"Doktor, ini chest X ray post intubation patient katil 2 tadi"

What to look for in post intubation CXR?
- To look for complication, especially pneumothorax
- To confirm placement of endotracheal tube

The position of tip of ETT should be 5-7 cm above the carina in the neutral position of neck. When the carina is not visible, the tip of the ET tube should lie over the second to fourth thoracic vertebrae (T2-T4) or at the level of medial ends of the clavicles as carina is located between T5 and T7. 

Further reading:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173625

https://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_et_tubes_anatomy#top_2nd_img

#ED
@nota_perubatan

Becoming a doctor is one thing. Choosing to stay in a public hospital is another.

There has been a growing culture of dissatisfaction surrounding work in the public service of healthcare system. The concerns of high workload, system pressures, career uncertainties, and the blurred expectations of covering multiple roles are real. Yet, the overall tone of the conversation has gradually shifted, where staying in MOH is sometimes framed less as an active choice and more as something one simply remains in.

And lately, there has been increasing discussion about recruitment from neighbouring countries, with doctors and paramedics drawn across the border by better pay and seemingly more efficient systems. It is understandable why many consider it.

But for some of us, the old saying still holds meaning: hujan emas di negeri orang, hujan batu di negeri sendiri lebih baik di negeri sendiri.

Yes. it is increasingly challenging with growing rate of burnout with overwhelming cases and tasks. But sometimes meaning is not measured solely by salary or system efficiency.
For some of us, we choose to be there…
I won’t say the doubts aren’t there. but for now.. here we are. Trying to make sense of it, trying to find footing within the system rather than stepping away from it

The public system offers something difficult to replicate elsewhere --- depth of clinical exposure, particularly in high-acuity and facilities, patients loads and complex cases. Nowhere else will you manage such a breadth of pathology, often at advanced stages, while carrying real responsibility early in career.
That high stake environment accelerates maturation not only technically, but in judgement, prioritisation, and resilience.

Beyond that, there is continuity in training and subspecialty development. MOH remains one of the few ecosystems where structured progression from HO to MO, through specialist be it parallel or MMED training, and onward to subspecialty and consultant level remains accessible without the fragmentation often seen in other pathways.

Then there is something less visible, but equally important: Purpose. Public healthcare places you at the centre of need. You treat patients because they require care. Can they afford options?. That by some means shapes a different kind of doctor.

Of course, many leave and for valid reasons. Better pay, improved work-life balance, or different career goals. These are legitimate decisions. But the fact that many still choose to join and stay should not be dismissed as a lack of options. More often, it reflects a different set of priorities.

Staying in MOH can mean choosing long-term growth over short-term comfort. It can mean valuing exposure, training, and impact over immediate financial gain. It can also mean believing that the system, despite its flaws, is still worth contributing to and improving from within.

Not every path needs to converge.
What matters is recognising that remaining is not passivity.
At the same time, we are not immune to the pressure. We hear the same conversations, we see the same frustrations, and there are moments when we question our own position.

But holding a firm decision does not mean closing all other doors.
"Keep he option open" sais my friend long time ago. Not because we are uncertain, but because we understand that circumstances can change.
A significant reason, a shift in priorities, or a new opportunity may alter the course.
For now, many of us remain because our reasons are still stronger than our doubts.
And perhaps that is the most honest place to stand not in blind loyalty, and not in reactionary escape, but in a conscious, ongoing decision base on calculated risk in every direction.

Staying isnt easy even until now continuing my journey in subspeciality training.

Public healthcare service in Malaysia, with all it’s imperfections, has given us something more valuable: our training, our exposure, our patients, and our growth. Not to forget with so many inspiring teachers who dedicate their expertise in public service.

The clinical depth here be it managing complex disease, late presentations, and resource-constrained decision-making has shaped who we are as clinicians. For some, that creates a deep sense of responsibility to continue contributing within the same system.

Not everyone will feel this way. Some will leave and grow in different systems, and that path deserves respect.
But choosing to work within the system and remain should also be respected.
Because staying is not about settle up.
It can reflect a belief that this country, despite its flaws, remains a place worth serving, worth improving, and worth building a future in.

And sometimes, it is simply recognising that what we already have here is enough to keep us established.

At the same time, as pressure continues to build across all levels… from HO to MO, specialists, and consultants. Thus, the stakeholders, our leaders.... should continue to review how to firmly supports and retains its healthcare workforce.

This also calls for addressing structural challenges within the system particularly bottlenecks in career progression at the specialist/consultant level, clearer role definition to prevent task spillover of other problematic supporting staffs and uneven workload distribution, and more meaningful opportunities for advancement into higher-paying roles that are appropriately benchmarked against comparable specialist/consultant positions elsewhere.

