a comprehensive physical/sports rehab clinic, catering for sports and general public needs? I really would like answers.

But if all that fails, emergency medicine and internal medicine are fallbacks.

5. Lastly, Abah is back in the wards, this time for overwarfarinization, bleeding gums, INR of 8. Unsure of the cause though. Sigh.

Random Thoughts (July 13 2010)

2010-07-13T11:16:00.002+08:00

1) I wonder if soft tissue work (in the atheltic sphere speak) is used in the world of physiotherapy for treatment of spasms/contractures. This might be especially powerful in the management of cerebral palsy, as there is a potential of > 10 years of spastic paresis.

For a general theory of the "scientific" basis (sports medicine is more observational and theory than experimentation), have a read of Mike Robertson's self-myofascial release manual.

Case in point:

I have regularly used self myofascial release on Abah to help with his spasms and maintain his elbow/wrist flexibility. Abah tends to get nasty spasm episodes with even slight passive elbow/wrist/finger extension or distress. To help with this, I "gently" massage in a cross-fiber direction his bicep insertion (for elbow) or finger tendons proximal to the carpal tunnel (for the wrist/hand); this allows for the elbow to extend without even exerting any force to extend them! And as I massage further, the extension is increased. I even use this method to do the regular physiotherapy while he is not experiencing spasms; the hypertonia is reduced greatly.

To understand this better, try this experiment:

Lie down and test your shoulder anterior flexion flexibility (by reaching your arms back in a forward direction ala windmill fashion); when your lumbar spine hyperextends or your arm "hangs in the air", you have reached your limit. Then, use a tennis ball and roll it along your lattisimus dorsi insertion (sides of arm, near the armpit) and retest. You'll find that you can reach farther back without the lumbar hyperextension.

I find (from my own severely limited observation) that most mobility modalities used in physiotherapy of patients employ only passive movement and static stretching. Ironically both induce spasms in people with hypertonia/spasticity.

2) If you want to think about starting but always asking about quitting as well, get the hell out.

For the Juniors

2010-06-15T17:19:00.006+08:00

The drama in my life ceases to stop, and at some point or another, you just accept it. An abnormal day is a normal day. Luckily, lifting and recently cooking has kept me sane. After marriage, I have no idea whether life will normal as others'. Yes, I've told her I will keep lifting (but certainly not in a 4-a week schedule, rather a 3/2 a week schedule once work starts and the schedule permits).

Anyways, one of the juniors asked me, what's my secret. After being asked the question, I initially wanted to record myself talking and uploading it as it's easier. But the internet connection sucks balls, so a long lengthy post is what's for offer.

But to understand how I did what I did, you must understand my situation. A background.

I have been active all of my life, physically and in extracurricular activities, though entering UIA made me more sedentary until the discovery of strength training. I was in MSC until 4th year as President. I debated during matric + MEDCY VP and later President too. I once dabbled in program compiling, and for a short while the Mac compiler for the Wesnoth game (recommended), and a bit longer among the moderators (still an MP server moderator). I love learning about other things than medicine. I'll leave school stuff out.

At the same time, I'm a perfectionist. I always wanted to be the best of what I think I can be. This is not the same as being first, in which I compare myself with others. I only compare myself with myself. And so, if I want to invest in something, I'll 1) want to beat all others, 2) once others are beaten, I want to beat myself. 2) comes after 1). This means that even if I was no 1 compared to others, if I didn't reach my standards, it meant that there was still room for improvement.

During the final year, my father suffered from clinically migraine paralysis, radiologically lacunar stroke. A few months afterwards, he suffered a watershed infarct secondary to left ICA thrombosis. He still hasn't recovered from the Broca aphasia and hemiparesis, and now suffered Gram negative infective endocarditis of the aortic valve requiring valve replacement. Radiologically there were new infarcts. He has not yet been discharged, and developed new onset fever with bacteremia. My wedding was supposed to be on this Saturday. It'll have to go on I guess. My mother still has not started working, our general life and finances are in disarray, and other stuff probably with no need of mentioning. The almost constant progress in my lifting keeps me mentally fit, relatively.

I returned home almost every week since the first episode of stroke, whether it was to help out or to prepare for the wedding. My father's op was done at the practically the same time as my clinicals. The initial op planned had a higher risk of dying on the operating table. And added to that, my long case was not revised at all before the exams, and I never saw the case, until the exams.

And my exams were never normal too. My ped's patient had multiple problems. The surgical patient lied, and had a language barrier too. My psy patient ran away. My IM patient was someone I knew 100 percent since admission, with an atypical presentation (bias). My O&G was a "contradictory" presentation. I never saw hemophilia until my Pro.

I'm not going to spend time telling you about the exams exactly, but how to prepare for that. It's how to go through the exams, and call your mother straight away "I passed" before the results came out. Even with my way of life then I told the junior, "I came to the exam not to just pass".

Preparation

It starts now. You need your basics, identify the ones that will last you throughout school, and never forget it.

What you use in BMS will be used in 3rd year, and what you use then will be used in final year. But not all of it. Identify them. Remember them.

Medicine is in some ways about memory. Use it. That means treating information as though you might not read it again. Punish yourself to make sure you never forget important information/values. I survived despite being someone who can't count in his head. If the -7 serial test was the ultimate test, I'd be a permanent Psy patient.

Medicine is about associations, cause and effects, and is not black and white. Cultivate your imagination, be willing to dissect the conditions of patients and relate.

A textbook is thick. A patient's file is thinner. The patient tells more than the file.

You can only read so much with focus. You can listen and discuss much more.

You are only as fast as you can find your information. The internet helps. Knowing how to use it helps even more.

The exams may go the advanced issues, but basics are never ignored.

Mr Hafiz: "You don't need to see any case, you only need to know it."

Timing

Should you go on full throttle very early? Probably not. Even I did not start on "full gear" until the final posting was over. But that's why memory is important.

It's okay to choose whatever method to revise topics, but remember 1 thing: does it help you remember it the next time you have to use it? What we chose was a "always study all postings" method without any particular phases. But early on we stressed more on Ortho.

MCQ's are a student's best friend. But memorizing T/F is rubbish. You should be understanding the spirit behind the questions. I never write T/F on my MCQ's. If you don't know why reread this post. MCQ's always tell you what you don't know. There's more to learn in an MCQ stem than a PMP case.

How to divide time? What we did was to answer MCQ's in the morning, read in the afternoon, discuss and short cases at night. I lifted in the afternoon.

Clerking

Remember: Complaint, course, cause, complications, current status. Start now.

Remember: Patients are not like textbooks. Throw away your scripts. Learn the art of clerking. Start now. With experience, you will learn to pick up what the extras are on a "case-by-case" basis. Some questions you ask patients may make you look silly, and hence are silly to ask.

Patients are people, and hence if they are in distressed, just gather the info you need and move on. No need to do a full cardiac exam on a patient with right sided failure when you just want to appreciate the P2 sound. Others want to examine him/her too. Saves time as well.

Be brave yet respectful. Think of when you will start working as well. I learned to insert cannulas into, um, myself.

You will have to cover wards, not patients. Learn to clerk without writing, and learn to present without reading. Start now.

Ward presentations are different from exam presentations.

Addendum:

Start learning by doing "full" clerking. But learn the shortcuts before the final exam. It might save you. And it's all you'll be doing when working. Clerk to diagnose within 10 minutes of seeing the patient. Dr Haji: "You don't need 30 minutes to diagnose your patient do you?"

Addendum 2:

For ward presentations, remember: presentation, diagnoses, problems, management, current status.

Friends

You are teachers to each other. Be critical of each other. Not to compete, but that's how you cooperate. Teach.

You are as slow as your slowest friend. It's your job to make sure he/she picks up the pace. Teach.

You remember what you teach. Make sure everyone gets a chance to yes, teach. The listener-only friend loses out as he only listens, while the rest loses out in terms of effort.

Sanity

Medicine is not everything. Learn other things. Many other things. I continued to read other stuff even during exams.

Physical health is important. No talk, all action. The fat slob sweating is a lot "healthier" than the skinny nerd.

Have avenues to relieve stress. Endorphins are useful.

Lifting was useful because:

1) The focus needed is more than during exams. A barbell falling on your neck hurts more than the scowl of an examiner. So you train your brain. Exams feel "easy" on the brain.

2) Endorphins.

3) Activity.

Just do something.

Arguments are not useful. Stay away from them, and get them away. Sacrifices, temporary, may be needed during the peri-exam period.

The effort-results curve is sigmoidal. If your aim is to be sane, understand this curve. To be in the middle, aim for 52. Always. Start now. Once comfortable, raise the bar and become crazy like me.

Exam

20 minutes history, 20 minutes PE, 20 minutes everything else. Halve that for your ward time.

Reorganize your thoughts.

Remember your summary, differentials, investigations, management. Start now (in clinical years).

What is the spirit behind the lecturers' questions? Steer them. Be "safe".

The exam is between you, patient and examiner. You can control yourself. Be prepared for the unexpected.

Bismillah before, Alhamdulillah after.

Anything Else?

Go ahead and ask, I'll answer as I can. Preparing for exam only questions of course.

The Professional Exam

2010-05-28T02:53:00.005+08:00

Thank you to all the lecturers, staff, patients, seniors and juniors (my teaching subjects, a source of study), study group mates (Abe, Aiman, Ammaar, Coax, Hafiz, Nadhir, and even Zaim for a short while), batch-mates. Thank you for tolerating my extroverted, cynical, nasty, narcissistic and mean tendencies.

Looking back, I am still sad that the memories of SPM haunted me again, consistently scoring among the top, but failed to deliver on the big day (1 B, in BM). And considering how hard I tried to achieve it, more than my SPM efforts, it hurt even more. Considering the potential I knew I had, the result was an underachievement, a failure of sorts in the objective point of view. Even as I type I am still having periodic episodes of tears welling up.

How I hate the effort-results curve (my imagination, and it's sigmoidal in shape). To get a higher result, you need extraordinary effort after a certain level. And when you fail to achieve the objective, you feel as though all of that effort was just, "lost".

Long story short, it wasn't composure that failed me in the clinicals, but my mental stamina. My mental energy ran out at the wrong time.

Long case - Hemophilia B. Never seen 1 in my life prior to Pro. I clerked according to logic.

Short cases - Twin pregnancy, acromegaly, ACL tear. Those who remember my luck with the Lachman test might be interested to know that again, I failed to notice a really obvious positive Lachman test while lecturers already saw it. Just like in year 4 revision. Only when I repeated the test did I notice it, a complete tear.

But subjectively, it was probably not a failure. None of the study group members had to re-sit their exams. Truthfully, when I heard every one of those names mentioned, I smiled in my heart.

And I did well for the Pro considering that Abah fell sick since the 3rd posting with stroke. Almost every week since December if I remember correctly I went back home during the weekends. It was extremely tiring, regardless of whether I travelled by bus or car. 70% of my knowledge of internal medicine was based on my year 3 knowledge, as there was a lack of time to read. Teaching juniors helped tremendously.

And right before the exams, Abah would again be readmitted, with an aortic valve replacement during my clinicals. The original planned surgery was to include an ascending aortic replacement with coronary reimplantation, and cardiac bypass; I only knew that the simplest was to be done well after the exams. And yet I remained composed enough, I blocked out any worries about Abah and focused on the exams. I did well enough that I called Umi right after the exams to tell her I passed before waiting for the results, the confident being I am. I knew a distinction was out of reach, but yet I remained hopeful until yesterday noon. I haven't told her yet the exact results. But Abah is now alert.

Inspired by the performance of Liyana Mazli, Mastura and Fatin of the previous batch, I tried to emulate their excellence. During that year I was disheartened by the fact that I was not considered for Ortho distinction due to failing an easy PMP on sports injury which I was confused by the manner of the questions. I vowed to keep myself average and sane, until the AGD, listening to the posting awards. I wanted to be at par with them. Since then I worked hard, getting distinctions in the first 2 postings, and good marks in the latter 3

Alas, the handicap I had probably hindered me, but to me this was probably an excuse. But yet I hope that Umi and Abah would be proud of their son, excelling in difficult physical, emotional and mental circumstances, although the true definition of excellence would have been the D. I cannot thank them enough, Umi for teaching me the alphabet at 3, and nurturing my competitive self, never settling for mediocrity. Is there any mother that scolds her child for not getting a distinction when it was in reach? She was the one who cared for Abah since his illness, and told me to focus on studying and performing. And for Abah, who never stopped helping me financially in living comfortably to excel, and for teaching me to work hard, even when you are a bright person. And thanks to my fiancee as well, who had to tolerate me ignoring her for weeks focusing on the exams. I've done what I could, but I guess second best is the highest I can ever achieve, until proven otherwise.

With that, thank you. Alhamdulillah. The pain may persist for months, but at least the "educational" ride is over. Now into the world as a working doctor, a different animal.

P.S. Mr Hafiz on me never seeing a hemophilia patient, "You don't need to see cases, you only need to know it!" I hope that he was proud seeing me present and discuss a case I have never seen outside of a textbook.

Thoughts, Training (May 16, 2010)

2010-05-16T21:26:00.003+08:00

Thoughts (It's been a while):

1) The LPT stretch from Gambang to Kuantan is dangerous in the presence of rain: T-Rex was skidding almost every 3-5 minutes.

2) An interesting quote from Harry Selkow to me:

"The quickest way to get strong is to be the weakest guy in the gym." I've learned to create my own ways to avoid a "jaguh kampung (big fish in a small pond)" mentality. For example, I always look at lift videos in the Internet, not really to humble me, but to motivate me.

MJ used to lie to the media that opponents smack talked with him, and admitted that he lied when he retired, with the intent of firing himself up.

3) An even more interesting quote from Michael Jordan when he was told to emphasize teamwork:

"There's no "I" in team, but there's an "I" in win."

4) People need to have a winning mentality. Standards must be individualized. You don't tell Federer to be grateful whenever he became second best to Nadal; hey at least he got into the finals. You don't tell the same to LeBron James when the Cavs just lost to the Celtics. When your potential is much more, why settle for less?

When I told Umi that I was close to getting a D for O&G, her response was to actually scold me (and my fiancee) for going back every weekend!

