Hi, I have moved my blog to this address https://benirusani.wixsite.com/beni
Good night and good luck.
Hi, I have moved my blog to this address https://benirusani.wixsite.com/beni
Good night and good luck.
I have been doing some reading lately. Come to think of it I was an avid reader in my teens. Mostly fiction. But now I have come to realize that non-fiction provides a different kind of enrichment into my life. I am not a fast reader, so with my full schedule at the hospital – my strategy is to flip some pages whenever I find myself not doing something. So instead of grabbing my phone by default for a quick check on Twitter trending, I would instead open a book. With this strategy, I could finish Atomic Habits by James Clear in 8 days. Thanks Dr Suhailan for lending the book.
I have been thinking about this. I need to update this blog more regularly. One post every week. Call it my new February resolution. Lately, I have been reading some books on productivity and they make me realize that as you write down your thoughts, your cognitive process becomes clearer compared to keeping them locked up in your grey cells.
So I will try to publish a new post every Saturday. How about that?
The cases are getting higher. What used to be around 5000 each day has now surpassed 7000 easily. My gut feeling says the number will rise even higher now that Chinese New Year had just ended.
I wish the number would come down and by default the number of death too. As for now, vaccines help reduce our risk of dying from Covid. But ultimately, I hope we do not have to take any more vaccine boosters.
What worries me is the lack of awareness in public. People get complacent. Nowadays, I see many groups of people coming from different households (c’mon, you could tell) occupying small tables in restaurants examples like at Naj & Belle in Bangsar (their tables are < 1 meter apart), restaurants at Kg. Sungai Penchala, and Artisan Coffee in TTDI (to make matters worse, their barista and friends smoke cigarettes next to their customer’s outdoor seating, yup < 3 meters). I am sure you could see a similar occurrence at your place.
Coming back to Covid, yes transmission is going to be super easy barely an inconvenience.
**Addendum: As of 5/2/2022 cases have jumped to 9,117.
Almost a year has passed since I last wrote anything here. I guess I got busy, another word for laziness. But mostly I feel uninspired. Life as always has a sneaky way of doing that. So here I am (again) sipping an 8 pm cup of hot latte at Maria’s restaurant while digesting 250 grams of Australian ribeye. Plenty of meat with enough fat for that juicy feeling. Happy Chinese New Year.
It all began after a quiet lunch and cleaning the dining table. My peripheral vision caught the dirt on the floor crying to be vacuumed. As I was doing the floor I could not ignore the bathroom. While scrubbing the toilet floor I remembered that I had to do the laundry and pretty much once I open the wardrobe I realized that I have not worn some of them in the past 5 years — a couple since medical school which I kept for sentimental value. But since I am no longer a sentimental guy, I put them in a big plastic bag. There is a donation bin at the hospital.
I then proceeded to wipe the shelve and found this book I bought many years ago. The title is “Goodbye, things” written by a Japanese man named Fumio Sasaki. It’s about the beauty of being a minimalist in which we live more by owning less.
By the end of the week, I had five trash bags containing things which I can’t recall by now. And that is just the beginning. Decluttering is not a destination but a journey — so if I were to remove one item each day I bet I will have a lot of empty space by year end.
So, what do you think of minimalism? Would you be interested in taking that step and reclaim your life from the world of consumerism, owning unnecessary item in life and having that peace of mind instead of a piece of furniture.
Exercise is good for you. That’s a no brainer.
No matter where you are, Summer in London or stuck in PJ during MCO 2.0 — you got to find a time for your body. American Heart Association recommends you (not sure to their 78 year-old President) to do at least 150 minutes per week of moderate intensity of aerobic activity and this could be as easy as brisk walking or berlari-anak or lenggang Mak Mah.
Should you wish to go faster you could do 75 minutes per week of vigorous aerobic activity. But don’t do y’all do it in one day, instead spread it throughout the week; and that could be as easy as 1/2 hour x 5 days of your week. That’s more than a fair amount to invest for your own bo-deh, comparing to the 9 HOURS you put in daily for your boss at his company.
I try to make this as regular as I could during this MCO 2.0. A perfect time to collect my thoughts quietly while getting my heartbeat within range of 120 to 150 bpm and thinking of a better ending for Rise of Skywalker which blatantly stole Captain Marvel and Avenger’s Endgame climax twist.
