The Ultrasound

The Ultrasound.  I guess most of the common people is aware of what ultrasound is all about, in some way. Any pregnant lady that came to me during my general locum days will eventually asked me, "Doktor tak nak buat ultrasound ker?". To them, ultrasound is maybe part of the important monitoring. But for most, they are truly happy to see what they will be seeing soon, insyallah. At one time, the father cried when I showed both parents the fetus little hand inside the womb.

Now there are more advance technology. Ultrasound is considered old, very old infact. Even the ultrasound had grew more, from 2D to 3D and 4D, some with real time colour. MRI and CT Scan, PET Scan had taken over lots of ultrasound role in diagnosis as they are more accurate and very visually attractive too while clearly define the anatomy.

I am a pediatrician. Not a obstretician/gynaecologist that used ultrasound like nearly all the time. But saying that, I am in love with this technology. And I find it to be a marvellous creation. And I used this technology most of the time now, on my own. The radiologist, the master of ultrasound, complimented my limited knowledge on it.

Taking care of small young kids, the premature especially is definitely a challenge. The 500 gram infant, the 24 weeker baby, not suppose to be out in this world yet, but somehow Allah had destined them to be alive outside of the womb earlier. And part of my responsibility with my team here , to help this little soul to survive. That is an amanah from HIM.

This ultrasound technology is helping me a lot in caring of those baby. I could try to visualise nearly everything and not just the brain, and I am exploring more and more of the wonderful creation of this machine. I learned to use it to monitor the growth of the baby's brain a year ago, and eventually learning to evaluate the heart. And now mastering to venture to the abdomens, genitalia, the spine and the lungs. And I am starting to use it for other things too.

My mentor, Professor Boo NY, who is among the main neonatologist in the world, had been teaching me nearly weekly a year ago, and I am back now under her guidance to explore the beauty of this machine. I remembered that she told me a year ago, "Adli, I am gonna teach you how to use the ultrasound to its fullest potential. As I could see that-despite it is an old thing, it has it own beauty especially in the world of pediatrics". And I believe in that.

Do I ever mentioned about one of my best friend before? Jessica Tan Ai Peng, or Ai Peng as I called her. She is my best buddy during medical school and we had been through the happiness and sadness through it together. Ai Peng is now a qualified radiologist in National University Hospital of Singapore and we recently met after nearly 3 years of not seeing each other. Being a radiologist, she is totally interested in intervention radiology and partly more into adults patients.

When I asked her opinion on ultrasound-she commented " Ultrasound is basically useless Adli. You cannot use ultrasound to do anything". That was her words on ultrasound, and I believe there are truth, as most of her patients are adults and ultrasound is maybe useless. But as I am seeing it right now, I am more into agreement with my mentor, Prof Boo. In the world of pediatric-especially in neonatology, ultrasound technology is still, so far, has it significant role and is an important diagnostic and monitoring tools.

Two days ago I was doing an ultrasound for one of the baby in the ward, and the anxious new parents came in the middle of the procedure. Initially there were shocked seeing the machine and  as the baby was "intervened" with it. After explanation, they understood and started to look at the images. "Tuh apa tuh doktor?" the mother asked. "Saya tengah tengok perkembangan otak baby yer mak, sebab bayi pramatang, penting untuk monitor perkembangan otak dia". Bear in mind, I usually called the mother as "Mak", acknowledging them as the mother of the child. As I was done with the procedure and switched on the lights, I saw a tiny tears on the mother eyes. I asked "Mak okay ker?", as I was worried anything happened. She turned around slighlty, partly embarrased. In her small voice, she responded "Tak doktor-happy dapat tengok apa dalam kepala anak saya". I sat down, and briefly explained my ultrasound finding. The baby is growing fine.

As I stepped back in the room, packing to go back home, then it occured to me. For the mother-seeing the brain of the child is like a "door" that open her to the child. Like seeing and partly knowing what the child is thinking. It had been weeks since the birth of the premature child, and what she saw was the baby in incubator going through a rough time. And I guess-it was maybe among the first time she was able to see what maybe the child is "thinking" and "feeling" through those images.