5) I've been feeling that I am very lax in preparing for the Professional Exam this Friday. Not spending much time studying, and more relaxing. No pressure for the most part.

This reminds me of SPM, a time in which Abah and I got into a very heated (understatement) argument, and a time in which I was even more hot-headed than I am now. Abah was pressuring me to study while I was home in between papers. I wanted to relax and take my time to read in the middle of a stressful exam period. The trigger was when he kept pestering me to come back after prayers while I was talking with friends. Hm...

6) Speaking of Abah, he and Umi are currently back to the general ward. Atrial fibrillation secondary to CAP. The neurologist said that there's probably new recent stroke(s), although there's no functional signs other than generalized lethargy. I guess the echo tomorrow is for that. Thanks for the wishes from everyone.

7) I'm finding that everyone loves my massaging skills. Maybe I should learn Active Release Technique (ART) or Graston (gasp!).

8) Hm, I can no longer borrow Abah's pants: my thighs have become too big.

9) I don't understand why casual gym goers waste their money with single joint, isolation exercises and getting no visible changes after even 1 year. Unless you can bench 100 kg (I can't), squat 140 kg (not tested yet), or deadlift 140 kg (yes), you have no idea imitating routines of people who spend at least 2 hours every day for 6 days a week with the help of assistance and are already fucking strong in the first place.

Sure, it's your choice, but money and time is precious for those of whom going to the gym isn't no 1 in their lives.

Training:

Since I'll be getting married soon (27 June, Bangi Golf resort - bookmark that date, invites will be sent out when they're ready), I'm going to start fat loss. It's time to dial in the diet 100%. I'm aiming for (generally) normal strength training via 5/3/1 3 days a week, with heavy conditioning on the same days + one. Every other day except 1 day per week will be filled in with general "light" conditioning, probably with Turkish get-ups.

Diet will be carb cycling. Previously I still took carbs on off days. Now it'll be carbs in morning and pre-training only on days with heavy conditioning, and no digestible carbs on off days. The aim is 1-2 kilos a week.

Soon I will also be going back to Bangi, with no lifting partners. At that time I'll have to reduce again my lifting maxes for the bench, which is my weakest lift relatively.

In the mean time, I did have a good deadlift session last week: 131 kg kg for 7 reps.

Stuff on My Google Reader

2010-05-05T23:18:00.002+08:00

I borrowed my mother's credit card for a few ringgit well spent on installing Reeder (a Google Reader client for the iPhone); the worth of it is 100 times more than the amount paid. With Google Reader, I'm able to subscribe to tons of news feeds, and scan them all in rapid time: what I need to read I can open up and expand, what I think it's not worthwhile I'll just ignore and mark all of them as read altogether. In 1 day I receive up to at least 200 entries of news. The only skill you need is fast reading. And using Reeder on the iPhone is a delightful experience, just as using Google Reader on the computer (ask Jusnimar/Nu'aim, both whom regularly use my (Abah's in actual fact) iPhone for news browsing).

Lemme just share with you what I subscribe to; maybe you might be interested in at least a few subscriptions. The only thing unavailable are my Sinfest and Girls Without Slingshot comics, as they don't provide RSS feeds (another prerequisite).

Google yourself folks these feeds, as some are subdivided into sections, making linking inconvenient in a way.

News:

The Economist - This periodical (with many blogs as well) divides its news into many sections, and I subscribe to most of them. English debaters, especially those familiar with the Asians, British Parliamentary style debates must be familiar with this staple source of information. Some stuff might be too heavy (as I found out as well) for normal every day people.

NYT (Global Home) - World news of various topics. Subscribing to this makes subscription to any other "World" news sources redundant.

The Star Online - The best mainstream English Malaysian paper.

The Malaysian Insider - An interesting online English Malaysian news-site. I read this most for it's opinions, as news items in the Star may be identical.

Apple (I used to read eWeek and PCMag but no longer) & Tech:

Daring Fireball - The mainstream Apple news analysis with commentary.

Mac Rumors - It is what it is.

Macworld - Interesting articles from time to time.

The Macalope - Mythical creature with dark humor regarding the industry.

Sports:

ESPN.com (golf, tennis, NBA, Soccernet) - Whether it's Wood's comeback attempt or Chelsea's possible meltdown in London for the last game, where else should you go?

Health, Fitness, Strength Sports including Powerlifting:

Alwyn Cosgrove - He doesn't blog much about fitness, but his insight into life is enlightening. A two-time cancer (leukemia) survivor.

Amped Training - Of Matt Perryman. Politically incorrect, and hence likable.

Bill Hartman - A physical therapist, co-owner of one of the top 10 gyms in America. Read for his knowledge on rehab.

Bret Contreras - An up-and-coming, using EMG to study and refute many myths of exercise.

EliteFTS - THE site for powerlifters, and has articles for strength coaches, bodybuilders and health enthusiasts. A bit ironic considering powerlifters are known to be fat, that's how we squat and bench well! I have my online coaching for my pullups from Harry Selkow, among the Q&A staff on the site, hence my Youtube videos.

Mike Boyle's Blog - Old-timer, functional strength & conditioning coach. Pretty controversial.

Mike Reinold - A physical therapist. Very scientific.

Robertson Training Systems - of Mike Robertson, co-owner of iFAST with Hartman. A corrective strength coach with a background in powerlifting.

The Fitcast - The premier contemporary S&C podcast, hosted by Kevin Larrabee

Tony Gentilcore - One of the coaches at Cressey Performance. A funny blog. Beautiful babes too. While I'm at it, I should mention that I subscribe to Eric Cressey's newsletters (via email).

Comics:

Brenda Starr - Dramatic reporter.

ButternutSquash - Irony.

Ctrl+Alt+Del - Gamer comics.

Diesel Sweeties - Pixel humor.

Dinosaur Comics - High level comics for the intelligent in you.

Flipside - A lesbian jester fighter with her swordswoman lover. NSFW!

Girl Genius - Steampunk

Indexed - Math has never been this funny.

Kukuburi - Fantasy

Least I Could Do - Comics for perverts. NSFW?

Looking for Group - Traveller elf and "friends".

Mystic Revolution - Gamer comics

xkcd - Geek comics.

Thoughts, Training Log Until March 21 2010

2010-03-21T15:27:00.004+08:00

I haven't written in a while; not enough time.

Thoughts:

1) Living in the fast lane, stress can either bounce off of you like a slab of concrete, or deliver blast through you, like a slab of concrete. Usually for me it was more of the former, but yesterday it as certainly like the latter, due to multiple stressors finally getting into me.

I need to keep my legendary temper in check: I think I punched the wall almost 10 times yesterday, hard enough to make people notice. The skin at my knuckles aren't hyperpigmented because of hemochromatosis, you know.

2) My aunt got operated for a "ruptured" appendicitis, but the operation was laparoscopic, so it shouldn't have been too bad. Get a good rest Umi Dah.

3) So far I'm finding that I need to do a lot more to get myself ready for Pro, especially now that the date has been pushed forward. And I can't enter the wards to boot. But with the current schedule and stress levels, I'm not sure how I'll manage to fill the hours in. With my current "intellectual abilities" I'm guessing that just 1 hour to study O&G and another to study for Pro consistently every day would suffice. Another would be to study 1 1/2 hours for Pro (which I've not started on my own yet, only group study), and depend 100% on bedside teachings and other "classes" (including on call sessions with 3rd years) to prepare for O&G (which was exactly what I did for internal medicine, and still got me no 2 in the group). We'll see which path I follow, which depends a lot on how well I cope with the stress.

But I want another distinction, for O&G and Pro. I want the money from the MMA award (though I haven't registered as an MMA member. 1K will help out a lot, especially with the internal drama in the family (not just Abah's illness).

4) Speaking of Abah, he has been talking a lot more, which is good. This morning he also started trying to regularly walk without his walking stick. But there's a lot more training required especially regarding his speech, and dealing with his upper limb spasms while doing ROM exercises are very difficult: too soft and you won't be able to extend the elbows & fingers at all, and too hard and Abah will be in pain. But he's laughing more, and interacting better with guests, who are still coming non-stop during the weekends.

Thanks for the support.

5) Next week is Naufal's wedding, the wedding of a person I can truly refer to as a best friend. Congratulations. Hopefully I'll be able to come over, unlike the so many I've missed lately.

6) Some people have it so easy: you'd God damned better be grateful.

Training (writer's block setting in):

The b-ball underground tourney is less than a month away, and what is hopefully going to be a special day is another 3 months away. It's probably time to reel in the diet, get a good more cardio in, and hopefully still increase if not maintain strength while shedding some fat. People don't care how healthy you actually are, just as long as you meet others' interpretations.

Videos are up on my Youtube page. But one thing is for certain: my pullup strength sucks, and I'm very unhappy about it.

Hm, Next Step: Re-Correlate Previous X-Ray with HRCT and Clinical

2010-03-05T12:53:00.004+08:00

HRCT Thorax this morning came up completely normal (already discussed with radiologist, awaiting full reporting), and there goes how many years of radiation into my chest. No bronchiectasis/bronchial thickening/consolidation/cavitation/calcification/enlarged lymph nodes. Considering that kind of result, I was then "grilled" by the radiologist to rethink whether one was warranted. Maybe Dr Haida was right in that a CT wasn't indicated.

Still coughing with whitish sputum, at most localized occasional crepts at right anterior lower zone (which was also normal on CT). Yesterday, my chest felt a bit heavy, and I auscultated myself. I could hear the crepts through my breathing, and "confirmed" it with friends. Today was much better though, since any kind of "physio" would bring the sputum out, including simple joking and laughing. Similarly the breathing "exercise" associated with a chest CT did make some reasonable amounts of sputum come out.

AFB results never returned, so I might have to consider retaking them. I doubt I want to expend the effort to produce enough sputum for another C&S and Gram stain.

Me wonders if it's asthma. Or malingering haha. In any case, I accidentally left the X-Ray film at home (so I'll have to bring it next week), which I of course didn't tell the radiologist. Radiologists are well known for their strictness. Hehe, hopefully none will read this.

On the bright side, I'm radiologically healthy!

Still Hasn't Ended Yet

2010-02-23T20:01:00.003+08:00

Week 6 of cough.

Still having cough, worse at evening, relieved by exercise, least in the morning. Scant sputum, whitish when productive. No fever, increased appetite, widening waist. Still good effort tolerance (gonna do some conditioning after typing this).

Coarse crepts bilaterally anteriorly mid-lower zones. No clubbing.

Sputum C+S rejected (too little sputum), Gram stain inconclusive (the same reason). AFB x 2 sent, MTB C&S as well x 1, no results yet. Didn't have time to send the 3rd AFB and 2 MTB C&S's yet.

Blood work...

Hb 16.7 (86.8/32.9/37.9) - Is it compulsory on me to donate blood?

WBC 6.34 (50.4/41.3)

Albumin 45.8

Globulin 30

Uric Acid 503 - Unrelated, but high; family history of gout. The lowest I've ever gotten whenever I do an RP on myself.

I'll see Dr Ng when I get at least 1 AFB back. HRCT thorax next week. I'm still doing the chest physio. I'm still worried as there is no clear etiology. And even though it's unlikely (I get URTI at most only twice a year before this), I'm not amused with the Kartegener references. Sigh.

Thoughts, Training Log Until Feb 19 2010

2010-02-19T19:23:00.008+08:00

I'm typing this at R&R Maran, taking the opportunity to charge the laptop...(T-Rex has no radio, remember?)

Thoughts:

1) This is the first time in a few weeks in which I decided to drive back to Bangi, with the reason being that I've an A&E on-call this Sunday morning. I had a nice chuckle when Syafiq asked me if it would be tiring to go back today, and back to Kuantan on Saturday midnight.

But I finally have the opportunity again to listen to podcasts. I tend to doze off straight away taking the bus, and with the iPod gone, lonely drives like these are the only time to listen to them.

2) Abah has been recovering remarkably since being afflicted with the stroke. He can walk very independently, but with slower progress in his speech and slower still with his upper limb. This has made it very difficult for us to care for him, especially with his "depressive state". Imagine at 3 am he'd suddenly go from the lower floor bedroom to the living room, on his own, limping, without "telling us". And since he can't sleep, he'd also suddenly get up just as we'd doze in the living room to go back to the bedroom. And of course 1 family member needed to stay awake and keep an eye on him because of this. His walking ability is now so good that we went out to eat, with him walking. For all intents and purposes, the walking stick is probably the only assistance device we need.

As for the upper limb, only the hand is making progress, in which there's more finger movement but still no strength. The shoulder and elbow are still limp. This is not surprising as it's around that area of the motor cortex that is infarcted based on MRI. As for his speech, he can speak a few more words with coaching by my lil sis Sarah. But you can't expect good development when she coaches Abah to say "Sarah comel" (Sarah is cute). Drama queen.

But there has been a lot of improvement in less than 2 months from being completely dumb and hemiplegic.

Along with the experimental hyperbaric oxygen therapy (which hopefully can stimulate angiogenesis to the ischemic penumbra based on anecdotal evidence), let's see if intensive physio and speech coaching can show neuroplasticity in action. Each hyperbaric session costs RM 300 a session (for at least 10 total sessions). But if helps with Abah's recovery to the point that he can work again, the investment is more than worth it. I'm not too worried about him recovering independence at all.

3) Abah is now pretty sensitive to temperature, and the current hot weather isn't helping at all. Imagine this: we set the living room air conditioner to 26 degrees C with automatic fan speed, with all family members sleeping together. By morning, the A/C is still on full blast, as we can't reach even that temperature. Even the tap water is warm without the water heater.

4) I'm still coughing, though not as badly as 2 weeks ago. The bouts are still severe, but reduced in the frequency of episodes. But the crepitations (lower to mid zone anteriorly bilaterally, coarse) still persist. In a way, I'm still hopeful that it's just bronchitis with superimposed bacterial infection. But the fact that the CXR showed bilateral bronchiectatic changes is a bit depressing. If it is tuberculosis (unlikely due to the location of signs), I'm hoping that the sputum I sent for tests would show results straight away; I only sent AFB twice out of 3 times so far. Then I'll be able to get the whole ordeal dealt with straight away.

