Couple Random Thoughts - March 11 2012

1) Since the Share Sheet feature in future OS X Mountain Lion includes Vimeo and not Youtube, I'm considering returning there for my video hosting needs.

2) The takeaway note from the recent hospital lecture in conjunction with World Kidney Day: you can't expect to receive if you're not willing to give. The Malaysian organ donor rates are really appalling such that the majority of recipients get their surgeries in China/India. I agree that we need an opt out instead of the opt in system in place currently.

3) The worst thing about being in the strength sports (powerlifting/strongman/Oly lifting/bodybuiling)? Your thigh size determines your pant size, not your waist. The belt *is* mandatory.

4) It's cool to have passed the anaest/ICU posting assessment without studying at all (the exam came as a surprise). Maybe I should return here. After all, being an intensivist is one of my interests along with (paradoxically) sports medicine/rehab.

Strength Training... As a Houseman.

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:

1. Your training schedule is never optimal.
2. You might train post-call
3. 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.

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

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.

Thoughts (July 24 2010)

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)

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.

Thoughts, Training (May 16, 2010)

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.

Thoughts, Training Log Until March 21 2010

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.

Thoughts, Training Log Until Feb 19 2010

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

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

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

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

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.