In the Dark

It's the human nature everywhere, including the medical profession, to learn the know-how by habits.

We practice medicine by copying what our predecessors do, though we're unwilling to admit this. After a while, it's second nature and we keep our routine doggedly. And if a bold student comes to ask why, there comes the dismissive reply, "Simply because we've been told to do so."

This morning, I went to see a patient whose large blood vessel developed a tear and began to rip. There is a good chance that my patient can die if the blood pressure are left unchecked. High blood pressure can weaken the wall of that broken vessel, further tearing the outer wall. His team doctor had started him a drug labetalol intravenously. I thought I'd do the same, too. But I was stupefied to see a "naked" tubing infusing the medication. By naked, I mean the tubing was not covered like how we wrap a candy.

"How come? We should have wrapped it to protect the drug from light," my resident shared with my view and shook his head. "We've been taught to do so since graduation from school."

We started to worry that naked tubing could have exposed the drug to excessive light, making it ineffective. It would appear that I should pull evidence to show the nurses why they should cover the tubing. What stunned me even more was that I could not find any evidence to prove them wrong. Not a bit of it. And then the pharmacist confirmed that it's perfectly fine not to keep the drug in the dark.

I gave a vague smile but could think of nothing to say. If I am candid, I'm among the ones kept in the dark.

Heart

I was asked to examine the first-year medical students yesterday.

The way simulation driving test gives novices an idea what driving is like, medical school examination teaches students how to behave like a real doctor. I handed out a detailed description that would begin something like this: "A 45-year-old man with the chief complaint of chest pain over several works came for clinic assessment. He worried about a heart attack. Please examine his heart and demonstrate to the examiner where you place the stethoscope to listen to his heart sounds." Heart sounds, by the way, are produced when blood is being pumped through different heart valves.

Unfazed and without losing a beat, the students meticulously showed me where they located the landmark to listen to the heart sounds. That said, I concede that, it isn't really what a real doctor like me usually do in flesh-and-blood patients. Rather, we make a cursory examination and back up with tests like x-rays and echocardiography. Unsettling as it is, it may be hard to resist the temptation to read the x-ray and ECG before listening to our patient's heart, and not the other way round. My daughter has been fascinated by the stethoscope and she often takes mine to listen to the heart sounds. Believe me, she spent more time with the stethoscope on the chest than I did on my patient.

Which brings me, somewhat uncomfortably, to my recent encounter with an elderly woman in the hospital. Her blood test showed that the body didn't do well to seal off any bleeding in case a blood vessel is injured. I dutifully followed the logic I learned in the medical school, and came up with the conclusion that the patient's liver was not doing well. I turned to the page of liver function test to find out the abnormal figure, which indeed it was. "Her liver is enlarged," I told my resident after pressing on that patient's tummy. We went on to see the next patient after making sure an ultrasound scan of the liver has been requested.

After the weekend, my resident told me the ultrasound scan result. The patient's liver appeared large because it was engorged with blood. Another doctor listened to the elderly woman's heart and then a cardiologist asked for an echocardiography. It turned out that the patient's heart was failing because the blood could not be pumped out through the left ventricle into the aorta, thus filling up the liver. Neat answer - to which I'm afraid I didn't think of. I kicked myself, but it's too late. My shoulder sagged, face fell, and heart sank. It would have made a heck of a difference if I had listened to the patient's heart - and it only takes a few minutes. 

First

Picture a twenty-month-old baby sitting on a potty for the first time. There's a good chance that you can't hear the sound of poo-poo going into the toilet bowl. You don't need me to tell you that the laughter and victory cheering ("Hurray!") from the parents are the loudest at that very moment.

Seeing a baby grow has been a fountain of joy for our family. The baby's first smile. The first word of "mama." Her first step. The first sentence "It's wet because it rains." Most parents would rate these key milestones even higher than that of Neil Armstrong's moon landing. We will never forget them. Ever.

For every first moment, I'd been reminded, there is another moment when it ends. We tend to remember the beginning and then forget the end. You will remember when the first tooth appeared, but won't be able to tell when the baby stops biting her toys. You remember the first "Why" and never realise when the kid stops the "why's" (and, of course, the answer should be the beginning of "Why not?").