But at least other than the sometimes debilitating coughing, I'm doing very well. No fever, no shortness of breath, no loss of weight or appetite (okay, I lost 1 kg, but gained waist circumference, so that doesn't count). The RP showed slightly high creatinine (125), which was expected as I lifted the night before. Hyperuricemia was expected (strong paternal history of gout). LFT was normal. I'll trace the sputum results next week (ample time to have them all done).

Functionally, I'm so good that after lifting on Monday afternoon, I played futsal on that night as well, and felt relatively fine. I'm still aerobically fitter than the gasping sisters who chased after Dr Ng during his short case teaching (hehehe). Seriously though, it has been exercise that's kept my airways clear; I cough more (and it's drier) during the non-exercise days. After I work out, I cough less, but whenever I do, all of the phlegm comes out, making me feel better.

I'm a bit anxious to look at the HR CT when it's done on the 5th next month. But it's more because of the fact that the exact cause of the bronchiectasis is still unknown.

And I regret not taking the H1N1 vaccine when it was available. Oh well, when the 2nd wave erupts in Malaysia I'll have to start wearing a mask again.

5) I don't know why, but I like teaching juniors more than studying. Throughout this block, most of my revision comes from taking juniors during my on calls (yesterday I teached them for about an hour and a half) and doing short cases and discussions. I love teaching juniors (in my "mean sadistic" way, which many, especially sisters in the same batch, don't like). I really haven't touched the textbooks or CPG's yet, which is alarming as internal medicine is one field where you need to read a lot, a whole lot.

But with Abah sick and now me "sick", I really don't have the motivation to study; I'm just cruising through the motions. Meh. Sorry Dr Azarisman, but I don't think I can fulfill your request and earn another distinction.

6) Talking of the sick role, I'm still a bit confused as to how much of a sick role I should have. I mean, I have clinical signs of illness (my crepts are so clear that I could teach my mother to hear them; colleagues and juniors have been listening to them too). But I don't look sick; lay men wouldn't know it. I don't really "deserve" to be absolved of responsibilities. It's like a gray area.

Nevertheless, since Abah's illness, Fiza has taken over posting leader duties (I only handle the short cases, badly) and Iwan taken over full leadership of the AGD. And both have been doing well. Thanks.

7) I've also gotten more and more jealous of others lately. This has been especially since we had to postpone my engagement to another date. I hate seeing others having it so easy to get engaged and married. Hopefully the wedding itself won't be affected, as it's 4 months away. But Umi's dreams to have a "lavish" wedding for her first child has been shattered.

We've been in a relationship for almost 7 years now. And I'm seeing others in a relationship for less than that and are now married, or very soon to be. Yes I'm jealous. But at least my girlfriend is now very much a part of family. With approval of her family, she stayed with Umi at Bangi and helped out especially with sending Sarah to school, getting herself a red punchcard every time. She did this during the most critical time, at which Abah was still in the hospital. And she outstayed Tok and Tok Ki in helping out. Is there really any way to thank her?

8) I've always wondered about how we should respond to hearsay. Some people make conclusions straight away. Some wait until there's concrete evidence. Today was the first time I got burned big time for deciding not to act on it.

Confirming hearsay is time-consuming, and thus I tend to block it all out. I wonder how others deal with it and why.

9) One thing I don't like about TM Gym is the music played. Imagine yourself entering the gym and hearing:

Suck my d*ck

Suck my mother-fu*king d*ck

(Repeat x3)

Followed by bastardized Cascada songs..

But I really have to salute the cardio bunnies who continue to ignore the really offensive stuff played at the gym, loudly. These are the makciks and pakciks, including Dr Alik who has become a regular of the elliptical machine. The sight of him training really hard while "listening" to "Suck my d*ck..." is priceless. I can't warm up for a minute without laughing uncontrollably due to the "distracting" songs played at this gym.

Abe has suggested throwing away Abg Mat's (the manager) mix tapes. But then again, I don't want to go back to hearing Taylor Swift while benching or squatting. So keeping the gym only for those above 12 is a good idea.

10) Initially, doing this blog was just to write down thoughts to share with others. Never did I think that it'd turn more and more into a diary.

Training:

Nothing much, the wrist is better. Have resumed pullups, and hence almost back to normal training as pre-injury.

Monday:

Deadlifts - Up to 110 kg x 9

MP - Up to 40 kg x 9

Pullups - 5 sets of 3

Followed by an hour of futsal that night.

Wednesday. Based on the inverted rows, I need to get my core up to speed. Heavy core training will need to be done next week.

With the time constraints caused by Abah's illness, I really don't know how to prepare for the upcoming B-ball tourney in April. Conditioning targets may be barely achieved, but skill training is for all intents and purposes is impossible if I go back home every single week.

Ugh, Don't Be a Doctor Like This

2010-02-17T14:11:00.002+08:00

My friend recently went to the doctor with a complaint of symptoms suggestive of exercise induced asthma and night cough with wheezing, with a history of eczema and allergic rhinitis and a strong family history of asthma. The doctor was adamant on not prescribing medications (even for pre-exercise), and not to diagnose asthma as he was not having an acute exacerbation during the time of consultation. Instead, she told him to stop exercising at night for avoidance of exacerbations. The friend then told her that exercising at night is the only usual time, as there is usually no time to do so in the morning or evening.

Then came the hammer (I'm paraphrasing here from memory):

"As a medical student, you need to make some sacrifices. If it means not exercising to prevent an attack, then do so. This is because we are very busy blablabla..."

WTF, that is complete bullsh*t. Just because you are in a busy field like medical does not mean that you should not exercise. And when a person has obstacles to achieving a healthy lifestyle, you help him/her to do so. When a child has exercise induced asthma, do we ever tell the mother to stop the child from exercise instead of prescribing reliever medications to use before physical activities? Do you tell the swimmer to stop swimming because swimming can lead to shoulder impingement? Do you tell the blind to give up on education because he can't "read"?

What happened was completely stupid and fu*king irresponsible. At least she cared enough for this friend of mine:

"Let me prescribe you with vit B complex, as it can help you concentrate."

Talk about not treating the complaint at all. If he's not going to buy for himself the oral salbutamol for prophylaxis pre-exercise, I'll buy it for him.

What an absurd ordeal.

Thoughts, Training Log Until Feb 7 2009

2010-02-01T13:30:00.007+08:00

I had no internet last week, so all this are two weeks' thoughts into 1. The first "set" was what was supposed to be the blog for 2 weeks before (already typed halfway but not finished then). The second "set" will be for last week.

Chapter 1
Thoughts:
1. Abah has just been discharged from the ward. Turned out that he had hospital-acquired pneumonia (which Umi didn't know) and just a normal stress reaction (after we asked for a referral to rule out depression). He can only say a few words, most consistently Allah (just upgraded to Allah Akbar yesterday), Sarah once, Aida (ex-student) once. Not once did he say Ah (Umi) or Amir/Adib. Maybe some torture can get the words out, hehe.

Upper limbs are 1-2/5 for power, lower limbs are 2-4 (depending on the joint). We've managed to get him to walk with a stick from the car into the house, with support to prevent him from falling. But at the fastest, it's a 15 minute trip, with help. The problem though is with upper limb exercises, which is not as easy to stimulate than the lower limb exercises.

2. He has also been having problems with urinary retention. He is currently passing urine only once a day, about 700 mls. His bladder was definitely palpable. Tactile stimulation failed, and only long-term heat stimulation with warm water worked. Unfortunately, Abah hates the thermal stimulation, and would scold us because of the "temperature shock". The anger is more evident when bathing him. Fortunately there's no constipation.

3. Taking care of Abah has been very difficult for the whole family. As of last week Umi still couldn't work, taking care of Abah with Adib. She is now on half salary. My girlfriend still had to send my lil sis to and from school. Last week my grandparents stayed at home, alleviating much of the domestic stress. We are now going to try hyperbaric oxygen therapy for about 10 sessions. Each session costs about RM200, with the costs divided among Abah's siblings.

Nevertheless, logistics at the moment is still a nightmare. Umi needs to work, but without me around, there's no one who can help Abah move about the house alone (who weighs almost 80 kg). I was also strong enough to handle supporting Abah in the bathroom, and pick him up to standing position after he slipped from the sofa and sat on the floor. To move him around requires 2 people otherwise (Umi and Adib). The same number is also required to get him into the car, as unfortunately the two cars at home have high seats (Harrier and Rav-4). 1 person to pull Abah onto the seat, another to lift up his knees. My "suggestion" to use the Iswara was quickly shot down (a joke of course). Abah's colloeagues are planning on aksing UKM what can be done to help with the situation.

4. It is still cruicial to get him independent as fast as possible, which is why I've been millitaristic with his lower limb physio. At home, I've been forcing Abah to stand up despite his protests, and walk to and fro when possible. Abah tends to ignore Umi's suggestions to stand, and Adib is more of an enabler, keeping Abah in the "sick role". With him independent, there'll be no problems for Umi to resume working. But without intensive training, when that can happen is unclear. Speech therapy at home is also a big problem, as I don't know how to force him to keep on trying to speak.

5. I have a jinx with the HUKM elevators, always breaking down when I want to use them. And so I was forced to climb up 7 flights of stairs to bring the wheelchair to Abah when he was discharged, a challenge I relished and had no problems. It was unfortunate for the little 8 year old kid who tagged along to help bring the belongings to the car. He was wobbly from the 5th floor onwards.

Conclusion: I may be fat, but I'm fatter than a skinny 8-year old. And those who ridiculed my aims to be stronger (rather than purely bodybuilding purposes), now you have an answer as to its advantages.

Training:
Max week.

Good mornings - up to 66 kg x 16
Back squats - up to 78 kg x 16
Weighted pushups - up to BW+20 kg x 17
Standing DB presses - up to 40 lb x 16

My wrist has been getting better, with 50%1RM for deadlifts, bench and military press (empty bar) all painless. Penlay rows up to sets with 95 lb also went well. This week I'll try progressing and retesting the state of my wrists, working to hopefully 95%1RM.

Cardio last week consisted of barbell complexes, followed by sprints and light treadmill intervals. They were, um, killer. It was needed, considering that there'll be an underground b-ball tourney involving the old IIUM team. Think 4 games a day.

Chapter 2
Thoughts:
1) Abah can walk a bit faster now, but his hands are only flickering, still. I'm trying to aggressively train his hands, but it's difficult as it requires him to move and hold on to objects. You can't train the upper limbs properly while on the sofa. Otherwise I've kept with the grip training using a cup to give him sensory feedback about his movements. Due to the lead-pipe rigidity of his elbow, I've been pushing to have mobility work in his arms as frequent as possible to prevent a fixed flexion deformity. He can lift his legs up onto the bed now, and the headaches are less frequent. He'd still have giddiness on standing though. "Medically", there's no ankle clonus, although there's some "toe clonus" when I extend and dorsiflex the toes/ankle.

As regards to his speech, there has been no improvement, except when he accidentally pee'd in his pants (he couldn't go quick enough to the toilet, and he couldn't tell us he wanted to go). He mentioned "kain" (referring to the sarong) when he wanted us to help get him to the toilet in a different manner. Other than for that ordeal, the wheelchair is not used at home, as I was adamant on getting him to walk.

He no longer has urinary retention (no more need to use temperature stimulation), but he's consitipated, with no bowel opening in a week. Since tactile stimuli didn't work, we've started trying small amounts of laxatives. So far still no improvement. The amount probably needs to be increased further. I'm not too worried (yet) as he doesn't complain of abdominal pain/fever.

2) Despite cutting my training to only 3 days at most of trainining I still can't cope with the fatigue of going back home every week, even when taking the bus. In fact taking the bus probably makes it worse, as it gives me sacral pain. I leave the bus feeling more tired than before entering it. And since I have no small luggage bags, I end up having to lift the bag wherever I go to. At best I look clumsy doing that. The only advantage of taking the bus is that it's cheaper, and there's no danger if I doze off.

Even though before this I was also someone who wakes up late, it's even worse now. Either I feel fucking miserable when I wake up, or I wake up severely late. Both not a fun option. And the fatigue lasts the whole week. I hate mental fatigue.

It's now 10 weekends straight of going back home (interrupted by the weekend before exams) and counting. I still haven't started studying for internal medicine, depending on just the knowledge gained during year 3. And let's not get started on the issue of assignments...

3) I had 2 what the fuck moments with the telco's last week.

The first was with Celcom for my mobile internet, when it took a fucking 20 minutes call and another 40 minutes consultation at their shop just to figure out that my SIM card was defect. Come on, when I told you it worked before, the problem is not with using the wrong settings on my computer, morons. Okay, so the differential was a problem with the modem, but 40 minutes? Seriously? At the very least you could've made free the RM5 replacement fee to repay for the insane unproductivity and horrible problem solving.

The second was with DiGi, as regards to my old mobile internet account. When I terminated my old account, they did not bring up the fees due for the half month when I did terminate it. And so what did they do? They decided to ask for the fee via an annoying call (in the middle of Dr Zain's class) with a menacing tone and threats. All for RM58. Take the money and shove it in your throat DiGi.

4) I find that stupidity has a bimodal distribution: high among the poor, but also very high among the rich. After the Bollywood love saga last week, there's no denying the truth.

5) On another note, how come I only knew about it when the pot was literally boiling? I guess I've become more and more detached with my surroundings.

6) Added with with my problems with my car (battery is now officially RIP'd) and family finances (Abah's credit bills still need to be paid, which I have to do as Umi needs to care for Abah), there's reallly too much in my head. At least Abah still has full salary while Umi has to request for half pay. No offense to Wahida (all the best for her therapy), but I think I need a "long-term" break just as well just to get a hold on my bearings, at least mentally.

Training:
I had a severe lack of time last week. My wrists feels better. But I broke my old PR's. Enough said. With a just recently injured wrist (2 months is recent in the soft tissue calendar). And so 1 gym session (strength) and 1 at home was all I could muster.

Deadlift - 140 kg x 1 (10 kg PR)
MP - 60 kg x 1 (6 kg PR)
Fat-man pullups - Back to the lowermost level, but pain at rep 5. If there is no pain this week with 5 reps, I'll retry inverted rows, with the stability ball, and see if there's pain.