The Ultrasound technology maybe old, but for me and as for the mother of the child- it brought significant moments to me as the clinician, and even the patients-for many other reasons.

Talking about Malaysian burger

Everyone knows a burger-even a 3 years old knows it. My first memory of burger was the classical home fried Ramly Burger that we usually ate in between 2 slices of Kunci Emas bread or the always so good Gardenia. It was a fried beef patty that was good with bits of white beef fat mixed with mince meat. Chicken burger was a rarity then, and if we were rather lucky, there was the burger bread, that add to our imagination of a real American Burger.


When McDonalds came over to Malaysia, blooming it popularity by 1994-the Burger culture in Malaysia started to change. Before those time, American Burger that we know was only at the hotel, and unfortunately was pale to comparison to what a real burger is all about. McDonalds came with too much of choices and eventually make it cheap, that other contenders started involving in the same tactics. Many choices and cheap, I am not complaining, I am grinning with satisfaction. Saying that, I am proud to know, our McDonlads is maybe the cheapest in the world.

Then came the Chilis's and TGIF-the big grilled burger-which is so really good. Larger thick juicy beef patty, with wholesome sesame buns toast to perfection, lots of cheese with layered of sauce and freshly prepared vegetables, sides with huge chunky filling fries. It was to die for. Burger take over the steak culture of letting the customers choose on the way they like it to be cook-rare or well done, or with other stuff. Soon after-some boutique cafe started introducing gourmet burger. The uniqueness and the creativity has no limit. The asian culture was absorbed, the vegetarian has their burger, the seafood lover can have crab burger and my favourite- mushroom burger with variety of layered mushrooms.

It took the Malaysian burger a while to survive.However, it did survived. As we usually call it "Burger Abang", it does not taste as good or as interesting as the other "new" contenders, but as the price was good and it is nearly found every where on the roadside at the wee hours of night, it survives. But I guess, it doesn't take long for the new Malaysian Generation Y to evolve it, and it is for good.

Burger-bira, Burger-sel are a few examples of Malaysia Burger evolution. The beef patty was still the malaysian burger patty-but is marinated to add different flavours and layered with other junkies that you could ever imagine-cheese, eggs, vege, mushroom, beef slices. To be truly Malaysian-the sauces are flowing like madness-integrating cheesy sauce with Mayo, malaysian chili sauce and the black pepper. The price was not bad ranging from rm5-9-based on the complexity of the burger itself.

What truly wonderful now-is the Burger Bakar or Burger Burn. I had my bite of it last Saturday and I have to say, it will change Malaysian perpective on gourmet burger. With a little bit of improvisation, the burger bakar can definitely take over the American Burger at anytime. With huge chunk of real beef patty that is Halal, deliciously mould and seasoned and grilled to Malaysian taste, the layered with beef bacon, fried oyster mushroom, homemade onions rings, cheese and more cheese with vegetables, served with flowing sauces-eating it-I can forget my craving for that American Burger at Chili's of TGIF. With the price and the "lepak"ambience that it offers, I bet more can enjoy the real gourmet burger.

Malaysian food is so amazing, no one can deny that. On the other hand, we malaysian is truly good on recreating the food from others. And I believe, with more budding ideas, we could create a burger that will hook the world to it taste. When I was doing my posting in Singapore 2 months ago, one of my singaporean lab staff was complaining to me that during her recent KL weekend trip, she did not managed to eat the "Burger Abang" and she was feeling so dissapointed. And when I asked her back-is the "Burger Abang" was what she was really referring too, showing the stall picture on the net- she replied "Yes Adli, that is the burger. I had it before, once, and it tasted so soooo gooood". With that-it concludes the potential of a Malaysian Burger

Lift events

I am a person who like to ponder on certain daily stuff ....and one of those moments was about the lift elevator. Lift or elevator is a marvellous creation, isn't it? Imagine life without it on a day you need to move up things from ground to the fourth floor.  There will not really gonna be KLCC or KL Tower, if there is no lift. Or very limited numbers of "not-so lucky" people could appreciate the romantic view of Paris from the Eiffel tower.