No, I am not Jack Ryan nor Red Furniture is the latest Typhoon-class Soviet submarine with silent propellar. I want a dining table and sofa for the new house. A sturdy looking big dining table (preferably wood) which I will use to write sequel for Breathe, while eating maggi.
By the way did you know that “wooden table” has basically three types which is solid, rubber and plywood. Solid itself has various kinds depends on which tree kena potong and from which region. Some wooden table comes in one single piece which looks more natural with those alur2 as opposed to ‘joined wood’ which may have several straight parallel lines on it. Ceramic is in now but I don’t really like the texture.
I have been spending the last few weekends hunting for furniture (of course by maintaining strict covid SOP , hey we need to revive the economy too ya?). So this might be useful one day when you want to replace that old furniture in your living room, so bookmark this page. Basically, I found these 3 steps are practical:
Look up online for shops and their type of product eg. Scandinavian, minimalism, antique etc you get the picture. I find the best way is to scroll Instagram and go to their websites.
Visit the shops and inspect the material, quality and price plus whether they look as accurate as or pretty like on the websites. Some tips
1) ask if they do FOC delivery or you need to spend extra $$$ on transportation 2) Whether they have it stock-ready or you have to wait 3-4 weeks aka pre-order. I don’t know if some of you would buy furnitures directly from online like Shopee or Lazada without inspection. Would you?
Open your wallet.
There you go, simple right? And this is what I discover from my adventure. Rozel in TTDI offers quality furniture at premium Ringgit — but if you are observant you could still get a good catch at reasonably good price.
So far I’m quite impressed with Ruma, located in Atrium Mall, PJ. Ruma carries modern minimalist design at reasonable price. I bought a sofa bed for my hospital office at Rm600+ / but they charged another RM100 for delivery maybe coz they don’t own a lorry.
MUMU in Shah Alam is pretty okay too. Their design have Japanese touch and they do FOC delivery within Klang Valley. Joy in Uptown Damansara on the other hand has limited selection compared to their amazing Instagram.
SSF in Scott Garden has a vast collection almost Ikea-like, but IMHO they look rather plain. Damansara Furnishing Centre nearby Uptown has 4 huge shops. I like Nordic Gallery which has cool err Nordic-ish design. Celllini is just okay but I find the design is tad boring yet with pricy tag.
So there you go, I’ll update once I found my dream table and sofa.
Good things take time. As with everything else in life, yes?
But then again some do not.
Once upon a saturday night.
I was doing post-graduate in HUKM. A 70-year-old Indian gentleman presented to the emergency department with neck pain aggravated by movement. In most cases this would fall into your typical ‘atok with sakit tengkuk’ case folder. A seasoned ED physician who was about to finish his night shift took a glance at the cardiac monitor noted something wasn’t right — The old man’s heart rate register at only 26 beats per minute! (by right it should be between 60 – 100 bpm)
He quickly asked for a 12-lead-ECG (another fancy way to say a complete ECG picture) and it revealed a second degree heart block specifically Mobitz type II, which could progress to 3rd degree (or complete heart block) which happened to be Mr Grim Reaper’s favourite supper.
Did you know? the heart pumps roughly five litre of blood every minute into circulation. But to do that, the heart needs an electrical supply to coordinate its pumping activity. Unfortunately, that old man’s heart electrical wiring decided to go on short circuit.
The grey-haired handsome ED doctor knew what needed to be done but he didn’t have the resources, so he paged cardiology to take over the case — and that’s where I came into the story. It was around midnight when I got the call. He sounded cool and firm, “Get down here and pace him.” On further questioning the old chap admitted to have giddiness for the past three days. To ensure that his heart didn’t suddenly stop that night, we decided to put in a temporary pacemaker — so we could increase his heart pronto!
We pierced his right jugular vein (a big vein lying at the base of the neck, under local anaesthesia and push the pacing wire into his heart and tucked it to wall of the right ventricle. We then set his heart rate at 60 beats per minute. That gave us a couple of days until we put in a permanent pacemaker.
My only concern that night was what if the old man suddenly ‘mengigau’ at 2 o’clock in the morning and pulled out the pacing wire that was hanging out from his neck!
