In the land of the rising sun

Hey everyone,

Well its been about 16 hours into our trip, and we are in Tokyo waiting for our next flight. It's already been an interesting trip!

First, we originally had a 9:40am flight out of Raleigh to Chicago, then connect to Tokyo, then to Shanghai. However, this morning around 6:30am an American Airlines representative called and said that flight was cancelled, and that they only had an 8:55 flight from Raleigh to JFK, and then from there to Tokyo, and that it would be coach rather than first class. So we had to rush and scramble to get to the airport to catch that flight, or else we wouldn't make it to Tokyo. Everything went alright - we ended up with a flight actually from Dallas to Tokyo.

The flight from Dallas to Tokyo was 12 1/2 hours, but we were in business class so it was sweeet! Except the part where the dreaded announcement occurs, "if there is a doctor on board, please come to the middle of the cabin." So hesitantly, I step up, but also a female doctor (cardiologist) also steps up, and I follow her to the patient, who is allergic to shellfish but accidentally ate some clams, and was having tingling of her face and voice changes and wondered if there was an Epi pen on board. We give her benadryl and prednisone from the cardiologist's stash (she has kids with asthma), and the patient does great. Whew!

Finally, our poor dog Sofie has had diarrhea the past 3 days, and even had an accident at home before we left - which is very unlike her. Our dear friend Stephanie is staying at our house and watching her, and we check our e-mail when we arrive to Tokyo - and Sofie has crapped in our house 3 times. =(::::: I hope she's ok....she's eating and playing, so it sounds like a simple case of the shits.

We'll upload some pictures of the luxurious 'first class lounges' and of the Japan airport soon....thats all we have so far...

Will keep you posted!

Alan and Nicole

About to board...

We r about the board our flight to china...let the games begin :)
Sent from my Verizon Wireless BlackBerry

Facebook

Well I have officially joined facebook, and I'm addicted.

You can check it out at www.facebook.com

Just got back to Durham, from a very awesome vacation. Had a guy's weekend with Andy and Aarish in DC!

Then, Nicole and I and Sofie took a week-long vacation, stopping through Savannah, and staying with Jason and Amy Rice in Jacksonville, then seeing Amy (my sister's) apartment at UF, before finally arriving home in Tampa to see the family. Spent the weekend playing Rockband with Jenny and Jeff, and hanging out with their ever-so-cute kids Tyler and Kaelyn, had dinner with Danielle and Mike and Kristen and Colin. Then, Nicole flew back, and Sofie and I drove back north, and stopped over in Atlanta where I got to hang with Ben Yin, and stayed with Amy and Nate, and then it was back up to Durham! I just started back at work, although in a nice cush rotation where I do exercise treadmill tests for the old folks for cardiac rehab.

Will write more soon!

Old habits die hard

Well, again I knew it would be hard to keep up with the blog...its been since November. And then I start my vacation, and realize I need to get a lot better at this.

My first post in 2008. And with the old wishful thinking, I'm hoping to keep up with this again. I'll try my best. There's alot thats happened since my last post, too much to tell all at one time. So I won't try to do it all now...I'll be writing a series of posts to get you up to speed.

Here's a summary, and I'm sure I forget a lot too...

- Our whole family, including Nicole and I, are goint to the Beijing 2008 Olympics!
- I've been offered the position of Chief Resident for 2010-2011
- My family came to stay with me for Thanksgiving (while I was on crutches)
- We spent a weekend at Barkwell's, a dog friendly resort in Asheville, NC with Amy and Nate
- Spent Christmas in Dallas, with Nicole's family
- Just finished two challenging months on Cardiology and Oncology
- Was in Washington DC last weekend hanging with Aarish and Andy
- Dave and Karen, our friends from residency, are pregnant
- Visited Amy in Gainesville and saw her dingy apartment!
- Have recovered from surgery pretty well, now jogging again and playing basketball
- Will see Kristen and Colin, and Danielle and Mike during this vacation
- Little Tyler is getting so big - now in preschool, and does soccer practice!
- Little Kaelyn is now able to stand!
- Amy and Nate, and Phil and Zenia are engaged and getting married this summer
- Aarish now purchases technology for the government
- Andy now works on offshore wind power policy
- Jason and Amy are pregnant, and Jason is about to become an orthodontist
- Alex and Sarah just bought a house in Tallahassee, and Alex is about to finish his ER residency

So much to talk about, I'll start on that soon. In the meantime, here are some pictures from Washington DC.