Since I couldn't go to the gym again, I tested my wrist by doing pushups at home:
5 x 10 puhsups, back to back with 5 x 10 bodyweight pushups, using the palms instead of the fists as before. No pain. More of a conditioning than strength type of work.

If things go right I'll reduce the weight and up the weights again. But I'm not sure when I'll restart doing pullups. Maybe I'll try negatives once inverted rows with the stability ball becomes painless for at least 8 reps, or if I'm able to do again Penlay rows up to 165 lb x 10 as before.

Thoughts, Training Log Up to Jan 24, 2010

2010-01-24T11:04:00.003+08:00

And so the verbal reports are much exaggerated, and assessment by yourself is always better. On the bus back to Kuantan (I left my laptop charger at home, yikes!)..

1. Case report:

A 50 year old man, a known case of DM for 20 years, migraine, AAA, ureteric stones (I know it's irrelevant) and recent history of CVA (with no disability prior to the new admission) presented with reduced ability to speak and right upper limb weakness. CT brain at the A&E did not reveal any abnormalities. The patient was advised for rest in bed in the ward. On day 4 of admission the patient suddenly deteriorated, with Broca's aphasia (inability to speak but understands input) and right hemiplegia. Urgent CT scan revealed slight hypodensity at the left frontoparietal region. Subsequent MRI revealed a watershed infarct at the left frontoparietal region. CT with contrast revealed contrast flowing into most areas except for the hypodense area mentioned earlier. A subsequent CTA revealed a complete thrombosis of the left ICA just distal to the bifurcation of internal-external carotid arteries. The right ICA is atherosclerotic but not stenosed. The circle of Willis was normal, and evidence of flow from the right cerebral circulation to the left side was present. Previous lacunar infarcts were present but not enlarged.

This was with a picture of atherosclerotic right and left ICA via MRA 2 months earlier.

2. The good news is that Abah actually survived the incident. Had the thrombosis occurred much more acutely (and hence without the good collateral flow) death was certain. At the time of typing he is surviving with blood flow to the brain coming from the left ICA and vertebral vessels only. The right ICA is certainly pounding in character. I'ved told my mother to not allow the artery to be occluded, ever. The bad news is the current disabilities: he can mention few words when "forced" (Sarah, Allah). His improved power is 2-3/5 for the lower limbs, 2-4/5 (depending on motivation/desperation) for the shoulder-elbows, 2-3/5 for the fingers, 1/5 (twitching is at least there) for the wrist. He has improved quickly due to the intense therapy. A lot of the bad news I heard earlier about him were related to psychomotor retardation from frustration, and just not wearing glasses (so he can't recognize stuff better). Otherwise he is much much better than how I feared. What Abe and I said to myself (I don't really listen to myself) was true: do the assessment yourself first.

3. Since rehab is a lot about neuroplascity, Abah needs a lot of motivation to keep on trying. He seems to resist Umi's efforts to get him to move, and hence that's where I come in. With me there, we've forced him to stand with a walking stick, keep on moving the upper limbs, walk albeit slowly, and speak. Due to him lying around, he's been getting multiple episodes of reperfusion pain (think folding your legs for a long time, then getting the pins and needles when you stand up), so I'ved taught him to sit and hang his legs first, letting the pain go away, then stand. I've also told him to keep the legs moving (and have others help the right leg) to keep the blood flowing and prevent reperfusion in the first place. From no power, to at least walking-shuffling with help in a week: pretty good. Talking will need more motivation and mental focus, so...

I've given him homework while I'm gone: walk 5 times a day, start every upper limb activity with trying to use the right arm first (mimicking retstraint-induced therapy), speak 1 new word a day, breathing exercises, and reading the paper. He doesn't like it, but it's for him. I'm a sadist. The only problem is that there's no time for him, as he's so popular and liked by friends, family and students, so the room's almost always full.

4. Those who know me well know that's how I treat myself and teach others: I'm very mean. And the simple reason is that the human body and mind is a fucking amazing thing. The ability for learning, readaptation and compensation is pretty good. Hence why many hate it when they ask me for help/coaching: ask Coax how it feels like to be doing pushups to failure to rehab the shoulder, Abe when slacking off on doing those squats with a light load, or juniors when asking me q's (I ask them back to lead to the answer). But it works pretty good, as it teaches the man to fish and overcome his own mental barriers to success.

5. Behind the seriousness of the situation, there was some humor. I'm bad with diplomacy, and it required Umi's diplomacy to allow us access to the reports and scans. I told Umi that Abah is a good candidate for at least a short case (with laughter from the staff nurses as well). And I managed to teach Faiz probably 30% of all he needs to learn about radiology. Even in a situation where Abah is ill I can see him with "medical" glasses. But that's just how I am.

But that's the nature of medicine: what is bad/painful for the patient is amazing for the student.

6. I'm getting fatter (can't train as often, and diet is not adapting to it), although my weight remained the same; there must be some lean mass loss as well. So I compensated with my lack of conditioning (I focused on strength) by walking up the stairs to the ward, at level 7. I even ran up the stairs this morning. 4 rounds in all, I'll do it again next week. But not at HTAA; the staff ward at UKM is air-conditioned.

7. Thanks for all who came by to visit, especially family members who kept pressuring him to keep trying to move. Some think of it as military motivation. Think of it as doing what's best for the patient.

Training:

My wrist feels good, but no heavy rowing is possible still. I've been pushing the work, as heavy training beats the stress way. This is despite combining 4 training days into just 2.

Good mornings - up to 63 kg x 14(?)

Standing DB presses - up to 35 lb x 16

Back squats - up to 67 kg x 14 (?) (I'm damn demented)

Weighted pushups - up to BW + 20 kg plate x 13

Seated cable rows - up to 100 lb (full stack) x 5 x 8 (these were brutal by focusing on not using my torso to compensate)

Penlay rows - these were uncomfortable when with 100 lb at reps 6 and more. I might focus on keeping it less than 5 reps.

I'll try the heavier deadlift, BP, MP work next week and test out further my wrist.

Thoughts, Training Log Up to Jan 17, 2010

2010-01-17T21:06:00.003+08:00

I'm typing this while Shahril drives the car...(Racing) Thoughts:

1) I'm just exhausted, and not even the 1 week break after psychiatry posting has been enough. So many things to do and think about, so little time, and even less cash. I'm weary of driving almost every week, arriving late at night/early morning. With fatigue from the gym, the tiredness is felt in the form of soreness. With mental fatigue/sleep deprivation the tiredness is felt in a sense of never having enough sleep, and an inability to think. It's worse. And it's really bad when not even caffeine can help you stay awake during the normal hours.

2) Abah got warded again, with possible Broca involvement; nevertheless the doc's said that there are no new lesions. The problem with his condition is that his symptoms fluctuate; one moment he's fine, another and he feels "blank" and can't speak, with right shoulder weakness (compared with predominantly lower limb involvement last time). He looks depressed at the times when he can't articulate complex things. He can still say simple sentences slowly when he enters "relapse". During brief "remission" periods, he's the same as premorbidly.

3) When you're a medical student, the fact that you can't look at the case notes is distressing. Appreciate the opportunity when you could look at it. At least I could ask for the figures in the investigations from the kind nurses at Wad Warga HUKM.

4) Due to the fact that Umi is caring for Abah, there's no one to take care of the younger siblings. Umi just asked my future wife to help out, bringing Sarah to school for at least the next 2 days, and might even have to sleep over at the house in Bangi. Talk about "kahwin sebelum nikah" ("married before solemnization"). At least she'll be able to use the car instead of the motorcycle.

5) Being the first son and grandchild (on my mother's side) to hopefully get married means that the "lavishness" of the plans is out of proportion to um, me. If it was up to me, I'd be wearing my old Camel shoes, without socks of course. I'm a simple man. And the hantaran would be books of course, my preference being historical non-fiction.

6) A rational discussion will beat rhetoric every time, but it will never win the votes.

Training:

My wrist feels good, Abe is stronger than ever, and Coax can actually paint his house without shoulder pain!

I'll still be using alternative exercises in place while I transition my training to that before I injured my wrists.

Monday - Good mornings, up to 60 kg x 8

Tuesday - Standing DB presses, up to 30 lb x 16

Thursday - Combined 2 sessions, in view of having to go back during the weekend. Squats up to 63 kg x 12, pushups up to bodyweight + 45 lb (plate) x 12. Had a hypoglycemic event afterwards.

Since my wrist is getting better, I'll start empty bar work so that I can hope to lift much heavier weights next month.

Thoughts Up to Jan 11, 2010

2010-01-11T00:20:00.005+08:00

1) Had an interesting run-in with the IMC guards. It was 11.50 pm, and they initially didn't notice me entering to send my future sister-in-law to her hostel. They did stop me when leaving. So they asked in an "intimidating" way what I was doing, then where was I going, and who am I. I answered, but not before I took off my glasses to get a good look at him, and removed my new earphones as I couldn't hear him. He then "scolded" me while tapping on my windshield that I didn't update my sticker, for which I had an interesting answer: I rarely enter IMC, so I didn't feel like buying the new sticker. The guards were even communicating with other guards via their walkie-talkie about me, and of course checked out my car (I'm a pimp and drug dealer (caffeine), they have to). I had to explain that I was a final year medical student. Of course they let me go, but it left the impression that Kuantan guards are becoming like the PJ guards. You know, the asshole type. A complete opposite of the guards taking care of the boys' hostel, with whom you can more than just chat.

As a guard, you're supposed to be on the more cautious side of things, but that was a bit on the too much. Or maybe I'm just not fond of being held up (type A personality).

2) The new Shure SE115 earphones I bought are pure heaven (to use with my mom's iPod Shuffle (she's tech-illiterate :p)). The output is just pristine. And the sound isolation...Well, don't complain about the quality of my singing, coz I won't hear you. I could barely hear the car engine, and I couldn't hear the water splashing while washing my hands. I can't even hear the sound of the keyboard while typing. With the music off.*

*You're not supposed to wear these kind of stuff while driving. It's done at my own risk. But useful to irritate irritable guards.

3) Ya know, most people should shut their mouths when talking about stuff they don't know. It's better to be portrayed as ignorant than portrayed as wrong and stupid. Yes, I'm talking about the God != Allah issue. It also applies to the man at Megamall that openly complained that obligatory prayers can't be done with an imam who's doing the supplemental prayers.

4) Regarding issue (3), it's a manifestation of Malay culture's obsessiveness with extravagance, care for "looks", and too such occupation with sentiment rather than substance. We care too much about the eggshell yet never care about the yolk. The cover is more important than the book. Too much attention to the minutia rather than looking at the big picture. Additionally, hey if something's wrong, make it more beautiful, more expensive! Let's cover up the really important stuff! It's not an issue, but hey, let's make it one so that [insert whatever motivation you need other than the needed motives here].

5) My wrists are much better. There's only pain at end ROM supination/pronation. I can finally do a normal (instead of fisted) pushups again, but I still can't sujud with normal hand position (still have to do them fisted), as the push angle still causes pain. I haven't tested tension strength; but I can handle at least 20 kg of weight without pain during the last cycle. However, coach Selkow and I have agreed to continue the altered training regime for another cycle while transitioning to the previous regime. It's better to go slow than rush these kinds of injuries. All I did to achieve good this good amount of improvement: nothing, as I was too lazy at home. Probably gained an inch of gut circumference too. But the physical and mental break was more than worth it.

6) Hmph, tomorrow IM starts. No mood. I haven't finished reading all of the military books I wanted to read. Currently reading "Crusader Castles in the Holy Land". Architecture students might like it.

Thoughts, Training Log (up to Dec 31, 2009)

2009-12-31T11:26:00.004+08:00

Thoughts:
1) My long case was a big "joke". My patient became unstable from physical and mental health aspects (it's a bipolar manic patient) at the 20 minute mark, and it took 20 minutes to know that I couldn't continue clerking him. I decided not to clerk another patient as I've already gotten what I need for the diagnosis and discussion. Dr Hajee said it best, "When you are working, do you need 20 minutes to make a diagnosis?"

2) Throughout the posting, I never wrote any clerking notes during the interview, and I only presented "one" case (more of a summary than anything) from memory. And I think I did pretty well during the exam. Practicing the hard way makes the normal way easier.

3) My wrists feel better. Most activities of daily living are back to normal, as long as I don't do the "painful" stuff. I still tremble after a training session from fatigue. You wouldn't tell that I'm injured unless if I accidentally lean on my hand, followed up by a scream of pain. As long as there's no supination/pronation/extreme flexion/extension (basically any form of torque)/tension more than 20 kg each hand, I'm perfectly fine.

4) If you're a waiter at a restaurant, you have no f*cking business going to the mirror every 2 minutes to check on your stupid hair. No matter what, you are not an Indonesian pop rock singer (the guy) or a runway model (the girl). F*cking idiots, go and serve your hungry customers! (Rasamas, Kuantan Parade)

Training:
Lots of replacement stuff. Out with most of the barbell stuff, and in with the dumbbells. There'll be a bench session today. But previously..

Low bar back squats yesterday - Last week I did high bar squats after the injury, and felt fine. The low bar position actually felt fine despite of the bar being supported by my delts and wrists instead of my traps. 78 kg x 8 (could do more, but the bar began to lean to the side and I got the reps I wanted). My lower back is sore today.

DB Bench Press - No pain, all I need is a handoff to prevent any torque on the wrists (which causes severe pain). 8 x 50 lb (the heaviest they have here). I'm aiming to do 9 reps today. Followed up with weighted fist pushups (neutral wrist, remember?).

Good Mornings - Did 8 reps with 60 kg in a high bar position. Followed up with 3 sets of 10 of natural glute-ham-raises. My hamstrings did not thank me.

DB Shoulder Press - No pain, as long as I had a handoff to hold the DB's. Did 12 (or 14, can't remember) with the 35 lb's.

I think the only thing that will regress is my grip strength. Everything else will either remain steady or will actually increase (my squats). A good way to end psychiatry.

