Foreword from Dr. Pujalte

Congratulations to Dr. Jewel Sadiang-abay for a thoughtful introduction to orthopedic residency at the Philippine Orthopedic Center.

Unfortunately, the medical school adage “see one, do one, teach one” is woefully incomplete because residency demands a deeper grasp of things orthopedic as it were. The popular author Gail Sheehy in her book “Passages” explains that one factor for success in life is a period early in one’s career of single-minded focus in work. This is exactly what I mean in eating, drinking and dreaming orthopedics.

To our residents - what more is there to say but “Buckle up!” it will be a great ride.

Jose S. Pujalte, Jr. MD FPOA FPCS FACS
Medical Center Chief II
Philippine Orthopedic Center
POC Resident 1991-1994

Foreword from Dr. Bengzon

Residency, while it is an opportunity for developing knowledge, skills & attitudes, is also a unique personal experience that will differ among all trainees. Each experience is colored by reflections & experiences one goes through and this experience goes into memory to be used in whatever way.

Jewel has used her POC experience as a lens for others who will walk the same path for orthopedic training. This being the first time (to my memory) for a graduate to describe their experiences during training, this detailed description serves to give advice for the younger residents through the bumps & trials they face. Hopefully, reading this will not only result in improving the approach to better patient care but also in a better person.

Thank you Jewel and good luck on your next journey. Godspeed.

John Andrew Michael Bengzon MD MBAH FPOA
Chairman, Training Committee
Philippine Orthopedic Center

Introduction

Dear new residents,

Welcome to POC!

This is a gift I would have given my younger self. Herein are the tricks I learned along the way. I hope this will spare you painful mistakes and anxieties and make your first few months more smooth sailing than mine.

Jewel T. Sadiang-abay MD
Banawe QC, December 2016

Rounds

  • Arrive earlier than the seniors and consultants
  • Organize your digital X-rays beforehand
    • By patient per floor
    • Inside the patient’s folder organize chronologically (injury film, one day post traction, second week, third week etc)
    • By order patients are seen from the P4W to P4E to MSB down to CW
    • There is just no excuse for a missing x-ray, so plan accordingly
  • Take latest picture of the wound
    • Meaning: yesterday’s picture (three days is an old picture)
    • Get an orientation view (example: a full leg where one can see the knee and the ankle taken in frontal, lateral and medial views)
    • Then get a close up view (so that the team can scrutinize if there’s a bone exposed, how large the area of necrosis, etc.)
    • Label picture with name age date taken
      • Place orientation markers of anterior, posterior, medial, lateral
    • Endorse in this sample format
    This is patient Juan Dela Cruz 70/Male
14th hospital day

Working impression:
- Fracture closed complete displaced...
- Hospital acquired pneumonia
- Grade 2 left decubitus ulcer
- DM Type 2 uncontrolled
- Hypertension Stage 2 uncontrolled

Results of latest and pertinent labs:
1. Hg
2. Hct
3. Coagulation parameters:
4. Na
4. K
5. 2D echo done showed
6. Ejection Fraction - (especially if you are doing
  cemented arthroplasties)
7. CXR
8. 12 lead ECG