This is my sincere advice to adik2 in high school (or parents) who want to become doctors in Malaysia (for those of you who are currently in med schools, remember to “Finish off what you started.” 🙂
First of all, I’m sure you are all well aware of the current situation in Malaysia. In the past few years, we have a steady amount of 5000 to 6000 fresh medical graduates each year — these include those coming back from overseas & 35 local med schools. That’s 35! Malaysia probably has the highest med schools : population ratio on the planet. At one point some of these med schools were ‘owned’ by politicians and retired ministers. Few were shut down for reasons I’m not sure of, but that’s for another story.
So, coming back to all these 5k to 6k graduates; every single one of them with hope and dream — without exception, they need to do a two-year housemanship. And once they receive their medical license & registration they will have to serve another 2 years of compulsory service in Govt hospitals. Only then they are set free to be independent medical practitioners. Free to roam and help the Rakyat without supervision.As much as I want you young people to pursue medicine, there are few things you need to consider before you start filling those application forms to med school. These are not factors to discourage you from taking up medicine. You just need to be aware of them, and this list is not in itself exhaustive:
Studying medicine in certain countries could be tricky. REMEMBER, do not be easily swayed by recruiting agents who guarantee you a financial solution after your 1st year. I was told by someone who studied medicine in ________ that this is the kind of promise they use to entice students to enroll in some med schools (not all) in the Middle East & Eastern European countries. From what I heard, in _______ for example, some lectures are not given in English despite the promises made in their advertisement. I’m not saying they have low-quality degrees. But you are risking your future if you run into problems after you’ve started your course and paid the fees. Not to mention, some schools/degrees are not recognized in Malaysia – which may require you to sit for Medical Qualifying Examination upon returning home. So do your homework by enquiring at relevant ministries and MMC and select your school accordingly.
If you still want to pursue medicine I strongly urge you to keep the option in your back pocket the possibility of working overseas. But in order to be ‘marketable’ you need an internationally recognized medical school/degree so that you could always have the option of working in other countries if you have to. Having said that, some countries now insist that you take their special exams before you’re given a job offer. Please spend some time and visit this blog https://pagalavan.com/ by Dr. Pagalavan who is a respectable rheumatologist and has done extensive writing on this and other issues concerning housemen training. Another good article in the Star.
In the mid-’90s, some of my colleagues and I were lucky that 🇲🇾 govt was able to send students abroad to do medicine. Even with that not all of us decided to come back and serve the Rakyat. But no matter where you will end up, I could tell you now that doing medicine is a life-long commitment as doing specialty will take another 4 to 5 years (some need to take up additional loan). I was fortunate to be able to carry on after med school, did not quit my housemanship (Thank God); and proceeded to do a specialty. A doctor once told me not to make rash decisions when I’m tired, upset or hungry; which is a common trait when you work long hours during internship.
You may agree or disagree with what I said here, call me cynical or realist. The purpose of this article is to provide you with information so you could consider everything served on your plate. The future is uncertain so you have to be certain of yourself. There are so many things happening in Malaysia right now which may or may not favor your way. I want you to choose what you think is right for you. If you think medicine is what you’ve wanted all your life. Then go for it. Please be prepared for anything that will come your way.
Remember adik2, you live in a world where competition is all around you. Look after yourself and help your friends. Every dream has a price and you must be willing to pay for it, and here I’m talking more than just Ringgit and Dollar.
At the end of the day, in whichever field that you choose (or have chosen) – there is only one rule to success: “work hard or go home.”
When it comes to aortic valve pressure gradient assessment (eg in AS, Prosthetic). We have to be careful when measuring the velocity in the LVOT. This velocity is used in DVI or as VTI in the continuity equation. Placing the PW too far from the AV (closer to apical) –> will overestimate the severity of AS (eg. will yield a smaller AV area and smaller DVI). And vice versa if we place the PW too close to the AV.
Now, once we have done that, next think about how the placement of the PW in the LVOT could affect the DVI assessment of Mitral valve prosthesis? As we know DVI of > 2.5 suggest significant MR (in a normal Pressure half time.
Echo reflect how we live our lives, and precision could make that difference.
Instead of writing mushy-mushy post. I thought might as well write something useful. This post might be relevant to medical & allied heath students and junior doctors who want to know more about echocardiogram. And I’m sure a general public could understand echo after reading this post.