Not a Happy Person

2009-12-20T00:01:00.003+08:00

Just as lifting was among the few good things that was good in the past few weeks, I got injured, enough said. Bilateral DRUJ strain, with the gym conditions being a factor; my training partners stopped early due to the extreme heat and humidity (no A/C at the free weights area). Hint: driving on day 2 of injury made me scream and cry in pain, relieved by copious amounts of ice. I'm much better, but in no shape for lifting.

Turns out that Abah had a lacunar stroke from bilateral ICA artherosclerosis (from the MRI/MRA). At least he's now back to almost previous activity, just some slow walking, but walking is not a problem.

I've been going back every week this whole posting due to Abah's condition earlier, my dental appointments and the intermedical school sports competition (more on that below). I'm chronically sleep deprived, my sleep cycle is completely screwed and led to caffeine dependence, which led to a vicious cycle. I'm slowly withdrawing.

I can't believe I drove all the way to Bangi to participate in 1 round of tug-of-war, as it's done playoff style. And we lost due to bad turf. More sleep deprivation.

My modem has given out on me, leading to a complete waste of money with Celcom 3G. And more money was just spent to return to being online.

I don't know shit about psychiatry, and exam is in 1 week.

The only thing good now is that I've an interesting new military history book to finish reading, and that I'm f*cking my enemies playing Rhye's and Fall of Civilization mod for Civilization IV.

Latest lifting stats:

Deadlift - 115 kg x 10

BP - 66 kg x 12

Front Squat - 77 kg x 12

MP - 45 kg x 9 (on day of injury, after resting briefly after the accident; thank adrenaline)

Thoughts, Training Log Up to Dec 5, 2009

2009-12-05T00:17:00.015+08:00

Thoughts:

1) Had my first whiff with depression in a while, and it was not very fun. Got myself out of it with the help of training and eating...a substantial amount of endorphin-releasing food. I now have a nice bloat out of it, and I'll have to reel in the diet again during the next training cycle - no carbs except breakfast for most days to get some calorie deficit in.

2) I just took a look at the MRI/MRA, and I don't like it. Now to wait for the neurology follow-up, as I can't commment.

3) Going back and forth between Kuantan and Bangi has been severely draining. It's affecting my energy and mood in a very bad way.

4) Anybody else thinks that Celcom 3G is, in already nice words, a piece of shit?

5) Talking about point 4, I just had my last rage attack last week. Pretty funny in a disturbing way. Let's hope that the windshield lasts longer than the car; I accidentally cracked it by punching it while stuck in a nasty jam in nasty weather and nastily dehydrated.

Training:

It was rest week. Going to the gym felt like wasting time; that's how leisurely it felt.

I'm switching to a 3 day per week cycle. This will make the rest week fall nicely on the week after exams. More rest, so I'll add more conditioning. Hopefully I'll still make gains with lower frequency; ensuring that I go almost all out during each session will help.

Monday

Pull-throughs - 3 sets of 5 with 20, 30, 40 kg

Ab-whell rollouts - 3 sets of 8

Cable side-lying internal rotations - 3 sets of 10 each side

Tuesday

Stability ball DB presses - 3 x 5 x 35 lb

Standing cable rows - 3 x 8(?) x 11 kg (?)

EZ curl standing bicep curls - 3 x 10 x 15 kg of plates on the bar

Thursday

Overhead squats - 3 x 8 x empty bar, 30, 30 kg

Reverse lunges with clean grip - 3 x 5 (each side) x 30 kg

Side planks - 3 x 30 sec

Incline chest-supported DB face pulls - 3 x 10 x 10 lb

Friday

Incline DB bench - 3 x 6 x 35 lb

Scaption - 3 x 10 x 15 lb

Lat pull-down machine - 3 x 5 x 40 kg

Seated cable row - 3 x 5 x 30, 32, 34 kg

I've my pulling assignment for next week from Coach Selkow. These are my parameters for my main lifts next cycle (ignore my pulling work):

I'll be using complexes work from Nick Tumminello for conditioning every lifting day, a change from the b barbell complexes. My aim is to get +6 reps on every lifting session. That would definitely justify doing the 3 day per week training.

Have a nice weekend, peoples.

Thoughts, Training Log Up to Nov 28, 2009 (with video)

2009-11-29T18:13:00.007+08:00

Thoughts:

1) Abah is doing well. His diagnosis has been changed from migraine paralysis to mild stroke. Edema was noted at the left region of the brain only on the second CT (at readmission), consistent with right hemiparesis. He's now at home, and can now walk at adequate strength but with some persistent tingling, is smiling again, and has an excellent chance of recovery provided he's diligent with the physical therapy. He was told by the neurologist that it was due to his chronic diabetes (microangiopathic I guess).

I'm still wondering if it's migraine stroke, as he still has headache at home as of now, although the neurological deficit has stabilized. We're planning to have the MRI/MRA at a private center as the queue for the MRI at HUKM is at 1 month, earliest.

2) I probably shouldn't question the knowledge of a professor in neurology, but I'm still wondering as to why he's been prescribed sumatriptan at a high dosage despite having his diagnosis as mild stroke, not migraine stroke. This is added with the fact that sumatriptan is contraindicated even in migraine paralysis, much less TIA/mild stroke. My worry has led me to withhold Abah from the sumatriptan even though he still has a headache, for now we're relieving him with PCM and Ponstan. So far, it's working enough.

The whole ordeal with Abah has reminded me of one thing. Those who have not entered family medicine will learn it, those who have passed it must not forget it: never ever forget to tell your patients the plan when discharged. Patients must know when to come back.

3) I've been very slow in learning psychiatry; too slow in fact. And still with no case for the write-up. I should be worried.

4) I've been rethinking the times when friends asked me whether I would be able to maintain my work on fitness when I become a houseman. Then, I answered, "I'll just go on maintenance to keep what I've achieved". What I should have added was, "If we're not going to start because we're afraid of having to stop in the future, we might as well stop living. It's rare that we get to do something from our youth all the way until our death. Probably 99% of things in life has a start and a stop. Just do it."

5) I've uploaded part 1 of the Raya Haji BBQ at my house, is uploading part 2, and will probably upload part 3 tomorrow. Not for the easily offended; you have been forewarned, hehehe. It's the last before I become a houseman, the last before Naufal gets married, and probably none will be organized next year as the Aussies won't be here and unsure of whether Hamzah will be back too.

Training:

Training went well, except for 1 thing: deadlifts, Penlay rows, and front squats+military presses on back-to-back-to-back days have annihilated my back, especially considering the "max" nature of last week. I'm currently having back spasms whenever I stand still. The last time this happened was during my basketball days (think the defensive position with poor posturing). Luckily next week is deload, and I'll get plenty of rest. Results:

Deadlift - 117 kg x 7 (11 kg PR from 5 weeks ago)

Bench Press - 71 kg x 7 (3 kg PR from last week)

Front Squat - 81 kg x 8 (+1 rep, 4 kg PR from last week)

Military Press - 44 kg x 7 (5 kg PR from 5 weeks ago)

All in all, very good. After the deload I'll shift to a 3-day per week schedule, so that deloading would fall right on break after exams. I have also bought a lifting belt for use with my top sets, I think I have earned the right to use one, considering that I'll be deadlifting 120 kg's for reps; when I started with 5/3/1 120 kg was my max.

As regards to the log,

Monday

Tuesday

Wednesday

Friday - Pistols (3 x 7), Paused pushups (3 x 12), Front plank with salutes (3 x 12)

Saturday

I can't get enough of this video. Have a happy week people!

Thoughts, Training Log Up to Nov 21, 2009 (with video)

2009-11-21T16:01:00.033+08:00

Thoughts:

1) My body feels like crap, and so is my mind. All because of an abrasion wound on my shin from futsal last Sunday.

2) The abrasion wound on the shin is healing, albeit slowly; I can see the reepithelialization occurring. I'm back to praying normally, except for sitting between the sujud, in which I look like someone doing hip thrusters, as it avoids both pressure and tension on the wound. Which makes it painful if you have to ask. The really bad side effects of this are:

3) I'm really feeling a sore lower back, as I can't move as well as I should due to the shin pain; anything that stretches the skin gives it pain. This lead to some overcompensation by more lower back movement, which I'm quite sensitive to from activities of daily living. Lifting was not a problem: the knee isn't bent much during deadlifts, and I squat to only just below parallel, before it's too painful. I've been doing some intensive SMR on them glutes/piriformis area, and it's been feeling so good I want to cry. In pain.

4) As the wound is pretty sensitive, pain while sleeping was also an issue. During the first few days, even wind blowing on the wound causes pain; that's what I call hyperalgesia. Because of that, I've been having up until Thursday interrupted sleep. Which made my mind feel like crap. Maybe that explains why I did so poorly for the DCP (for my standards anyway). When you still feel sleepy after drinking Diet Coke + teh tarik + 2 Starbucks coffee in less than a 4 hour span, you have a problem. I need sleep, hopefully a lot tomorrow.

5) Coax has joined the team, and is doing well. Very well. His whole body is in pain, which gives me great pleasure, and proves that sadism is related to masochism.

6) People always assume and laugh at others for what they themselves do not know. Don't do that, cause deep inside, you know you're an idiot for doing so.

7) "Your eyes don't see what the mind doesn't know." This saying for medical students should be heeded by anyone. You cannot appreciate anything you see in this life if you know nothing. So keep learning.

8) Abah should do well with his migraine problems causing TIA episodes with rest and propanolol. And as long as the pattern of illness is diurnal than constant throughout the day, I think the recovery would be excellent, even though I'm pretty guarded as a son. But neurology was never my strong suit. I still don't understand why the aspirin was withhold too.

Training:

Tried something new, aka videos of my sessions. They might say more about what I did than words. My pullups this week sucked though; I hope that Coach Selkow won't be too displeased with that. It was the end of the week, and the lack of sleep was getting to me. Click on the days for the videos.

Thoughts, Training Log Up to Nov 14, 2009 (with video)

2009-11-14T20:24:00.005+08:00

Thoughts:

1) I sometimes find that some people want to hear confirmatory answers, nothing contradictory. I you don't think that you can like the answer, don't ask me the questions.

2) I find that many girls also don't like it when I answer their questions the way I do, ie by asking them back leading questions, so that the initial person inquiring can use their thinking to derive the answer by themselves. I can teach many things, whatever I do know, but I won't cure laziness to think.

It's the way I've programmed myself. I don't want to know whether an MCQ is true or false. I want to know "what does the question want me to know?" If you don't like it, just suck it up.

3) Coaches have always stated that most people should just follow what is written and stop asking questions. Just follow the fucking manual. Probably applicable to more than egoistical, damn-rich, pampered-to-the-max, many-of-whom-are-pretty-clueless athletes.

3) On another note, Coax has joined Abe, John and me in training. And not to forget, he does have rotator cuff impingement, very symptomatic.

The goals I've set for him as follows: to get his lower body stronger in general, which will actually help strengthen his upper body as well. And for his upper body, it is very simple: I have 6 months to rehab his shoulder. I will make sure that by the time we graduate, he will not need surgery. I'll make his shoulder so good he'll default further follow-ups. There are 3 components to this.

1 - Improve his posture and ROM - pec minor stiffness/shortness is probably the most important thing to fix.

2 - Improve his trap/s. anterior strength, and promote proper movement mechanics to prevent pain (i.e. proper scapulothoraicic mobility + stability).

3 - Restore strength to his supraspinatus, infraspinatus and teres minor. Subscapularis is optional.

And through 2 sessions, so far so good. Better ROM, and better pain free ROM. We'll be slow and steady; 6 months is a long time.

Training Log:

Nothing much, a lot was just a repeat of 2 weeks before.

Monday

Deadlifts - Up to 104 kg x 9. Did all in hook grip instead of mixed grip, which made it much harder than it was 2 weeks ago. Remember than my mixed grip adds probably 20 kg's to my deadlift.

Tuesday

Bench Press - Up to 63 kg x 11. 2 kg's more than 2 weeks before. I'm still on track to reach 1RM of 100 kg; hopefully BP progress will not slow down a single bit.

Thursday

Front Squat - Up to 74 kg x 11. Was a bit unstable in the middle of the set, but I got all the reps eventually.

Friday

Military Press - Up to 40 kg x 10. I was feeling good, so I did an extra rep, with at least 2 more in the tank. Here's the video for this session.

Youtube and the comments by coach Harry Selkow.

Training progress continues as usual, Abe is progressing well, Coax is relatively pain-free doing upper body exercises, and John has the confidence to train by himself (due to training on different days). And I got the distinction for Surgery. Life is good and to be savored while it lasts.

What Medical Students Can Learn from Strength and Conditioning Coaches and PT's, Part III

2009-11-13T00:26:00.004+08:00

I initially wanted to finish up my series on the rotator cuff, but I've instead decided to instead write about the way "strength" people approach life. This is due to events earlier, in which it was confirmed that I achieved the distinction for Surgery, making it 2 postings in a row for final year. Despite the undeniable joy (I did shed a tear), it was hard to be happy knowing that there were a few friends who failed the last block.

So for this blog post I'll talk about what we can learn from these strength athletes etc as regards to their approach to life.

Among the most dedicated people in the world with the highest most levels of patience and perseverence are the powerlifters. I mentioned it earlier in Facebook and I'll say what I typed again, as it literally visualises how powerlifters approach lifting - the pursuit never stops, and setbacks are never a hindrance:

"Live like a powerlifter. Break a personal record, break a division record: you don't stop training to break further PR's. No complacency. You get injured, you bomb in competition, you stagnate or regress in training: it still doesn't matter. You dust yourself off, reanalyze, and go back to working your ass off to break your PR's. Fix your weakneses, train around injuries, whatever it takes to keep on breaking PR's."

Powerlifters are never satisfied, due to an insatiable desire to lift heavier and heavier. It doesn't matter whether they are among the best or among the weakest; since their no 1 competitor is themselves, there is never a lack of motivation.

Powerlifters are also among the people who have the highest amount of determination. The smart powerlifters train around pain; the most determined among them train right through it, regardless of whether it's the wrong or right thing to do. There are powerlifters who deadlift 250 kg's of weight after a consistent 4 hours at most of sleep, due to having not just handling a day job, but also to take care of children as a single father. Day in and day out, never missing a training session. And of course, despite nagging back pain, hip pain, whatever pain.