Plan:
1. Total hip arthroplasty
- implant provider is XYZ
- implant sizes XYZ
- cementless
- show template (ideally template has been done even if patient
  not yet lined up for surgery)
2. Co-managed with Pulmo service for pneumonia
3. Day 5 of Cefuroxime
4. 2 units blood available
5. Clearances status from Pulmo/IM/Cardio/Endo(?)
6. Pin tracts are dry
7. Decubitus ulcer addressed by bed turning, etc
  • Show your tablet/phone screens to the consultant (common mistake when the resident endorses the patient, not minding the screen of the tablet, and the consultant is straining to look at the x-ray)
  • Speak loud and clear so other co-residents will also get acquainted about the case
  • Refrain from chatting when a co-resident is endorsing and pay attention to the patient at hand
  • Take physical notes (not mental notes, lest you would forget) of comments made by your consultant. A tickler/compilation (not a loose leaf) works best so that you can review your notes from weeks past. This is also helpful when you are doing your personal rounds.
  • Suggest to see the patient a day before the rounds if wounds warrant consistent dressing
  • Arrive 30 minutes prior to the actual rounds and make a quick ocular check of all your in-patients:
    • Dressings are not soaked
    • Skeletal tractions are in correct position
    • Pin tracts are dry and they have fresh gauze around it
    • Patient has no blisters (especially at the posterior ankle where the foot rests on a towel in a patient with BST)
    • Posterior molds have adequate wadding sheets underneath and are adequately padded
    • In patients with leg external fixators prevent the foot from assuming an equinus position by gently putting an elastic bandage around the foot to keep it in neutral
      • Leg molds should immobilize the knee in 20-30 flexion (not in full extension).
      • Extremities are elevated accordingly
      • IVFs are removed (where appropriate)
      • Drains are removed (where appropriate)
      • Patients are made to sit/mobilized (where appropriate)
      • Patients know about their rehab and post operative plans (consultants tend to quiz the patients about this), so the onus is on the resident to educate their patients
  • These things come in handy during rounds:
    • Bottle of isopropyl alcohol
    • Hand sanitizer
    • 1/2 inch leucoplast
    • Bandage scissors
    • A pair of gloves
    • A few packs of gauze
    • Elastic bandages
    • Wadding sheet
    • Adjustable wrench
    • Bring your own trodat and pen
    • Know the ins and outs of your patient
    • Read up on your cases
    • Know the surgical indications for each case

OPD

  • Work fast but thorough, not sacrificing patient care and chart documentation: a formidable balance!
  • At the OPD, you will have the chance to see patients you have seen at the ER two days ago. A chance to re-evaluate and re-examine.
  • Now is the time to be meticulous and detailed in the chart documentation.
  • If you have missed an ER diagnosis now is the time to catch them (the set up for common missed diagnosis)
  • Watch out for compartment syndromes and infections (the common morbidity)
  • Know what is surgical and what can be managed conservatively ( meaning: measure the angles with a goniometer or digitally in the PACS and categorize if the patient needs surgery or not)
  • LAPM/LLPM and all other molds should be unwrapped and the skin inspected to check for blisters and compartment syndrome. No exceptions. The one that you let slip usually is the one that had the complication
  • All wounds big and small, even those that are just pin point should be inspected and managed accordingly.
  • Is the cast loose on the extremity? It is not doing its job, change cast to a snug fit. Patient has no funds for cast materials? Send to social service with a polite request to help patient secure the materials.
  • Scrutinize all your x-rays when they arrive to you. Here are the usual x-ray mistakes:
    • X-rays not taken on true AP or true lateral
    • X-rays has one joint above but missed the joint below
    • Pelvis AP with not enough internal rotation of extremity
    • Over exposed or under exposed
    • X-rays taken with a cast or a mold
    • Foreign body obscuring the view (buckle of the belts/coins/zippers etc)
    • Soaked diapers compromising the quality of your pelvis x-rays
    • Not requesting ancillary/special views (does the patient need a traction x-ray? pelvic inlet/pelvic outlet/radiocapitellar/Judet views/false profile etc?)
    • X-rays the part of the body that may have an associated injuries (example: fall from a height? check thoracolumbar, pelvis AP, both calcaneus)
    • At any point that an x-ray does not satisfy the criteria, send a note politely asking for a revision and what particular improvement you wish to make
    • Better yet, repeat X-ray under your supervision
    • Again, the x-ray you let pass may be crucial for you in the future (think: morbidity, mortality, court summon) so it has to be done properly
    • Properly taken x-rays are vital part of good documentation
  • There are are many accounts of thievery in the OPD, in all the different departments across many years; hence, be extremely careful of your belongings. I personally bring a smartphone, (to take pictures, and receive calls and messages) a pen and a trodat. All other valuables should be locked up in some place safe.
  • Limit patients entering OPD to 1-2 patients per doctor (this lessens the chances of theft; provides some sort of privacy during the doctor-patient interaction, brings focus into the patient at hand when the doctor is not overwhelmed by too many patients waiting in front of his/her table)
  • Politely manage the crowd
  • If patient influx becomes unmanageable, call the centre gate and ask for security personnel to handle crowd
  • Promptly respond to Room 4 calls so patient turnover in that room can also be fast
  • Bring two wrenches (for tibia and radius) and bring the service drill (fully charged) during the OPD so that ROI at the OR-OPD can be promptly done
  • Bring inpatient X-rays for review and discussion in preparation for the pre op conference the following day
  • At the very start of the OPD day, before even starting to see patients at the fracture clinic; call or visit the OR OPD to check if you have patients lined up for surgery, (This will help you manage your time when you are seeing patients at the OPD and you are called at the OR OPD to do a surgery.)
  • If you have a patient lined up at the OR OPD, review the chart and x-rays and make sure the surgical indication is correct prior to induction. (Sometimes the surgical indication changes over time while the patient awaits for their OR slot and the plan has to be revised accordingly). Always inform the senior regarding patient diagnosis, surgical plan, recent x-rays prior to induction.
  • In the setting of an OPD and the long line of patients waiting for you and in preparation for the service rounds the following day
    • PACS viewer closes at 5pm make sure you have retrieved your X-rays prior to this
    • CT scan personnel is off at 4pm make sure you have retrieved CT scans plates/CD prior to this
    • Implant offices/personnel goes home at 5pm, this day is the latest you can retrieve acetate of templates for your pre operative conference
    • Hence, plan accordingly