Yet, like any other human creation, lift elevator do have it flaws. The "haunted" lift of UKMMC at the back, I was stranded in it several times for minutes either alone or with people inside. I watched a CCTV recording of a guy that nearly turned mad caused he was stucked in the lift during the moment he need to empty his bowel. He eventually had to do it in the lift, and stranded with no water and food for days. I am not that sure of the final event-but some said he was still alive, while most said he was found dead. On certain day, the elevator just not in the mood and decided not to work. On some day, the lift just too popular and overwork,and many will eventually decided to use the conventional stairs. And remember, the elevator is "prohibited" during the emergency evacuation.

Saying that, this usually squared or rectangle cubicle, had created memories to some. There are numerous stories of relationship blossomed or created while in the lift. "New Year's Eve" the recent movie early this year, showed us how Lea Michelle and Ashton Kutcher eventually an item by the end of the new years eve, thanks to the Mr Elevator. I read about a relationship evolved in an elevator between two married couples that used the same elevator, at nearly the same time of the day-and eventually leads to the spark of a new love, broken of marriages and eventually death of both of them, in the same elevator.I have none of those romantic or deadly moments as dramatic as that. But, I believed everybody have it shares of elevator moments.

My elevator moments are usually during when I was in it, alone. Some elevator are well, nicely decorated. The common events is the mirror wall. I am not that vain, but I guess when I was alone in that kind of elevator, I will eventually do check on  myself. I was caught on one event, looking at teeth reflection on on the lift door while flossing, and walla, I was smiling full teeth to an aunty outside the lift door.

How about singing or talking to yourself? And eventually again, the doors open, and that was your consultant. I never really singing that loud in the lift, but I did jingled and was caught by my specialist. Or even while waiting for the lift, too bored waiting with my nano, I did sometime hummed while making some minor dance moves, and again-caught in action.

My sisters just cannot help other than to take pictures on self-reflection on the lift. And it is also awkward when you had a conversation with your friends on the lift when there were only both of you, and at the other level, peoples entered, and you stopped talking, but your friends on the opposite side of the square, still wanting to continue with the conversation. Or, when you were arguing  on the phone and need to stepped in a lift full of people. Or at instances, cannot help to indulge with dirty jokes of others, or secrets of others in the lift. To be honest, nobody can help but to listen when you are in the closed small square moving cubicle.

Ohh, how about, you farted and it smelled terrible and then someone entered the lift and shared the same fragrance you just eventually sprayed from your butt. But I guess the one that I really missed and currently was eventually starting to be aware of, was the CCTVed elevator, which is a common thing as part of development. My sister had changed head scarfed while in elevator and eventually realised it was cctved. A male collegues shared a story that he was scratching everywhere and again then realised the lift was CCTVed. I surely do my routines in the lift, like tidying up my appearance in the morning, or eventually moving around to my nano, which currently I am limiting myself in the CCTVed lift.
 
I came across this video and I can relate on some of the lift events. I guess some or most of us will able to relate to some. Happy Saturday friends

Through it alone

A child is Allah's gift and amanah to both the parents. And it is the responsibility of both mother and father to be the guardian and shape the child's life until the child is ready to be on their own.

This incidence happened nearly 3 days ago. In the real world, not everything will turn out as planned despite all the preparation was to perfection. This is so true when it come to the birth of a child. Pregnancy is not an easy task- 9 months of uncertainty, of not really knowing what happening inside the womb. Medical technology had advances that we are able to peek into it and try to manage and intervene when required. Nevertheless, we as physician, well understood it is HIM to decide on what HE planned it to be. A mother may survived the 9 months with no complication, but i guess the end of the pregnancy, the starting of the birth of the child, is actually the real test-not just for the mother, but for the father as well. And again, as a medical proffesional-everyone of us, well understood-the best of care during both pregnancy and delivery may still lead to unwanted outcome.