We medical students should be the same. Never stopping to improve ourselves after getting high achievements. Never stopping to improve after a setback. There is no complacency, and no giving up. There's no being a pussy.

And how about the bodybuilders, who are frowned upon as drug-assisted narcissistic gay shameless bastards? Of course, we're talking about the serious ones, not the ones you see at the gym "playing around" without direction every day, ending up looking as if they never did touch weights.

Bodybuilders are the ones to look for inspiration when you want to learn discipline.

Bodybuilders are known to calculate and record everything: training, diet, whatever. Their training is carefully monitored to ensure that their body is in symmetry. Their diet is made up of carefully selected portions, to be eaten at exact times, to provide them with just enough proportions of carbohydrates, proteins and fats. They examine if their diet conforms to their protein:body weight requirements. Which is different for different days.

All this is done while suffering hunger pangs and irritability. All in the name of getting shredded down to 2-4% body fat contest time. Need an idea how much fat there is on their bodies during contest time? Try pinching the skin over your knuckles. That's how thin their skin is everywhere on their bodies contest time. It requires 100% discipline to achieve it. And 100% discipline to make sure that during off season, their body fat doesn't rise too high, so that it is never too hard to achieve the same level of leanness during competition season.

And this fact is the same regardless of whether the bodybuilder is natural or drug-assisted.

How disciplined are we?

And how about their quest for knowledge?

Strength athletes are known to learn not from textbooks, but from their own knowledge. How do bodybuilders know the function of a particular muscle? It's by gauging their soreness after a particular exercise. That's how they know how to bring up a lagging body part.

For example, bodybuilders know that the lower part of the pec major is used in horizontal adduction, while the clavicular (upper) part is used in shoulder flexion, along with the anterior deltoids. Why? IT's because they know that regular benching enhances the lower pecs; doing normal benching only leads to what is known as triangle tits (when seen from the side). To enhance the upper pecs, bodybuilders employ incline benching to give the chest a full, well-rounded look.

There's no need for an EMG to examine the function of most of the functions of the skeletal muscles; bodybuilders study themselves to find out which exercises enhances most what muscles, allowing them to derive the function of a particular muscle. That's how they know the difference between the soleus and gastrocnemius, upper and lower pecs, the different range of actions between the 3 heads of the triceps, the difference between the brachioradialis and biceps. They learn from themselves.

Is it really any surprise that serious strength athletes understand the musculoskeletal anatomy more than medical students?

Powerlifters on the other hand, are the masters of human movement. They understand how the body moves as an integrated unit. Why? Again, it's because they study themselves. They understand how the increased strength of particular muscles can lead to high gains in terms of movement strength. They experiment on themselves to see strength gains.

How many of us medical students actually take the time to formulate the forest from the trees? Or improve the trees to get massive forest improvement? The fact that most of us suck in terms of problem-based approaches to patients certainly suggests that we're not very good at it.

And lastly, strength athletes are known to study medical (especially orthopedic) conditions to integrate into their knowledge. They are known to circumvent medical intervention and succeed. They are known to fix their own musculoskeletal problems without relying on the knowledge of doctors, of whom most only understand "ice it and rest it". Never understanding the underlying functional problem leading to the injury or even suggesting ways to fix it.

How many of us spend time learning something that is just not in our textbooks?

What Medical Students Can Learn from Strength and Conditioning Coaches and PT's, Part II

2009-11-11T23:47:00.006+08:00

Now medical students, let's learn about the 2nd most injured body part in both sports and general public: the shoulder joint. An estimated 70% of all people will have shoulder pain at 1 point in their lives.

Granted, this information is much simplified, as is not for your exam purposes: your ortho lecturers might not approve! But don't be shy to open your atlas, as from my own experience musculoskeletal anatomy is surely among the more neglected aspects of anatomy. As if anatomy isn't enough neglected!

The key to the shoulder joint complex is understanding it as 2 separate joints - the glenohumeral joint and the scapulothoracic joint. Different muscles act at each.

The main common problems with the shoulder joint are impingement, bicep SLAP injuries and traumatic injuries (AC joint, GH joint dislocations). We will look at the former here.

The main cause of impingement is a reduction in the subacromial space, leading to injury of the supraspinatus. There are a few factors which determine the risk of impingement:

1) acromial arch subtype (genetic/acquired)

2) slouched shoulders (acquired)

3) downward rotated scapula (acquired)

4) glenohumeral internal rotation (acquired)

5) weak rotator cuffs (acquired)

6) hyperkyphotic thoracic spine (acquired)

7) weak scapular stabilizers (acquired)

See where I'm going? With that, it's easy to identify people at risk:

Computer users - slouched shoulders, internally rotated humerus, hyperkyphotic thoracic spine

Strength athletes who don't train their mirror "muscles" (too much bench pressing, not enough rowing) - internally rotated humerus, inactive serratus anterior

Swimmers - internally rotated humeri

Let's examine how impingement occurs or is prevented.

When talking about impingement, most talk about the rotator cuff. Why is it so important? Let's look at a simple example.

The deltoid acts as a shoulder abductor, similar to the supraspinatus. But look at the point of pulling. The insertion of the supraspinatus, and the rest of the rotator cuff is much closer to the glenohumeral joint than the deltoid. Thus when the deltoid pulls the humerus upwards, the humeral head is also pulled up, reducing the subacromial space. The rotator cuff acts to depress the humeral head into the glenoid fossa, preventing this space reduction.

Internally rotated humeri expose more of the supraspinatus to the subacromial space. An easy way to induce impingement is to perform shoulder abduction with the arms fully internally rotated, ie thumbs pointing down. What are your internal rotators? They are the pec major, lat dorsi and subscapularis (which is a part of the rotator cuff muscles). Have these dominant against your main external rotators (infrascapularis, teres minor), and the static posture will be internal rotation.

A slouched shoulder reduces the subacromial space. This is prevented by having proper posture, in which the shoulders are retracted. A slouched shoulder also indicates a shortened pec minor, which pulls the scapula (and thus the acromion) downwards & anterior "tilts" it. This reduces the space.

Another thing to understand is the concept of upward and downward rotation of the scapula. When performing overhead movements, the scapula must rotate upward to allow further flexion/abduction. If it can't rotate, the subacromial space becomes smaller.

The scapula is controlled by a myriad number of muscles. These are the upward rotators:

Upper trapezius

Lower trapezius

Serratus anterior

These are the downward rotators:

Levator scapulae

Rhomboids

Pec minor

The upward rotators must be active and strong enough to pull the scapula into upward rotation. The downward rotators must be flexible enough to allow it.

When transmitting force, the base must be stable. Can a cannon shoot from a canoe? Or do you want a ship?

The upper limb is unique in that force is transmitted not through bony structures, but through 100% soft tissue, except at the AC joint. The scapulothoracic "joint" has no true bony articulations. The scapulae are attached to the "core" by means of the traps, rhomboids, levator scapulae, serratus anterior and pec minor; all muscles. Out of these structures, the traps and serratus anterior are responsible to maintain scapular stability during movement. Weak stabilizers predispose one self to injury during heavy upper limb movement.

Proper scapular movement also depends on the upper back posture. There should be only normal thoracic kyphosis. Try slouching your upper back forward. You won't be able to flex the shoulders overhead. Good thoracic spine flexibility is a key component to safe overhead movements.

So what do we need for a healthy shoulders to prevent or reduce the risk of impingement?

1) Good rotator cuff strength

2) Retracted scapulae (good posture). Some S&C coaches prefer retracted and depressed scapulae (relaxed rhomboids, levator scapulae)

3) Proper internal rotation-external rotation balance. This includes having good flexibility for external rotation

4) Strong, dynamic scapular stabilizers

5) Good flexibility of the thoracic spine

6) Scapular upward rotation

For this blog post, let's identify shoulders at risk. Another post can be done to examine various methods of reducing the risk/rehabbing the shoulder.

The Internally Rotated Shoulder

Stand up, and grab a pencil in each hand, let the arms hang loose. In what direction do the hands point? If it's straight forward, you're good. If it's 45 degrees inwards, you're OK. If the pencils point towards like each other, you have gorilla arms and are at risk, just like Justine Timberlake.

The Slouched Shoulder

Stand sideways to the mirror and look at the shoulders in relation to the body. The best posture is one in which you see more of the anterior deltoids than the rear deltoids. The shoulders should occupy the posterior 1/2 of your AP dimension. The more forward the shoulders, ie the more of the rear deltoids are seen, less of the anterior delts, the shoulders are more forward as regards to the AP dimension, the worse. You're looking for the "showing off look" or "busty model look" or a "military chest out look". Whichever motivates you more.

The Downward Rotated Shoulder

1) Have a friend examine from the back. Perform full flexion of the shoulders. The scapulae should rotate.

2) If they don't rotate, have them perform a shoulder shrug while the shoulders are in full flexion (ie directed upwards). This "exercise" is known as overhead shrugs/shrug-ups. Again, they should rotate.

3) As the shoulders are being rotated, look for limitations. The person will either compensate by lumbar hyperlordosis (especially with hyperkyphotic thoracic spine) or with "forcing" the humerus to become perpendicular to the floor despite lacking the flexibility for it, which might lead to pain.

Active Impingement Test

Put your hands on the opposite shoulder. LIft the elbows past the head, without lifting the hand. Look for pain.

There are some other tests, but these tests are for other problems.

We will talk about fixing the above problems in the next post. If you need pics/more descriptions I'll link them for reference/elaborate further.

What Medical Students Can Learn from Strength and Conditioning Coaches and PT's

2009-11-10T12:04:00.009+08:00

Medical students are renown for their arrogance and sense of grandiosity, like me. We think we know the best regarding the human body. The fact is that most medical students only know a bit regarding the various physical pathologies that can occur. Most of us do not understand the "functional" aspect of it. When it comes to back pain for example, medical students are clueless as to understanding the pathophysiology and management and the reasons behind it. The only thing we know is "don't bend over", "do more jogging", or the best yet, "kurangkan nasi (reduce your rice intake)".

Ever since I've started strength training, I've come to a greater appreciation for the work that people like S&C coaches, PT's, bodybuilders, and nutritionists/dietitians do, as these are the people that deal with optimization of human function. They have to put various knowledge together and integrate them. By optimizing function, they prevent or reduce pathologies. By knowing about the trees, they plant them to build the forest. Allow me to share the various knowledge that I've learned from them.

And in some cases, it is not the science that dictates the work; it is actually the work that dictates the science. And sometimes the science is several years late.

Injury Prevention:

There are 2 major injuries that occur in the public and athletes: shoulder and back injuries (almost 100% of people will have some form in some severity of it at least once in their lives). Shoulder injuries occur due to improper posture and muscular imbalances. Back injuries occur due to a lack of lower back stability. And unsurprisingly, many medical students know nothing and thus do nothing regarding their own back pain. If it's not due to TB spine/trauma, we're just clueless.

Understanding back injuries requires an understanding of a "joint-by-joint" basis of training. A joint may either be designed for mobility or stability. The only exception is the scapulo-thoracic joint (part of the shoulder joint complex), which is designed for both mobility and stability. And in most cases, theres is an alternation of stable and mobile joints.

Despite a lack of lumbar "ribs", the lumbar spine is actually designed for stability. This is especially noted following various research, some of which are done by Dr Gray Cook, a spine biomechanist. The easiest clue is to look at the orientation of muscles around the lumbar-anterior abdomen region: it is actually like a criss-cross of fibers, which is designed to act as a reinforcement. In fact, it is actually the thoracic spine that is designed for mobility, and along with the hip joint, are designed to have maximal movement as compared to the lower spine.

An example of immobile hip joints can be observed in 2 aspects - tight hip flexors (especially the psoas) and tight hamstrings. The former induces hyperlordosis, with a concomitant anterior pelvic tilt. The latter induces kyphosis of the lumbar spine, with a concomitant posterior pelvic tilt. When the hip cannot flex/extend due to this tightness, it is the lumbar spine which is forced to compensate.

In a patient with severe hip flexor tightness, standing will cause severe hyperlordosis, with excessive stress on the facet joints of the spine. Chronic stress can lead to spondylosis-spondylolisthesis. These people will have extension-based pain, worsening on standing.

In a person with severe hamstring tightness however, the patient's pelvis is always easily tucked under the spine when he/she flexes the hips, associated with lower back rounding (kyphosis). This leads to excessive stress on the intervertebral disks, and tension on the spinal ligaments. Excessive stress here may lead to disk herniation. Unsurprisingly, the pain thus occurs more on hip flexion, aka sitting.

In this case, when a doctor in the KK sees a healthy person with back pain, is pain meds the way to go? The solution might be as simple as assessing his/her posture. If the pain is worse on standing, and you find limited ROM in hip extension, teaching him/her to stretch the psoas, glute activation and abdominal bracing/core stabilization may bring a ton of relief.

If it's flexion based pain, as long as the disk hasn't prolapsed with neurological symptoms, prescribe him/her with hamstring stretching, along with proper movement patterns, aka moving with the hips, not with the back. As long as the person rests properly and rehabs himself well, the person can return to daily life pretty well.

To be continued...

Amir's Shortcut Guide to Clerking Patients

2009-11-08T22:03:00.006+08:00

Since I'm already taking a rest at Temerloh while driving back to Kuantan (psychiatry starts tomorrow), allow me to talk, as I like to talk a lot.

A lot of the lecturers/KKM specialists have lamented a lot about it, I have listened to 3rd degree accounts from other students, and my own anecdotal experience has confirmed it: many of the juniors do not know how to clerk patients, or at least do not know how to do it efficiently. The most basic skill of a doctor is the art of clerking, which is more important than the art of diagnosis. When you make a wrong diagnosis, colleagues and seniors can correct you based on what you got from the patient. But you can't correct if the clerking is not complete.

Regardless of whose fault it is...

Let big brother step in to help (no Barney references please). This information may be useful for juniors, or even batchmates, and other medical students from other medical schools. Okay, which would only be comprised mainly of my 2 cousins. This is not a shortcut to clerking in itself, but is a shortcut guide which is holistic in its approach to getting a patient's history. This is different from the art of diagnosis, which requires an amalgam of history, physical examination and investigations.