There's McDreamy and McSteamy...

Many of you have probably seen Grey's Anatomy, where there are two attractive surgeons nicknamed McDreamy and McSteamy.

Well, Bryan has given me my own Gray's Anatomy name...McSquinty! Not quite what I was hoping for, but I think it will stick.

- McSquinty

Bum foot

So I spent halloween morning on the operating room table, having a walnut-sized cyst removed from my right ankle. I had whats called 'tarsal tunnel syndrome'; its like carpal tunnel syndrome, where your median nerve is compressed causing pain and numbness in your hand. Instead, my posterior tibial nerve was compressed from this cyst, and I had these symptoms in my foot. So for the first time in my adult life, I became the patient and underwent the series of clinic visits and tests that we often send patients to.

First, I visited UNC's orthopedics clinic, which wasn't bad at all. Got x-rays, then was seen by a resident then the attending surgeon. Told me I had tarsal tunnel syndrome, and suggested an MRI and an EMG-NCS (electromyography and nerve conduction study).

So I did the MRI - which is sitting in pretty dark and narrow tube, with lots of loud machinery sounds, for about 40 minutes, just to scan my ankle. I received gadolinium, which is contrast, and couldn't help but wonder about the 1:10,000 odds of an anaphylactic reaction or possible kidney toxicity. But I managed just fine.

Then I got the EMG-NCS. The nerve conduction part is easy. They place stimulators on your ankle to stimulate your nerve, and then place sensors around the other parts of your nerve, and see if the nerve can transmit the signals. Because my posterior nerve was compressed, it was not conducting any sensation at all.

The EMG portion is horrible. They stick a not-so-small needle in your muscle that they want to test, then they say "flex that muscle" even with a needle sticking in it, and it can read both the level of nerve and muscle activation. So there was a damn needle going in sideways into the arch of my foot, and they're telling me to move my foot around and spread my toes. Painful as hell!

So of course, the MRI revealed the walnut-sized ganglion cyst. Interestingly, they're also called "bible cysts" and most commonly show up around the wrist area. People use to put a bible on the cyst, and then slam the bible hard to pop the cyst! Wasn't an option in my case - it would just make my nerve impingement worse. And the NCS showed abnormal nerve conduction. The EMG showed that I wasn't able to activate the muscle. And I was scheduled for surgery.

Now I haven't undergone surgery since I was 6, when I was bit by a black lab on my face and had to get plastic surgery. All I remember then was that my jaw hurt and it was hard to eat the frosted flakes after surgery. But as an adult and a doctor, I was kinda fascinated by what I was about to go through.

Here are some observations:

- Wearing a hospital gown really does render you very vulnurable. I had the good fortune, however, of being given one-size-fits-all boxers so my bare ass wasn't hanging out.
- Versed (a benzodiazepine, like valium) is a sedating medication that's like IV alcohol. Instantly, I felt drunk, drowsy, and uninhibited. What a weird feeling.
- Apparently, I was belligerent when I was awakened after the procedure. According to Nicole, I was blabbering very loud, saying things like "I didn't get a Foley....that's awesome"; "You ligated my nerve?!"; "What was my drip rate for the propofol?".
- Percocet, a common narcotic prescribed for pain, makes me feel dizzy, out of balance, and nauseous. I don't know how people are hooked to it.
- You get many separate bills. For the MRI only, I got charged for the MRI itself, then the use of "hospital facilities", then a bill for the radiologist to read it. Its about a $2000 test!
- IF YOU HAVE A WEAK STOMACH DONT LOOK AT THE PICTURE BELOW.

I TOLD YOU!!

And now I have a large splint wrapped with foam and an ACE wrap on my leg, and I'm not allowed to walk for 4 weeks. All in all, the process has gone pretty well, and I'm lucky to have Nicole and my mom taking care of me. But it does suck to be a patient.