This was what happened to one of the patients here. The pregnancy was uneventful, being the first pregnancy -the antenatal care was good. The delivery was rather uneventful too-yet despite that, ALLAH had planned that the child not to be as good as the care was. The baby was not breathing and responsive at birth despite all measures-and only after a long period-there was a minimal response. The outcome was bad, the life was dependent on the machine, with no sign to show the baby may survived. Saying that, it had been a job for the physician to try their very best and with any modalities. That all was done extensively, yet the outcome was unchanged.

In the world of pediatric especially in neonatology-one of the important responsibility other than providing care and giving hope, it is on the other hand-  to also realize the limitation and the destiny that ALLAH had planned for each of HIS creation. Explaining the situation to both the parents-is never something anybody can learn from any book or youtube. And in this case-it was truly a challenge. The parents' hope was termendous with a lot of misconception on the limitation of a medical world, and tend to forget on the reality of creation of life. The blaming game started with the father pointing fingers to the delivery and pregnancy-to any slight of "unreasonable" dissatisfaction. Each one of them was entertained to the fullest humanity.

After 17 days of going through it, the family understood and decided-there was no hope for the child. This was when the truth of a person really prevailed.

The preparation to let the baby "go" was done delicately with supposedly the parents to be with the child-cuddling the baby while letting the baby heart beat finally stopped. It is a powerful process and an important step for the emotional healing recovery of both parents. But, this was not what happened in this case.

From the start of the event-the father was not being responsive to the event, with unrealistic hope, followed by being argumentative and blaming. The mother was more receptive and accepting the faith of the child and try to understand limitation of human technology. It is something I see commonly in many cases.

Yet what touched me deeply, was during this final moment of the child, instead of being with the mother, going through the process of letting the baby go together-the father was sitting outside the curtain and "guarding" the cubicle-questioning the nurses and doctors who were doing their job, with no smile neither sadness-but full with confusion and unsatisfaction. The father refused to see the child and only ordered the nurses to take picture before and after the child had passed away, leaving the mother "alone" in a job-suppose to be done together.  Fortunately, the baby passed away peacefully with not much waiting.

That, however was not enough for the father. He wanted to know why the baby passed away despite the physician explanation, and personally request for the child to go through a postmortem to look for cause of the failure of life in his baby. The procedure was not easy as it was not a classical postmortem case-but finally was schedule with lot of arguments with the father.

The next day, the child was planned for postmortem as requested by the father. One of the first step of conducting postmortem is identification of the child by the family member. Despite the father was the one who eagerly want it to be done-yet, it was the mother that was "force" to be alone in the mortuary room, to identify the body of the child before the postmortem procedure.

I have enough to describe on this event. I do understand that it is not easy for the father to go through the death of the first baby that he had been waiting for. Yet....he totally forgot that the baby was his and his wife too. And being a "husband" and the "father", he have all the heart to let the newly delivered "fragile" wife to go through all the moments that he refused to be in, all alone. And I guess he never realised that if he felt terrible, the wife who was the "mother"-who was feeling and carrying the child for 9 months and had went through the labour all on her own...and yet-was eventually "forced" to go through this moments all alone on her own.

I wish for allah to give us guidance...and not to be selfish and ignorance, and to be unresponsible.....

The Six Parcels

As I was driving back home from work yesterday, I came across a supposedly advertisement of a coming students' camp on excellence achievements. Lousy at it may seem, I was captivated with the "6 Bingkisan" or the Six Parcel that the speaker shared at the end of it, which was exactly at the time I switched on the radio.

According to her, every parents has a very prominent role in the children's life, which is a well known fact. The same apply on the children's academic achievement. What was interesting was her summary on the 6 parcels that the parents should hold in helping the children with their academic archievement.

"Bingkisan Hati dan Jiwa" was the first parcel. She did not elaborate it, but this is the basis of every single things. This is niat or intention. And when it say niat, it mean intention with the fullest commitment and sincerely doing it for Allah. And I guess, despite the child who is the one going for the examination, I totally agree that the parents is also required to have a "hati and jiwa" that fully ready to do the same.