I derived this clerking system during third year, based on my experiences presenting cases to Dr Alik during O&G. This was because there was an incident in which none of the housemen reviewed one of the patients in the acute cubicle; I was the only one who knew, and thus had to present to him. He described the principles in which he wanted the history to be presented to a clinician. This was further augmented a year later when Dr Zamzuri (sports surgeon, KKM) described what he teaches as the 5 C's. He remembers it as "complaint, course, cause, complication, current status." I remember it as "what, how, why, what happened, now what." Pick your choice.

"What" - This is the chief complaint.

"How" - This is the "HOPI" as most know it. Your aim is to "describe the illness".

"Why" - This refers to the cause of disease. Causative factors and risk factors are described here, regardless if it's a medical/family/social/whatever history issue.

"What happened" - This refers to the complications, and management history by the medical team.

"Now what" - What is the current status? Basically, "how are the symptoms now?"

With that, you've covered 80% of what you need for diagnosis. Others may be picked up during your systemic review, or other aspects history, which you initially thought was irrelevant.

You need a shortcut guide to clerking, as when you work, you don't always have the time to write. You'll have to clerk history in your head. And you have limited time to clerk; 1 hour of clerking is for medical students, not medical personnel. With this guide, you'll be someone who can safely clerk patients and get the most required history in the first round of clerking most of the time.

Oh and another thing: for most cases, you only need 20 minutes to clerk a patient's history, and another 20 to examine the patient for long cases. The other 20 is to gather your thoughts and fill up whatever gaps there are. If it's a simple case, there really is no excuse to not get it done within that time period.

I may be someone who's unorthodox in his approach to stuff, and certainly not the smartest of students, but I'm sure that some of you can take heed of what I've taught here. I've no time to spend teaching juniors like a lecturer with my personal gym commitments and so on (unless if you're willing to wait for me for which I'll spend my time hehe), so this is a pretty good alternative to at least pay my dues as a senior. Maybe I'll talk later about my approach to diagnosis.

Chinups, Pullups, Whatever, Just Get Your Body UP (with video)

2009-11-07T06:57:00.014+08:00

I was starting to stall in my chinups progression (poorer form and lack of reps/set, so I asked for help, from non other than Harry Selkow of elitefts fame. My problem was that I felt that my chinups were progressing a bit slower than my overall lifting. Told him what my goals were although it was a bit too general.

Since it requires knowing my rep max, I decided to have myself well rested and test at home, using the outdoor "gym" we have at the house in Bangi. So all I did were singles with holds at the top on Sunday, and no more pulling during Monday and Wednesday. So here's the test (just so you'd know, it ain't abuse if nobody's using it).

Got the reply quickly as usual. He told me to do pullups, so let's see if I can do them for training instead of on a "just seeing if I can do them" basis. 5 sets of 3. With almost double of my usual horizontal pulling as he told me to do 2 exercises on bench day. I guess it's logical to cut out my monday chins+holds, and keep the face pulls. As for the exercises, I'm thinking of keeping my inverted rows (supinated grip) and adding DB rows (neutral grip). As he said, 3 sets of 8-10. I'll do sets of 8 and get a feel first.

But with doing pullups comes the inevitable: how about my biceps? I want/need big guns (aka biceps)! It's what girls dig!

I'm joking. Hence keeping the supinated/neutral grip on horizontal pulls, for a healthy dose of biceps, as such compound moves are my only exercises to target the biceps (everything was with supinated grip). No curls.

Thoughts, Training Log Up to Nov 4, 2009

2009-11-04T22:43:00.006+08:00

Thoughts:

I hate being a perfectionist like I am. During times when I want to excel like exams, I stress myself so much that I experience psychosomatic symptoms.

On Monday, I experienced crushing retrosternal pain, centrally located when leaving the hall after PMP. But there was no signs of increased sympathetic activity: no tachycardia, no palpitations, no sweating. I had to sit to relieve myself. Stand up again and walk: return of pain. It only disappeared about an hour while eating (an early) dinner. And of course, there were no symptoms during training.

Today, I experienced some severe claudication in my right leg when going back after the short case exam. And of course, the pulses were palpable, the pain didn't disappear with rest. There was no pallor/congestion or other signs. It only started disappearing during training (almost 9 hours later).

I hope that I get the D, not because I think I deserve it (I don't), but because the wreck it would give me if I don't get it. I like underestimating and overachieving, simply because expectations (whether they are from yourself or others) are a burden. Believe me.

Training:

It's exam week, so no conditioning, partial deload, change from 4 days to two days (today and Monday). We'll push it hard again next week.

Monday:

Deadlifts - Up to 110 kg for 5 reps. All with hook grip. The first time I did my last sets without a mixed grip in a while.

Bench Press - Up to 68 kg for 5 reps.

Front Planks with Salutes - 3 sets of 12.

Today:

Front Squats - Up to 77 kg for 5 reps. Easy.

MP - Up to 43 kg for 5. It was supposed to be 41, but trying to be accurate is probably a waste of effort.

Pallof Press - As usual, up to 3 sets of 6 each side with 29.5 kg cable.

This week, John joined the team (Abe and me). He'll be doing a program similar to mine; more functional leg accessory work compared to Abe (more mass-building). Welcome to hell. I can't wait to coerce him into doing barbell complexes with the barbell rather than the doomstick (the bamboo stick). Lady Gaga people!

Viva for Distinction

2009-11-04T13:48:00.004+08:00

This is Part 1 of Surgical Exam series. If I've the mood/energy I'll share my other experiences especially for my clinical exams. My theory paper sucked in my opinion; there were just too many careless mistakes here and there.

Prof Azmi called me for viva for consideration for distinction. He said only if I passed the viva would I be even considered for distinction, with consideration of my other marks. So there's nothing guaranteed yet, people.

It was a roundtable viva, with Prof Azmi, Mr Junaini, Mr Khairussaleh and Mr Yan.

Prof Azmi:
TNM staging of colorectal cancer.
Differences of T2 and T3.
Commonest type of colorectal cancer.
Location of rectal tumor felt on digital rectal examination.
Divisions of the rectum.
Length of the rectum and anal canal
What is meant by the sphincter complex.
Innervation of the sphincter complex
Endoanal manometry.
Actual thing measured by manometry.

Me:
Sphincter complex - Internal, external sphincter, levator ani, puborectalis.
I was not able to answer regarding what is exactly measured during endoanal manometry (internal/external sphincter pressure), only that it's used to measure the pressure.

Mr Junaini:
What is the commonest cancer of the liver?
Commonest origin of secondary metastases to the liver.
Gross morphology of HCC.
Histology of HCC.
Tumor markers of HCC.
Difference between HCC & fibrolamellar liver ca.
Determination of tumor resectability.
Criteria for Child-Pugh.
How many points for A, B, C Child criteria.
T staging of HCC.

Me:
Did not know the answer for gross/histology of HCC. Answered that fibrolamellar tumor hass better prognosis, due to (after he gave a clue) being well differentiated. I could not answer regarding the A, B, C classification for Child-Pugh criteria, nor the T staging for HCC. I did already mention that resectability was based on TNM (especially T and M) staging and the Child-Pugh status of the patient before that.

Mr Khairussaleh:
Adjuvant therapy in breast ca.
New advances in chemotherapy.
(Prof Azmi) Other hormone being targeted by the new advances. The term for these advances in chemotherapy.

Me:
Accidentally answered regarding the neoadjuvant therapy of breast cancer.
Explained regarding the adjuvant modalities - radio/chemo/hormonal therapy. Answered regarding the criteria for all three.
Explained regarding antiangiogenesis agents (e.g. Herceptin)
(After Prof Azmi gave a hint) anti epidermal growth factor.
Targeted therapy.

Mr Yan:
Classification of surgical sutures.
Type of surgical sutures used in intestinal surgery.
Types of abdominal incisions.
Advantages of different abdominal incisions to the patient.

Me:
I didn't know the sutures used in intestinal surgery.
I answered that "horizontal incisions are better, as vertical incisions would lead to more scarring due to not following the I-don't-remember-the-name-line." (Prof Azmi) "The Langer's line".

And that was that. If you want to know how I specifically answered some of the questions I was able to answer, give me a q.

Prof Azmi:
Are you interested in surgery?

Me:
(Couldn't say no and that I wanna be an ED physician now, no?) I haven't made up my decision, Prof.

Looking at the Bigger Picture of Things

2009-11-03T08:52:00.006+08:00

Well, you can get too obsessed with stuff that should be long-term progress, but I can't help myself. 1RM estimation (based on Wender's formula [weight + (weight*reps*0.033)]), body weight, and body stats.

Current Weight:

Fluctuates between 83 kg (this morning) and 85.5 (two days ago). I guess it's all water changes. Not much change since all the way before fasting month.

Body Stats:

Neck - + 0.5 inches (15.5). Deadlifts do that.

Arms - Stayed the same (14).

Forearms - -0.5 (12). Oh wait, I'm still getting stronger?

Chest - + 1 (42).

Waist - -1 (38).

Hips - -1 (40).

Thighs - Stayed the same (23).

Calves - -2.5 (14). Wow.

So I'm getting leaner, with better proportions, while keeping my weight as is, and lifting stronger? I'm very happy. Now to study for tomorrow's clinical exam.

Thoughts, Training Log Up to Oct 31, 2009

2009-10-31T18:56:00.004+08:00

Thoughts:

1) There's a sense of urgency, but my brain is just fried. Not the best way to approach exams, especially when you know you're underprepared.

2) Celcom 3G is becoming worse by the minute. On weekdays, I only get 3G at midnight from my hostel. That's not what I payed for.

3) Listened to Zaim's study group methods. I think I'm happy to continue with our current set up, with Mondays being Ortho festival days, and incorporating Coax's idea of Saturdays for seeing patients in the wards.

4) Prof Azmi reminded some of us to mingle with others. I at least have my gym members who I do chat with (usually after my sessions); how about you? At home I try to chat with friends, although that has become a bit harder with a tight schedule whenever I go back home. And I always lurk forums to read up on hopefully intelligent discussions and contribute if possible (not much). I find that many medical students including myself are compensating with an increased Internet presence; with an unstable life scheduling (except for my astonishingly consistent 3-4 days of training in the gym per week), that's not at all surprising.

5) Along with the theme of my very consistent training: do you have a goal? Have you made a plan to achieve your goal? If you can answer these questions, you are more likely to succeed than to fail. Fail to plan and you'll remain weak/stupid/whatever that's negative you want to put here.

Training Log:

I focused to get more reps in my bench and front squat days, and achieved them. Increasing the reps to all my assistance exercises has turned the intensity up a notch.

Monday - Deadlifted 104 kg's for 9 reps

Tuesday - Benched 61 kg's for 11 reps. It was supposed to be 64 (I forgotten how much it was supposed to be), but it's still an improvement.

Thursday - Front squatted 74 kg's for 11 reps. These were brutal (I'm still sore and beaten), and since the fellow gym members I asked to spot didn't really spot, I really had to focus on not failing.

Friday - Overhead pressed 40 kg's for 9 reps. My overhead press is shit weak; is there really any difference between 39, 41 and 44 kg's? Might as well push it.

Conditioning went along as usual, but added 2 measly kg's to the bar. For next week I'll train only 2 times, Mon & Wed, and restart the cycle next month and aim for higher reps. This will synchronize training with the study schedule (rest week during break week).

My weight has gone back up to 85 kg's, but I don't know if it's fat/water/lean mass. I haven't measured myself in awhile, but since the clothes are becoming looser still, why should I?

Stuff that Tickles My Mind by Other Students

2009-10-28T21:30:00.018+08:00

We medical students are so funny in a disturbing way. At least to me. And I'm probably just as disturbingly "funny" to others as well. So don't be angry if you're in any way referenced.

1) "Hey, I'm still thinking about how you told me that being in a warm environment doesn't "burn" fat."

"Mm hm."

"So being in a cold environment "burns" fat."

"You could say it's something like that."

"Why do most people think it's the opposite?"

"Because most people don't want to think. Actually some do. Like the US Army. They've found out that in winter temperatures, daily energy expenditure of soldiers rises up to 40% more than normal."

"So that's a good thing right?"

(Eyes opened wide) "Hm? They have to eat more to compensate for the heat loss and avoid hypothermia. That's good?"

(I hope no physiologists read this.)

2) "I want to shape my muscles."

(Borrowing some words from Rippetoe) "There is only stronger or weaker. Bigger or smaller. Leaner or fatter. You can't shape your muscles."

(I hope no anatomists read this. And no, you can't shape your muscles. Well technically you can, but you'd look like an idiot, and it's technically still just getting "bigger".)

3) With many:

"Why do you go to the gym?"

"To get stronger while being reasonably fit."

"..Is there such a thing? ..The only reason people go to the gym is to get big, to bodybuild..What's the use of being stronger? Being stronger is not useful. Looking tough is."

"At least I can potentially carry my wife around. That's definitely useful and romantic."

4) On not taking carbs during lunch (usually):

"Oh my God, you're on the Atkins! Do you take any rice?"

"It depends, but I always take some carbohydrates during breakfast, usually a roti canai. And it's not Atkins. The moment I take no carbs at all for at least a week, not even these vegetables, then yeah it's Atkins."

"But it's not rice (the roti canai)!"

5) Or how about this about a year ago, "Hey I'm on a low carb day."

"So what'd you eat?"

"Noodles and bihun (mini-noodles)."

6) Asked by a lecturer to someone, "How do you know it's the testis?"

"We are able to elicit "testicular pain" when palpating it."

Obviously this person doesn't know the key to running away from a male murderer (and the severity of "testicular pain"): KICK HIS BALLS.

7) Female students' habit of not calling for a chaperone when examining a male person's hernia. Or a PR exam. Do they think that in comparison to female patients, male patients like exposing themselves to the opposite sex? Yeah some do, but the exception does not make the rule.

Thoughts, Training Log Up to Oct 23 2009

2009-10-23T23:05:00.003+08:00

Thoughts:

1) I still don't get the "self-liking" phenomenon on Facebook, the new symbol of histrionicism. When you post an update or a photo etc, is there another you don't particularly like, or at least think it's significant to yourself? By default, if you post something, we know you like it; there's no need for further promotion, as you make yourself look like a big fanatic of yourself. It's not a big deal if you do it occasionally, but it gets pretty funny when it's done all the time, without exception. And people accuse me of being an attention-seeker. And I don't self-like anything I post, unless if it's not so subtle sarcasm.