Saving a life

In medicine, I think its less common that we are honestly "saving lives". More commonly, we are treating flare-ups of common conditions, such as congestive heart failure exacerbations or COPD (ie chronic obstructive pulmonary disease, aka emphysema or bronchitis) exacerbations. However, there is a case that I treated recently, in which we saved a 21 year old's life.

I just finished the ICU (intensive care unit), a grueling and challenging month where you are treating the sickest of the sick. One of UNC's functions is as a "tertiary referral center", a place where other hospitals send their patients if they need more advanced care. This also applies to ICU patients. If other hospitals receive ICU patients who are too sick...they come to UNC, and we take care of them.

I had a 21 year old patient, who I'll call John Doe, referred to me from an outside hospital. He was found outside unconscious, and an ambulance was called. When he reached the outside hospital, he body temp was 88'F, and his toxicology screen showed opiates, benzodiazepines (like valium), and cocaine. He wasn't breathing well, so he was intubated and attached to a ventilator. Then, he was sent to us.

When he arrived, he was still cold, but in a matter of hours he began to have fevers, and he became exceedingly difficult to ventilate and keep his oxygen levels up. His lungs began to show a dense pneumonia (lung infection), and also began to show signs of diffuse injury, something we call ARDS (acute respiratory distress syndrome). ARDS can occur when there is any sort of severe insult to the body. He was at the tenuous balance, where we needed to give him as much ventilator support as we could, but not give him too much support which would injure his fragile lungs further. His kidneys had been injured. We placed invasive lines in many parts of his body - there was a tube in his lungs to help him breath, a tube in his stomach to feed him; a large central venous line in his neck to give him fluids and antibiotics; an arterial line in his wrist to closely monitor his blood pressure and take samples of arterial blood to make sure he had enough oxygen; a tube in his bladder to drain his urine; a tube in his rectum to drain his feces. We didn't know what kind of damage to his body the hypothermia caused - we hoped he didn't suffer any brain damage, or that the cold temperatures didn't hurt his organs. And just as dangerous, rewarming him can also cause "rewarming syndrome" which could hurt his organs.

And in addition, no one knew who this person was. We had no name, no ID, no family. He was found by strangers and an ambulance was called, and then was transferred to us.

I was his primary doctor. But we had an ICU team. Other residents and interns took care of him when I wasn't there. The ICU fellows and attendings provided guidance. The nurses carried out the orders, and looked after him very closely.

And then his family showed up, and we found out about this person's life. Had much of an antisocial life, misbehavior, frequently caught up in drugs, stole from his family. All too sad in a 21 year old kid, that he has been slowly ruining his life and killing himself, and now he's here attached to tubes in our ICU.

But he started turning around. Slowly made improvement. We were slowly able to wean the ventilator settings, and his ARDS and pneumonia were beginning to improve. He exhibited signs of drug and alcohol withdrawal, and required high doses of sedatives, but we began scaling back. And after 8 days, we were able to extubate (remove him from the ventilator) him, and he was breathing on his own. He was able to talk to us, and could move all his limbs. He was still intermittently delirious, but had survived the most horrible part of his illness, when he was in total respiratory failure. Now that he did not require a ventilator, and his vital signs remained stable, and no longer in withdrawal, we released him from the ICU to be taken care of by a floor team. I imagined he would be in the hospital another week, recovering and regaining strength and hopefully normal function. We consulted our psychiatry service, to address his underlying drug habits and probable mental illness, hoping they could share some insight with him.

2 days later, I got a phone call from one of my fellow residents. He told me that Mr. Doe was about to be discharged home, and that he would like to come up to the ICU to thank us. To walk to the ICU! And he did. This 21 year old guy walked up to us, and said "Thank you for saving my life." Gave me a handshake, then a hug. He wanted to see the room where he spent the past 8 days near the brink of death. He wanted to know how sick he was. And then he told us that he was going to change his ways. No more drugs, and turning his life around. Hugged me again, and then walked out of the ICU, and later that day walked out of the hospital and, hopefully, to a new life.

That was one of the best moments of my life as a doctor.

