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.

For the Juniors

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.

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 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.