2) Exams are around the corner. Next week will be panic mode, a quick transition from "I'm too relaxed it's unbelievable" mode. Having seminars still to present doesn't help.

3) I didn't go to the "caning issue" forum the other day, but I feel lucky I didn't considering that the SIS rep didn't come, and listening to news of everybody "takbir"-ing throughout the forum. As Prof Fauzi said best, the forum was certainly a case of preaching to the choir. Personally, I feel that the audience are a bitimmature to act the way I heard they did, though admittedly I wasn't there. I understand that it's a divisive, emotional issue, but there's no need to act like unintellectual commoners. Discuss, listen, form a final opinion, act, and maintain the mental peace. It was akin to the "teach in English" issue in UiTM a few years back.

4) The "no more squats" issue by Boyle is spreading throughout the Internet, and people are starting torespond. As long as you can justify it, you can certainly perform an exercise if it fulfills your objective. In my case, I only do front squats. I feel that I can get enough back, glute, hamstring recruitment by doing deadlifts, and front squats allow me to recruit my quads much more. But with these the issue is the opposite: the limiting factor is my core/shoulder strength, which determines if I can maintain the rack position to perform enough reps in a set.

5) Most people do know what they need to do in life. The issue is whether they 1) want to act, or 2) have trouble acting. In most cases you can help with the latter, but not the former. So give your advice and move on.

6) I can train more intensely in the gym in a rest week than some I dub the "group takde hala tuju". You don't need friends to help you to perform sets with the friggin' machines. I tend to only offer advice with potentially injurious form issues, not with "just going to the gym to chat and fool around with shit in the gym while chugging down some sport drinks because you felt like you deserve it" issues.

7) Abe's training is progressing well, especially for his shoulder. We're going to try transitioning from light dumbbell shoulder presses to push presses with the barbell (empty as a start). He did complain of some deep soreness after some test reps, which I think is due to unaccustomed rotator cuff work to stabilize a ballistic exercise and hopefully not impingement symptoms. If it becomes bothersome/changes to actual pain, we might need to revert to dumbbell presses and increase the weight. I feel the current regime of mobility and rotator cuff stability exercises should be enough to prepare him for the transition.

Another great thing about his training is that he has become a lot stronger and fitter (cardio-wise, mobility-wise, stability-wise). His strength levels are increasing, and if it goes well he'll definitely be deadlifting 60 kg's from the floor before the Pro's. He is an example of discipline and determination.

8) It's funny how you can be among the strongest men in your gym or campus even, yet you're really just a wimp compared to what competing people do with heavy ass weights. The human body is amazing, and it's physical potential is humbling. Like the brain, most people are just wasting it. My PR 130 kg deadlift is nothing compared to this. Anybody got tissue?

Training:

It was deloading week. I only worked up to 60% x 5 for the main lifts, cut reps to 60% for assistance exercises, and did conditioning work with barbell complexes on every training day instead of days 2 and 4. I also did some experimenting with technique, especially with the bench press. I find that a wider "powerlifting" grip is uncomfortable for me, especially with the associated pec stress. I guess I'm more comfortable benching narrow with a more shoulder dominant press, but may result in a less balanced look upper body wise: the lighter benchers have a more developed chest than me. But since my goal is stronger > better looks, why give an f?

Monday

Experimented with power cleans again

Up to 65 kg x 3

Failed 70 kg. I'm not going to clean with a hook grip again. Either full double overhand, or mixed when needed for deadlift-related stuff.

Tuesday

Benched up to 40 kg using paused reps

Thursday

Front squatted up to 50 kg using paused reps

Today

Shoulder pressed up to just 28 kgs.

Conditioning was with Alwyn Cosgrove's barbell complex. I used an empty barbell (20 kg). Abe used the "doomstick", aka Mr 0.01 kg broom-stick. Don't laugh, lest you want me to laugh at you puking trying these out.

Weight at end of the week - I'll test tomorrow morning. Nevertheless, I did touch 83 kg midday Wednesday, which is pretty low enough. Especially with the constant hypoglycemic attacks from a relative restriction during the week, it's a good enough reduction of weight.

Next month:

I'll try to push the reps during every week for 2 lifts, and switching it for the next week. Next week we'll aim for extra reps on bench and squat days. Hopefully I can get at least 10/11 reps with the bench press, my relatively weakest lift (with 64 kg on Monday).

Here's the template to follow for the next cycle:

Have a happy weekend with some entertainment people!

My Mind Speaks, My Hands Type

2009-10-22T20:20:00.001+08:00

You can always ctrl+c ctrl-v the words, but the same can't be said for the context.

Thoughts Before Going to Bed

2009-10-20T23:52:00.006+08:00

1) Psychiatric dissociation/repression is sometimes a good thing. In times of need, it allows you to only be stressed by what you want to be stressed with. Treat it like a trump card not to be used too often.

2) Self-accountability distinguishes you from the children and demented people. In the end, we're not responsible for you.

My Studying Resources and Methods

2009-10-19T20:05:00.007+08:00

This is something inspired by a recent "conversation" on Facebook, so I thought I'd share my methods. In no way is it the best way, but it has worked for me since 2nd year (the year I had mobile internet, beginning with DiGi).

My reading is always in order of importance (for diseases):

1) Internet - emedicine.com, wikipedia if all I want to know is a summary. The main problem with emed is that the information is not standardized as an educational resource, so you have to correlate with what you see in the basic text books/wards.

2) Text books - Read for the basic info, but I'm reading less and less of them. Unless if it's Nelson Peads.

3) Student's presentations - Very rarely. I feel that they're more imperfect than emedicine.

For BMS:

1) Text books - Getting the good books is the key.

2) Internet

For examinations/investigations:

1) Internet

2) Text books

Additional reading for examinations is supplemental anyways. The most important source is the clinical teachings.

The basis of my studying is "spontaneous" research, followed by attempts to memorize everything into long-term memory.

This explains my method of studying: I read MCQs and perform "research" based on them. I also don't mark whether they're T/F. This behavorial training forces me to remember stuff. The only thing I know is whether or not I've researched a particular q or not. If I don't remember it, I'll look it up again, hoping that I'll remember it this time. Usually, I'll either remember the particular information, or the particular resource I referenced.

I also love case scenarios, and approach-based learning. This is because

1) you can cover many topics in one go

2) you simplify your line of thought to consider your most important and most common differential diagnoses when seeing patients.

Disadvantages of my methods of study:

1) Time. There's a lack of time to make notes. I have not consistently made notes since the middle of 3rd year. To compensate, I save all of my internet resources in my computer. What is from written resources (like textbooks), I try to type the notes in my computer. Obviously, this is next to impossible to optimally use with anatomy/physiology.

2) There are no notes to bring with you, anywhere. My laptop is my notes. Luckily, I do have backup. And probably less than 5% of that is in my head.

3) There are times when I do have time to make the notes. Another problem arises: RSI. Nothings beats the ergonomics of writing versus typing, even if you're a trained touch typist like me, using among the best manufactured keyboards in the industry.

4) Sometimes you miss the simplicity of the important info in textbooks by becoming too engrossed in the complexity of the more informative resources.

Advantages of This Method of Studying:

1) You get more reading.

2) Approach based medicine is not covered in most textbooks, but may be researched via the web.

3) By studying via MCQ, you can cover a ton of topics within a few weeks time. This is because you can perform lightning revisions for "easy" topics, and intensive revision for topics you know you don't know. This is best appreciated in a group study setting. For example, for last year's Comm Health & Family Medicine, my study group only managed to start studying on Friday, with exams on Monday, due to on-going work that did not end until Thursday. No matter, as we all comfortably passed. This method in a group setting was further refined during the next two postings of 4th year.

There are a few prerequisites of studying like I do:

1) You have a knack of remembering things on the first reading/discussion. Or at least you think you do. Actually you can, as housemen can remember patients without looking at the notes.

2) You can digest multiple resources into one. The internet can provide quick information, but resources like emedicine is too complex and does not take into account local practices. You have to be able to correlate internet reading with textbook reading, and local epidemiology and practices.

3) Having a strong imagination helps too, as sometimes you need to make those mind-maps in your head, or at most, on a whiteboard (to be erased).

There you go. Not applicable to everyone, but maybe something is useful in there.

Thoughts on Random Stuff & Training, Inspired by Cheesecake

2009-10-18T12:52:00.005+08:00

Random Stuff:

1) Exam's in two weeks time. Looks like I'll have to start my "answer MCQ's" and study from them cycle starting from, now. I finally started reading my resources/notes seriously. It's too late to be making new or updating notes.

2) Based on what I see on Facebook, some people seem to have issues with stress, all the time. Not many, but some. Everybody can complain about life sometimes, but when that's all your status updates are, you have issues. I heard that PCM (paracetamol) overdose works wonders.

You also have issues if all of your Facebook updates are about your Mafia Wars updates. It's called "you have no real life".

3) This Rotiboy cheesecake deal with free white coffee is good (RM 5.5). Good food, good view of people in and out of the mall.

4) I considered entering the iQuest kayaking competition, but was too lazy to find a partner. I wonder if I had a chance of winning had I did find one.

5) Everybody's getting married. Am I jealous? Yes I am.

6) Here's some motivation for you folks: Give forth your best efforts, be prepared for the worst outcome. Paraphrased from Umar al-Khattab, but I can't find the original transcript. You really can't expect something good if you gave um, extremely poor effort now, do you? And quantity does not substitute for quality.

7) Lastly. Prof Tahir has proven that the masters may have forgotten more that the students may ever learn. And that sucks. I'm not even 25 and have forgotten my chemistry, and my most favorite science, physics.

8) I've no idea why I'm not interested at all in this year's iQuest as a whole. Maybe I needed the current weekend to lie down, relax, read, think. Nothing else. Besides, the next weekend will be "driving back home and back to Kuantan in less than 24 hours", again. And that's draining when you're driving a car that has no air conditioning, and is guaranteed to make you sweat even when driving at night with the windows open. Fixing it would cost more than selling the car. Not to mention that the laptop is the radio. I'm looking for solutions, but money is short.

Yeah life is good. When you're old, you'll miss the events of your youth.

Training:

1) I'll be adding power cleans before my 5/3/1 deadlifts. At the moment I know that I can clean up to 50 kg's. Ill test things out and see if I can go up to 60 kg's tomorrow. If that's the case, I'll use cleans as deadlift warm-up sets.

2) I'll try to get rep PR's every other week from now on, along with my "minimum additional reps" that I usually do (did + 4 for the last cycle). Last week, I did rep PR's for both deadlift and standing shoulder presses, both for 9 reps (5 being the minimum target). During the next cycle, I'll push it on the bench and front squat on the first week, and alternate for the subsequent weeks. It might be a good way to really push things without being too taxing.

3) I'm on my way to achieving that 160 kg deadlift before graduation, but not so much for my bench. Using Wendler's 1RM estimator, my 1RM bench is at around 80 kg's. Assuming that I get 2 cycles every posting, I will get 6 cycles, with adding of 6 * 2.5 = 15 kg's to my work sets. This again assumes that I do not plateau during training, which would give me an estimated max of 95 kg. I need to ensure that I get that extra 5 kg. Hopefully step 2 will help me with that.

Random Thoughts, Training Log up to Oct 16 2009

2009-10-17T09:45:00.003+08:00

Random Thoughts:

1) I think that many people underestimate the significance of other people's personal goals. Living a life of altruism is good and all that, but the easier way to gain much more satisfaction in life is by achieving some "selfish" personal goals. Ignoring these would lead to demotivation, and an unwillingness to work for others.

2) It was a lucky week for me, getting 2 case presentations in a week, both of which are unplanned. I'm having a knack for clerking patients without writing down my clerking notes, and simply presenting them just from memory. It won't be too good for exam purposes, but excellent for the future houseman years. I think I'd like to perfect this art inspired from Dr Sham Su Lia, hopefully making a transition to remembering clerking notes + investigation results from my hippocampus only, without looking at the patients' files.

3) I'm still a bit unmotivated to study, despite knowing that my knowledge of surgery is severely lacking. Is it physical fatigue, indifference, or something else? My days know only consist of reading the Internet (lots and lots of it), and training stuff, so there's not supposed to be much of distractions. Should I try playing Wesnoth + reading (like I did in the past) just to get some reading in?

4) Zaim did well presenting the Islamic input..

5) And so far in retrospect I'm very much enjoying a year of becoming a nobody (becoming the strongest asshole in UIA won't make you recognized). And having Abe do 5/3/1 with a Boring but Big setup is working; he's feeling the hunger from the need to eat. To get big.

Training (supposed to be at least 1 rep on final set of main lifts this week):

Mon:

Deadlifts - Up to 112 kg x 9 reps. Aimed for 5. Stopped because of grip.

Tue:

Bench Press - Barely made 69 kg x 5 reps. Bench pressing after all out pulling does that.

Thu:

Front Squat - Up to 77 kg x 5 reps, all straight reps. Fixed my grip issue by putting my hands just outseide my shoulders, and angling the elbows inwards towards each other. This allowed me to have my arms parralel to the floor. Being short compared to Westerners, 5 ft 4 in with 14 in arms, makes it impossible to clean grip the bar with elbows in line with the hands; the elbows just can't bend that much.

As a nice bonus, one of the bodybuilder-type members acknowledged the lift as being pretty good. Other than Abe and I who do full ass to calves front squats, the only people who do squats here are that guy's gang who does quarter back squats. But he's old and ripped (probably at least 50), so that is actually a complement.

Fri:

Overhead Press - Up to 41 kg x 9 reps. It's the last training day of the week, so I was feeling "let's trash this body".

Followed by 3 x 5 chinups, and 1 chinup hold for 10 sec, just to fry everything up.

Result - I'm feeling like a pile of shit ran over by a train, and goodie, next week is deloading week, of which I'll add conditioning into every training day.

Weight at end of the week: well, last time I checked it was 83.5 (early morning weight).