Perhaps it is also worth speaking directly to those at the beginning of this journey... to medical students, HO, and young MO navigating these early decisions.
It is understandable to feel uncertain in the current climate. The surrounding conversations can be intense, and at times, discouraging.
But before deciding too early, allow yourself the space to experience the system for what it is…
not only through what is said about it.

We definitely will encounter pressure, but also encounter room of growth. The exposure to complexity, the responsibility carried, and the pace of learning within the public system continue to offer a depth of experience.

Many who have trained within this environment recognise its role in shaping clinical judgement, resilience, and professional identity.
We do not have to commit to one path indefinitely. But giving yourself time to build a strong foundation as a doctor.
The decision to stay or leave will eventually take its own course. But the foundation built during this phase often becomes the reference point for whatever direction you eventually choose.

My humble opinion.
DrAnorHidayah

7Ps for #Intubation.

Kalau korang nak intubate patient, biasanya MO akan tanya fasal 7Ps ni.

Kalau tak tahu, melepaslah peluang nak intubate patient sebab kita tak tahu details about that procedures 😅



Nak belajar lebih lanjut tentang #intubation & post intubation care?

Jom praktis sama-sama di Clinical Skills #Workshop Medicorp; 17+3 procedures in 1 day ❤️

"Dr patient collapsed, on going CPR" - HO

"Ok I'm coming - please prepare for #intubation!" - MO
.

What to prepare for intubation?

Remember MALES;

M 👉🏻 mask ie BVM

A 👉🏻 airway adjuncts; OPA etc

L 👉🏻 laryngoscope

E 👉🏻 ETT (correct size & type)

S 👉🏻 stylet, syringe, stethoscope 🩺
.

Learn more #procedure for HO with Medicorp's Clinical Skills Guidebook;
.

Or get this book for 🆓 when you register for Clinical Skills #workshop;

https://medicorp.onpay.my/order/form/clinicalskillsuturing_workshop

More QR codes for #procedure demonstration included in Medicorp's Clinical Skills Guidebook,

Get your copy here https://medicorp.onpay.my/order/form/bookstore ✅

Compulsory #cases ie topics that HO need to know in O&G posting.
.

As medical grads waiting for HOship, focus on the 🟣 highlighted topics as your #preparation for O&G posting soon ‼️
.

You can refer each topic in any of the O&G #protocols earlier 😉

Let's start our #revision on common topics in Obstetrics 🤱

‼️ Stages of Labour,
& definition of each stages

Wajib hafal ‼️

⬆️ Normal labour & #management of each stages

Ref; Kedah O&G protocol

So today we'll focus on management of 1st stage of labour ie intrapartum management;

All these plan are HO #responsibilities at PAC, antenatal wards & LR (labour room)

🤰Intrapartum management
(during 1st stage of labour)

🌟according to VenOMMS 🌟


1️⃣ Plot #partogram & T/O LR

[Ventilation]


[Oral intake] 🔽🔽🔽

2️⃣ Allow sips of CF (clear fluids)

3️⃣ Insert large bore branula & start IVD NS/HM/Dextrose Saline; 125cc/hour

❗️In PIH patient; only 1cc/kg/hr (risk for APO) & use only NS ‼️

❗️In Diabetic patients; if DXT less than 7mmol/litre, use D5% solution instead of NS ‼️


[Monitoring] 🔽🔽🔽

4️⃣ V/S monitoring hourly

✔️If PIH in crisis, every 15-30 mins
✔️add on GM monitoring in GDM patients


5️⃣ CTG #monitoring (tracing on admission & post ARM), then to repeat accordingly based on risk factor

6️⃣ Time #contraction; aim good contraction (4:10 in primid, 3:10 in multipara)

7️⃣ NRVE in ? hour (according to current V/E findings)

8️⃣ 1 to 1 care (if enough LR personnel)

9️⃣ Husband/#companion to accompany during labour (not available during pandemic 😷 )


[Medication] 🔽🔽🔽

🔟 #Analgesia if strong contraction

1️⃣1️⃣ For Pitocin #augmentation 1 or 2 hour post ARM if contraction inadequate ( <4:10 in primid, <3:10 in multipara)

1️⃣2️⃣ DIK regime (for GDM patients)


[Special Order] 🔽🔽🔽

1️⃣3️⃣ Amniotomy ie #ARM (if membrane intact)

Source;  ❤️ Medicorp’s O&G #online course❗️local LR protocol varies