Let me tell you what I feel about echocardiogram. Echocardiogram is the new stethoscope. I recommend all medical students & junior doctors to get use of holding the probe and start scanning. It will take time to be good at it. Gee, I’m still learning everyday. Only when you start doing your own scanning that you would be able to appreciate what need to be measured and why they are important.
In brief, I will tell you how we use echo to understand the heart and its function. To keep it simple, every echo machine has 3 main modalities:
And Doppler has 3 types:
We use 2D echo to see the heart structures, and measure the distance, the length, area, even volumes. For example in the picture below, we use 2D mode to measure the distance of the LVIDD (Left ventricle inner diameter in diastole), IVS (Interventricular septal wall), LV posterior wall, among other things. This is important as this is how we tell if the heart chambers are dilated (cardiomyopathy) or has thickened wall (hypertrophic).
Whereas, M-Mode looks at ‘motion’ (hence M) and is able to calculate length/distance more precisely as you freeze frame the structure along a single line over time (see pic), but you still measure the same stuff as in 2D.
Okay now Doppler. We use colour Doppler to look at regurgitant flow and turbulence jet. And believe it or not colour is essentially a form of pulse wave Doppler. To see video example of Colour Doppler, click here: Beni Facebook.
Okay now Pulse & Continuous Wave Doppler. They look scary at first, but trust me, it’s FUN. This is where you apply your high-school physics. So to begin with, we mostly want to know the pressure. So by using Doppler we can estimate pressure. But, since we are using an ultrasound machine… all we could measure is velocity. Remember, echocardiogram is a study of SPEED (velocity) & PRESSURE. Now lemme get into my red Mustang while flexing my Vin Diesel biceps.
We use Pulse Wave to find a velocity of blood (or tissue) at a specific depth. For example if you wanna know the pressure inside the LVOT (left ventricle outflow tract), all you need to do is place your sample volume inside the LVOT and hit pulse. It will give you a spectral Doppler. Either you want to measure the VTI (or TVI depending on which side of the Atlantic you live) or just the maximum velocity (Vmax). Then you use the modified Bernoulli Equation (P = 4 x V squared) and convert Vmax into Peak Pressure. Eureka!
Whereas, we use Continuous Wave to find the highest velocity along the Ultrasound beam. This is how we know pressure gradient across a valve – say the Tricuspid valve. Now you might ask why on earth we want to measure the pressure gradient across the Tricuspid. Well, the answer to that: “that’s how we estimate the pressure inside the Pulmonary artery or the PASP (Pulmonary artery systolic pressure)”. An important disease that unfortunately under-diagnosed (or under-recognised) is PULMONARY HYPERTENSION. Your patient is breathless, help her.
Beside measuring blood velocity, we could also measure tissue velocity by ‘pulsing’ the tissue, remember PW here, not CW. We measure tissue velocity to assess myocardial tissue function (e.g: example at the mitral septal or lateral annulus). This info will tell us how good the heart muscle in relaxing (psst! Diastolic function, yup E/e’ and e’ velocity). Coz’ in echo all we are interested is how the heart looks (anatomy) and whether the heart function is normal (physiology).
BONUS: We don’t talk much about 3D, but technically we use 3D volumetric dataset. And currently common features are Live 3D, 3D zoom and Full Volume (for a higher volume rate, notice we don’t use 2D lingo like frame rate). And this is useful when we want to interrogare the valves better and understand what causes it to be abnormal – think mitral valve prolapse, endocarditis et cetera. What the heck, just take a look at the 3D image. You savvy, aye?
NOTE: If you guys find this useful, please leave comment & feedback. So I could do this again 🙂 Until then study hard.
ps: hm, I tried posting some videos but WordPress no longer allows me to upload videos as they want me to upgrade my account to premium version. Cit!
I’m not sure why I feel the need to write this entry. This blog is technically dead. I had totally forgotten about it. But, something brewed inside me as I listened to Mr. Armstrong a few minutes ago. His songs keep me intact these days. When everything seems to be at lost – Louis, his friends and Jazz keep my shit together. Simple melody yet heavy on trumpet and piano. And not to forget that song by Israel ‘IZ’ Kamakawiwo’ole – Somewhere over the rainbow. Now, that would be my official life soundtrack. Well, my friend – good or bad – that’s life, and what a wonderful world it has been.