Okay okay trying to keep up

Hey everyone,

Well this is better than before, only a couple of weeks since my last post. But its been an eventful couple of weeks! Another step in adulthood. We just bought our first new car! It's a 2007 Honda Accord 4-door, EX-L, V6, in metallic graphite. Its an amazing car - sporty and luxurious, and fast. 240 horsepower! Only thing we didnt get was the Navigation, a bit expensive. I can't believe I'm saying this, but we did have to consider having a car that would work when we have kids. Yup, we thought about something smaller and sportier, but we worried about a carseat. So our top choices were the Prius (hybrid, cool and different), Camry SE (sporty, but still has stigma of a "camry"), and '08 Accord (but expensive as its brand new). But we got a great deal on the 2007 model, and we love it.

In addition, our friends Amy and Nate just got engaged! Amy is one of Nicole's close friends, and they were in PA school at Emory together. Nate planned a big surprise, where he took Amy to the Bahamas and proposed to here there, without her ever knowing a single detail. He never even told her he got a ring until he proposed! Nate also surprised her by having us secretly going on the trip with them! We had a great time, and Amy was swept off her feet with the proposal.

Nate asked me to join him on this trip to the Bahamas, for the whole purpose of proposing to Amy, more than 8 months ago. I tried to keep it from Nicole as well, but she's too smart and figured out what we were doing. Nicole and I flew from Durham to a connecting flight in Atlanta, where we surprised Amy and Nate! Then we flew together to the Bahamas, and had an awesome time. The resort (Sheraton at Our Lucaya) was absolutely beautiful, and very quiet since it was the "slow" (aka Hurricane) season. Luckily, only a few showers, otherwise it was sunny and warm! We spent time poolside, on the beach, sailing Hobie Cats, and enjoying jerk chicken. Not to mention, the exciting engagement on the docks surrounded by a beautiful harbor and yachts!

Here are some more pics:

Well I just started a rotation in the MICU (medical intensive care unit). But this time, I'm a resident, not an intern. Overnight, its just me and my intern. I now have the responsibility of making decisions for these critically ill patients. I'll have to decide if they need to be intubated (have a tube inserted into their lungs and hooked up to a breathing machine), or if they have come to the point where we recommend withdrawing care. If a patient "codes" (or has a suddent serious event like a cardiac arrest, or can't breathe, or becomes unresponsive), they call the "code" over the entire hospital intercom, and we are the ones who have to respond immediately and decide what to do in the emergency setting. Whew, its quite anxiety-provoking to have to be this person to make the call! I guess I feel "slightly" prepared for these situations...whereas last year as an intern, I felt in no way prepared. Of course, we always have people above us where we can ask questions, but they are at home. We are the ones who are there, and we're the first call. Eek!

One more thing...HAPPY BIRTHDAY MOM! (Sep 29)

More later...and thanks those who are still reading!

Alan

"I'm growing up! Aren't I cute?" --Sofie Cheng

Well, I am guilty of procrastinating soooo much, that it seems I haven’t written in almost 6 months. If anyone is still reading this, I will be so shocked! I am sorry to have not written so long, especially since a lot of things have changed (and many things remain the same). I hope that some of you will pick this back up, as I am trying to renew my commitment to my blog as well.

So, here I am…back again.

So much has happened, that I guess I will just summarize.

I finished my last few months of my internship, and officially finished being an intern on June 24! It went by fast, but at the same time, I never thought it would end. What a long, tough, crazy, and educational year. In medicine, I think you grow more as an intern than any other year the rest of your career. I officially became an “upper level” or a “resident”. I now spend some time running the teams in the hospital, responsible for a set of interns and students, as well as a set of patients. I can look back and say it was a pretty good year, but often it didn’t feel that way. But, the last few months became much easier as I became more adept at being an intern.

Some of the boys - Mark, Bridger, me, Jason, Scott, and Andrew - chillin' at intern retreat 2007 in Wrightsville Beach, NC.

Our friends Jenny and Tem, at intern retreat.

More of our friends, Leslie, Mily, Karen, and Nicole at intern retreat.