Tinkers

Shortly after the family trip to Taiwan, I packed my suitcase and headed for an investigator meeting in Seoul. No one will mistake a business trip with a family journey. I didn't, at least not knowingly.

Before boarding the flight to Taiwan one week ago, I came across Paul Harding's novel, Tinkers, at the airport bookshop. I thought of buying it but decided not to. I made a reservation from our public library system, now that it can be done electronically by pressing few buttons.

And then I received a notification the book was ready for pick-up today, just before leaving for Seoul. It turns out that this Pulitzer Prize winner made a good read. In Tinkers, an old man lies dying from cancer and kidney failure over the course of eight days. This dying man, a repairer of clock, is drifting back in time to his recollections, the opposite of winding a clock. Like free radicals, his story unwinds in a chaotic manner, but with a passionate theme.

And as if that's not enough to convince me that the gears and cogs of experiences are intertwined, I watched the movie Hugo on the aeroplane. That's another story of tinker who takes care of the clocks.

Travel

You might have been led to believe that holiday trip comes to an end after the arrival of baby. I don't. It's always a comfort to have the same view shared by others. That is the reason I purchased the book Travel With Children from the Lonely Planet shortly after my first trip with Jasmine.

As parents, we're no longer footloose travellers off the beaten track with itchy feet. This isn't to say we have less lovely memories for the family trips. We spent another brilliant week in Taiwan, where I wrote this blog together with my wife painting next to the lake - before my daughter woke up.

Like magic, travelling with kids is highly unpredictable and yet fun. Each morning we ventured out after packing the baby wipes, snacks and loads of plan (okay, and most of them not fulfilled at the end of the day).

Our idea to travel with kid is not to have structure; our sweetheart will suggest her own mileage as she goes along. Instead of checking out every detail of aboriginals at the cultural village yesterday, for instance, we ended up soaking in sunlight and chasing each other in a long stretch of pasture. My daughter's laughter looked like it's fun - and it is. If you come to think that those "must see" items on the travel guide sound irrelevant to a kid, that's because it is.

Ginkgo

The very first time I paid attention to the yellow triangular leaves of ginkgo tree was when I visited Hiroshima more than four years ago. After taking a stroll around the city, I saw quite a number of ginkgo trees. It is called Ginkgo biloba, "biloba" meaning "two lobes", which indeed its leaf is.

I learned more about Ginkgo after my recent reading of Survivors, written by the paleontologist Richard Fortey. This tree appears to have survived for a long time, even longer than the dinosaurs. The more I read about it and the more I thought of the ginkgo tree, the more impressed I got with it.

Living fossil of Ginkgo biloba has been found to survive the blast of the atomic bomb dropped on Hiroshima at the end of the Second World War, even though it was only 1.1 kilometres from the epicentre of the explosion. Ginkgo trees simply regenerated from scarred trunks one year after the total destruction. No question, it is a survivor.

For those of you who have seen the fan-shaped ginkgo leaves, you'll find veins radiating into them from their petioles. That means they are easily recognised in the fossil state, and fossils tell us that the ginkgo must have survived for 280 million years. And then you will reckon that Ginkgo biloba must have survived several mass extinctions. Atomic bombs, as Fortey says, is probably small potatoes in comparison.

Wild

A coda to this weekend's true delight is an outing with my daughter at the countryside, spending time under the tree and savouring its glamour and allure.

The lively walk was sprinkled with surprises. We met butterflies. We bumped into bird nest. We touched the ferns. It's hard to imagine a more funny way to learn the beauty of nature than playing with achenes attached to pappus of fine hair, watching them fly in the wind.

Which brings me to the scene with the glee of Jasmine pretending to eat the leaves of Ginkgo biloba before. She was one. It was another sunny afternoon, I remember, colder in temperature but warm with my kid's laughter. Jasmine resisted the temptation to laugh, when her mother's eyes bug out like a cartoon character's ("Wait wait, can we eat this leaf?"). You may call this acting silly. We think this is my baby's brand of humour.

In fact, there shouldn't be a time too early for children to have humour, and neither is there any age too late to play.