This update is dedicated to a friend of mine in US. A shout out to Michelle (hey, I keep my promise).
I couldn’t remember the date but I was heading back from the 2017 Cardiology Congress in Barcelona to Kuala Lumpur. It was a long flight and the Emirates plane transited at Dubai airport. It must have been just past midnight when I found myself wandering aimlessly in the duty-free terminal unsure on what to do. It could have easily been a scene from Lost in Translation – minus Scarlett Johanssen.
Like what you would probably do at any airport, I got in-line at a McDonald. The place was packed despite the wee hour of early morning. After taking my BigMac meal from the counter, I spotted a table with two seats, a man in his 50’s sitting in one of them.
I asked him if the other seat was taken. He nodded, “It’s yours.”
We finally exhanged conversation after 30 minutes of comfortable silence. He’s on his way back to Melbourne. The man was a carpenter whom had spent two weeks in his birth-town (I can’t remember the name of the place) – somewhere in South of Italy for his father’s funeral. He had left Italy when was a very young man. And had last seen his dad ten years ago.
“I should have visited him earlier,” he said at some point. There was a fresh tear at the corner of his eye. The tear lingered there – refusing to flow down his left cheek .
I lifted my cup, “To your dad. A great man.”
He lifted his cup, “Thanks mate.”
We continued talking for two hours, from health to politics, until the final boarding for our flights were announced. As we parted our ways it dawned upon me – that some of the most candid and honest conversation we had in our lives happen at unexpected places with a total stranger.
If only once in a while we stop playing with our smartphone. Look up and connect to another real human.
I walked out of the elevator on the 3rd floor, headed east toward the ward. This would be around seven every morning. As I had expected, he was sitting on his favourite chair outside the ward.
The Chinese man was in his 60s, medium built. I had seen him there for the last six months. Sometimes, he would be there at any random hour or even in the wee hours of morning.
Who is this man?!
He wasn’t a hospital staff. Never wore any kind of uniform. Unlikely to be patients’ relatives coz they would come & go with the patients – and very rarely they were warded more than 6 months.
I asked around but nobody seemed to know or noticed this guy before. Was he a fragment of my wild imagination?
Curiosity finally got the best of me one early morning. It was appoximately 3.30 a.m. when I happened to share an elevator with this mysterious man. This time he was in black shirt and black pants. I didn’t even want to guess the color of his underwear. There wasn’t a hint of emotion underneath those dull-colored eyes.
“Excuse me, I noticed you’re always here in the hospital. Err… are you visiting someone?”
Stupid! I could hear my carotid pulse slapping my neck. What if he took out a shiny German made 5-inch hunting knife and stabbed my nostrils and pushed it far deep – until the tip of the cold blade grazed the base of my skull. My mind ran amok.
An awkward silent passed between us.
Finally, he opened his mouth, his voice was crisp and clear, “I scout around for dying patients.” A faint of smile cracked at the corner of his lips. “And hoping to sell casket to the families.”
Padan muka aku. I felt like an idiot. Meanwhile, Mr. Curiosity just killed the cat in the elevator with a candlestick.
I wrote it because I wanted to see if I can.
Whether I’m capable of writing a long story. After all, it began as a challenge from WhiteCoat/Dr. Anwar Fazal/Dr. Aizzat. So, I said okay. I believe that without facing your darkest fear, you’d never see your true depth. As Dr. Mafeitz (Author of Hipnotis) have always responded when someone asked him: Why did you do it? He replied: “Why not?”
BREATHE wasn’t a smooth sailing project. The story, well the story came much later.
I cannot remember the exact date, the story was conceived. I had tried several drafts before I settled in with Adam and his world. I had to scrap some of the earlier drafts because they were not good enough. And I don’t have any idea what to write. I was forcing myself. It didn’t work that way, and I learned it the hard way.
All I remember, it must be sometime in August 2015 as I was sitting 30,000 feet in the air on my way to a conference in London. The sky was crimson, the sun was on the east side of the plane, with a fine looking stewardess smiling at me, offering a drink (maybe it was the guy sitting next to me) – when a thought came to my head: it said ~ write your emotion – what made you deliriously happy and sad, and above all what could possibly strike fear into your bones. So I opened up my laptop and started to type.There are many things I want to mention here. But I don’t want you to start thinking of this as a self-grandiose blog post. So to cut long story short, between my duty at the hospital and late night writing and editing, by the end of February 2017, BREATHE was born.