We redid our lawn! It was filled with weeds and spotty grass, and we’ve always wanted a fenced, grassy lawn for Sofie to run around. We had a fence put up, then had the lawn killed and tilled, and had new sod put down. It’s looking much nicer now, but is still full of crabgrass that we will kill by next spring, and finally will have a nice lawn then.

Above, our lawn after it has been tilled bare.

1 day after the sod has been laid. Ahhhh....green.

After I finished my last days of internship, Nicole and I took a road trip down to Atlanta to see Keith Urban play at Phillips Arena. If you remember our first dance, our song was “Making Memories of Us” by Keith Urban (who sang this very song to Nicole Kidman on his wedding day…but we picked it first!). It was an awesome show! Michelle Branch opened for him…we caught one of her songs. Some of you remember that I had a crush on her too…

Above, the guitars for Keith Urban and the rest of his band, before they came on stage.

There was a catwalk from the main stage to the middle of the floor. We were sitting about 15 feet from the catwalk stage! Sweet!

Keith Urban...great show!

Sofie continues to grow…the last pictures on my blog of her were as a puppy. Now she is about 65 pounds! She’s training us to be good parents. She’s become such a sweet dog, excellent with kids, doesn’t beg for food, and makes a so-so guard dog. She acts like she growls when someone new shows up, but I doubt she’d ever attack even a burglar!

Jenny and Jeff had their second child, a baby girl named Kaelyn. She is absolutely adorable, and her big brother Tyler is taking care of her! They were just up here visiting, and we had a blast swimming in the neighborhood pool, visiting the museum of natural science in Raleigh, and going to play video games at Frankie’s! Interestingly, Nicole’s cousins are also Katelyn and Tyler…I’m not sure why my sister is choosing almost identical names for their kids!

Tyler giving his baby sister, Kaelyn, some love.

Don't we look like a happy family! Good thing they're not ours...I couldn't handle it!

I have decided on a career path for myself – after much deliberation over whether I do primary care (clinic) medicine, being a hospitalist (a “hospital doctor”), or pursuing a subspecialty (such as gastroenterology, cardiology, nephrology, etc), I have decided to pursue a career as a gastroenterologist (GI doctor). It’s a great field that involves a lot of interesting disease, involves a lot of different parts of the body, and has really cool procedures (which are much like toys or video games). As a specialist, you do get to spend more time with your patients on each visit, and don’t have to rush to see 35-40 patients a day just to pay the bills. I’ll be applying this year to be a GI “fellow” after I finish residency. A “fellow” is a step above being a resident, when you are training for a subspecialty. Once you finish your fellowship, you are finally an “attending”, or full-fledged doctor.

Nicole has continued working for the UNC GI program, and is really enjoying her job. She sees patients in her and her attendings’ clinics about 3 days a week, and helps out with research and patient follow-ups and procedures the other 2 days. Her bosses are excellent – they really teach her well, and really appreciate her work…hard to get that combination from a lot of people. She works with world-class GI doctors who specialize in esophageal and stomach problems, and specifically cancer and precancerous lesions of the esophagus. They are among the leaders in the world in treating a condition called Barrett’s esophagus, a precancerous lesion of the esophagus coming from excessive and chronic acid reflux from the stomach. I am very proud of her! (Plus she makes all the money for us)

Well, I think that’s enough for now. Now that I’m starting this blog back up, I can start my random journal entries and free associations. I am really going to try and keep this up!

Also, I’m trying to start up a MySpace page, to also keep in touch with everyone that way too…

Miss everyone,

Alan

The last 4 months...

Events from the last few months...

Nicole graduated from Emory physician assistant school December 2006. She was one of the 5 people in her class with a perfect 4.0 GPA! What a smarty!


Andre, Colleen, Nicole, and Amy at the awards banquet before their graduation. Sorry, they're all taken...

Nicole's parents (aka the in-laws)

Us at the banquet...

Jenny, Nicole, Tyler, and Jeff at Nicole's graduation day.

Amy (far left) is single!

Our house lit up for Christmas 2006!

We got only 2 days of snow this year. Sure is pretty though...

Ben and Jen came to visit! Sofie loves him.

The wife in her place!
Dinner at our house, with Alex, Sarah, Ben, Jen, and her friend.