The second parcel was "Bingkisan Doa". Doa is prayer. And I believe, even in a non believer, they do said prayers in the time of hope and uncertainty, showing how relevant it is. Prayers is some way is a servant's "request". Sometime I had difficulty to even think what I want to request from HIM, but my parents always said, despite Allah knows everything, do said your prayers as much as you can, cause Allah like the servant to do so, for us to remind of him and praises him.

"Bingkisan Kata Kata" or Parcel of words was the third parcel. Remember that when people call you with bad name etc, and the old generation always said that if you keep doing so for 40 times, that will come true. Or people say that name of someone, the way we address someone, will have some effect on the person personality. I believe in it, and that is the third parcel consist of. The way the parents address the child, the way we called them, is important. How we wanted to scold and confront an issue must be firm but with respect, with correct words for them to understand. And "Kata-kata" also include the "encouragement" and the response to their good deeds.

Bingkisan Tahajjud and Tawakkal was the 4th and 5th parcels. I remembered that Mak always remind me and my siblings, that at any time we woke up at night or before the subuh azan, do as many tahajjud. The meaning is simple, waking up from sleep prayer-but I always felt that tahajjud means a lot more to the one who perform it. Tawakkal is dependence to god. For any effort that we had put, we must follow it with tawakkal, which truly what it means, cause after those efforts that we had done, we have no power at all to change or influence it. So tawakkal is the best way of dependence, cause Allah knows the best. I believe Allah had plan the best for every of his servant. If the outcome was not as good as we expect it to be, my parents always said, that Allah is trying to tell me something, and usually in my case, it was that I had been a bit far from HIM.

The last parcel was Bingkisan Maaf dan Redha. And the speaker agreed that this parcel is the hardest to achieve. Maaf is forgiveness and Redha is acceptance. Many people forgive, but not as many is fully redha. And yes, as she mentioned, if the parents never really redha what ever the child wrongdoings are, the "hati" of the child will not be calm, the barakah from the parents will not be delivered and the prayers will not truly be granted.

As I sit down here, not yet as a parents, I know that the six parcels is true in fact in everyday situation, in every deeds that we do. And I am lacking in most of it....

Pilihan Raya - Choices of celebration

It had been a lot of speculation on when is the next general election will be. It was initially said to be in May, then it was in June. As no news of it yet, peoples are speculating it to be by September or so. How much different it makes? To be honest, for people like me who tend to be an "observer" without much prejudice, I am getting a bit numb. The parties flags had been around since every time for the last 6 months, and numerous open speech are like a norm nowadays.


When I was young, I only realised of election at the late of my primary school age, and it was only during that every 4 years when it was held. Even then, it was more of a brief transient period of coloured flags with picture faces along the road with words like "UNDILAH" or "PILIHLAH". It was a simple affair that was temporary without much of happenings.

Things definitely changed nowadays. The elements of politics changed, as well as morality and the principals the politic holds. The peoples in it, gathered together but none really with a united reason. All equipped with different personal, and secret agendas. Honesty and sincerity is rare. Young children are cultivated with those political elements even when they are not able to understand on a simple life basic reasons.

Back to my point- despite whatever your political view are, try to keep it within yourself and keep your children out of it. Naiveness is a beauty in children, and we like to keep it that way.

It was last week, when Ariff- my nephew, who are currently 8 years old was watching Buletin Utama with me and Atok. The news was blurting on some facts, while on the screen was written the topic regarding it. Aliff who had started reading and enjoying the knowledge of the skills, started reading the topic of the presented news. " Jen..te..ra ..Pi..li..han ..Ra ..ya ..akan di per..giatkan..pa..da..bulan..Julai" he read.

He suddenly stopped and was thinking. Soon after, he blurted out to me.."Bulan Julai...ehh dah dekat nih..Sekarang Bulan Jun". He continued to be excited with blinking his eyes,,"tinggal lagi sebulan..."..and he continued..."Papali...kita dah nak RAYA". I, who was initially amazed with his enthuathism of his possible knowledge  on the election, was stunned and could not stop from running out of the AV room and laughing, conveying the stories to other family members. Realizing his papali was laughing and so do the others, Ariff knew he was wrong about the Raya and the Pilihan Raya.