A big thank you to fellow readers who have read their copy and those who had commented on Goodreads: Feel free to read them or add yours here Breathe on Goodreads – without putting in any spoiler 😥
Some questions and comments, I’ve gotten so far:
(Below are photos from last weekend. Courtesy of WhiteCoat Instagram)
To be honest, the WhiteCoat people were not convinced of a local English can make it among general Malaysian readers. That’s why they printed only 2000 copies, but Alhamdulillah, we ran out of copies after 3 days of PBAKL 2017.
Now, they’re running the second print, and only manage to get another 500 copies (so sapa cepat dia dapat). If you want to own this Malaysia’s FIRST medical English novel as part of your collection – well, head down to:
Our formal Meet & Greet will be on 6th May (12-1pm, but I’ll be around until 2-3pm for M&G for FOBIA & M&G Perang Melawan Mitos).
Trivia: I wanted to name the main character – Adam Daniel Haiqal. Until my sisters, Nura & Rini said: Seriously? We didn’t know this is a script for Samarinda slot on TV3? — Hence, it’s only Adam.
Some of you might have followed me on blogging since 2005. Well, BREATHE is from me to you.
Happy reading guys!
Later, I drove to Bangsar to do some thinking. The 2×2 table at Madam Kwan’s appeared larger than usual when you were sitting alone without a company.
“Loneliness has never been so inviting,” I said to Lolly.
“Well, welcome home,” she said. “It had been a magical journey.”
I decided to take up a coach tour to Milford instead of driving.
Nigel, our guide is fluent in Japanese. Cool guy. He knew where to stop for a short walk (along the route), and places to snap photos. There are 7 others besides me in the group. Kinda small group so we get more personal interaction with our guide. There were: Jag and Kim from US. Stephanie from Melbourne (and a Japanese family which I can’t remember their names now).
It took 2 hours to reach Te Anau further down south of Queenstown, which was the gateway to Milford. Nice spot to stretch your legs and refill your tank. From there it took another 3 hours to reach Milford. Once you’re there. You could do the kayaking or jump onto the boat cruise. I chose the latter. But on a hindsight, the kayaking would be more majestic. Try it!
Get some solitary moments on your own. Put on your headphones and play some Walter Mitty soundtracks too, whatever rock your boat.
The one hour and half minute cruise was amazing. We saw bunch of seals lazying on rocks and awesome waterfalls. Tips: Get your raincoat on & hide your camera/phone when the boat approaches one of the waterfall.
The thing about Milford Sound is, it isn’t the final destination that matters. But the places and the new faces you meet along the way that make everything’s memorable.
If you ever thinking of backpacking in Queenstown, you could try Haka Lodge: it’s a bit hidden back on Henry street. But the place is new (with thick cosy mattress).
I tried Absoloot hostel too. Also new facility, just 4 years old. This one faces Lake Wakatipu. You can watch the sunset while enjoying a cool breezy evening walk by the wharf, or from your bed.
And don’t forget to bring your favorite book. There’s always time for a page.
As I said let your feet do the walking, but let your mind do the wandering.
Psst.. if you can’t travel now due to budget constraint. Start flipping those pages open, choose your genre or fantasy (… either that or we could the next trip together).
Hello constant readers,
You might remember I spent Xmas and NYE in Amsterdam/France last year.
Yes, time flies, it is time for another long solo trip.
I got up early. The airport backpacker was okay, but not great. Grab the yellow bus as they charged you only $5 to get to the domestic terminal.
The flight was smooth as babies butts, and it took two hours to reach the small town on the South West of the island.
The backpacker in the town is way cooler. George the receptionist was, to quote him, a ‘big bear cuddle.’ And with a beard too.
Got myself to the top of the skyline. Absorbed the view which was nothing less the magnificent, reminding myself that 2016 is about to end. What a better way than to finish it off with two scoops of ice cream.
Now I’m back at the backpackers, in the company of a Canadian who just did the big jump. And a Dutch who’s going to cycle to the Sound tomorrow morning.
The sunset is at 9pm. I got plenty more light to kill.
The wind is cold, but this time it’s forgiving.
Yes, I’m back.
Her prodigal son has returned.