Yet, despite he knows it was wrong and Ummi Ijah briefly explained the differences- I personally feel, Ariff still do not understand much of the differences. As far as he knows-Pilihan Raya, and the Raya he knows are to very different entity. I again.....I like to keep that way, and I guess everybody will agree on that,

Saying that, Ariff is still partially right...Raya is not really that far away....

Ignoring the obvious

Elephant in the room-will definitely be obvious, but not to the person who do not know an elephant is, or who sincerely able to ignore the elephant. Or maybe the elephant is too small, or the room is too big?

 Last week is my first week back to the Clinical with my new post as the Clinical Lecturer and a Paediatrician here in UKMMC. Mixed feeling of excitement and fear,but overall is a wonderful feeling. On the first day itself I was put oncall, and so far Alhamdulillah, it has been okay, while I am adjusting to my current seat.

It was yesterday, during my second oncall at the General and PICU/PHDU side, the event took place. Part of my oncall job is to review all the new admissions on that day and to review all patients in high dependency ward and the ICU. It was a Sunday afternoon,and I guess I am partly in my casual weekend mode.

 Joyce, my Registra brought me to a cranky Chinese Boy who was about 7 years old, admitted due to a bad infection of Streptococcal Pneumonia complicated with effusion. He was initially admitted to a Private Hospital but was transferred here for continuing of care. By this time, he was already out of the woods, with only antibiotic and oxygen supplement on board. Despite that, he still remains cranky due to the harsh experience of his earlier stay.

 As I approached him, he was inspecting me through one corner of his eyes, thoroughly picking any signs of "danger" I may bring. Realizing that, I stopped and smile while took a step back, and talk to the mother. It took him about a minute or so for him to approved my presence, yet he still know I am a Doctor and I will "disturb" him in some way, despite how mild and kind it will be. So being a kid, he started to complain to the mother of being itchy at the chest, wanting the mother to scratch here and there.

Part of my four years training was learning how to captivate a child. It is an skill, and skill comes with practice and a bit of wisdom. With some "funny" body language and tilting of head with some face grimaces, the boy reluctantly allow me to do my job of examine him. After doing part of my peripheral examination, I took my stethoscope to auscultate the lung.

"Vrup,dap, vrup,dap, vrup, dap" was what I heard and it put me back. I lifted the stethoscope diaphragm and move to the other site of the chest, and what I heard was a more intense similar sound with different variables. It put me to a stop. I looked at Joyce across the bed trying to non verbally communicate with her on my "finding". Obviously, she looked back at me, puzzled.

Hurriedly, I flipped through the folder, while asking my other MOs, "Is there some heart lesion?". Joyce still with her puzzled face asked me why. "There is a weird murmur, you are sure he do not have a heart problem before?, I asked her back. Her puzzled face turned shocked and with that I gave my stethoscope to her and carefully put my diaphragm on the boy's chest for her to listen to what I heard. She was initially shocked and I let her indulged in it, while looking at the patient's note. About a minute after that, she came to me and said slowly..."Adli, I think what you hear is not really a murmur...I think it is the mother's scratching".

I looked back to the boy directly, and there it was. The mother who was sitting at the side of the child, was diligently scratching her beloved son as initially requested by him. With that, I walked back to him, and asked the mother to stop doing what she was doing, and wallaa.....the so called "murmur" were gone. I smiled to Joyce, signalling her she was right and as we moved to PICU, we laughed on how "stupid" the incident was, and how ignorance I was.


As I was driving back home after the round-it tickles me, how we tend to ignore the obvious. My incidence was a sincere and honest response, and it was mainly because I was shocked with the bad finding despite a relatively healthy child. Yet, I bet, there are lot more moments where we tend to ignore the obvious. I always taught my students to look for obvious sign to explain the situation, and there I was, doing exactly opposite of what I taught. Despite it is not true in this case, usually we tend to ignore the obvious because we want to believe in it, we want it to be in that way. It is different from ignoring the truth, cause in ignoring the obvious-the person sincerely do not realised the obvious.

I was wondering how things ever happened when it is so obvious? But I guess it explains by itself when you basically the one in the shoe of ignorance.