Preoperative/Indications day

  • Patients for surgery:
    • Have appropriate units of blood ready for surgery
    • Hg at least 100 or higher
    • Na K Cl has been checked 3 days prior- correct as needed
    • Check PT PTT not deranged and correct accordingly
    • Urinalysis/Dental clearance checked and made sure there are no foci of infection prior to joint replacements
    • Clearances are valid
      • IM/Cardio good for one month
      • Pulmo good for one week
      • DM good for one month or longer as long as coordinated with Dr Alba
      • If patient’s clearance is expired for one or two days, call the internist and ask if it is possible to proceed with surgery without having to repeat all the labs
      • Ask male elderly patients if they have BPH or other prostate or urinary problems day prior to surgery
      • Surgery will not proceed if an indwelling foley catheter cannot be inserted due to a mechanical obstruction
      • You may need to do a stat Uro referral on the day of surgery which will cause a delay or deferral of the procedure (hence, plan accordingly)
  • Pertaining to anticoagulants:
    • Patients should be off aspirin and clopidogrel days prior to surgery
    • Hence, review patient’s medications days prior to surgery and coordinate with internist regarding the discontinuation
  • Contact numbers and duty schedules of internal medicine consultants are available at the information desk of the emergency room (local 214)
  • Contact number of hospitals and co-residents are available at the nurses station at the ER (local 212)

Templating

  • For proper templating refer to Chapter 2.4 of AO Volume 1.
  • The templates should be cut out/scissored and put back together.
  • Make an AP and lateral template (not just an AP)
  • Note your reduction technique
  • Note materials and equipment needed for the surgery: cerclage wire, k wire drill, pin passer, straight needble, bumps/sand bags, posts, reduction clamps
  • Implant sizes: 2 sizes up and 2 sizes down
  • Detail plan A, plan B, plan C
  • Study surgical approaches; Hoppenfeld Orthopedic Exposures is invaluable. Most questions asked by consultants regarding approach and dangers will come from this text
  • Study principles of fixation AO volume 1
  • Study fracture epidemiology/read the chapter of that specific fracture in Rockwood
  • Know the specs and technicality of your implant
    • Who is the company provider
    • What sizes (from smallest to largest)
    • Which one of these are locally available
    • Laterality of implants (when applicable)
    • Cemented or uncemented
    • Titanium or stainless steel
    • Do we need cerclage or additional screws (are they of the same material)
    • Screw placements how many cm away from the fracture lines
    • Will this give a stable construct
  • Incisions
    • Where to place
    • Consider future surgeries
    • Make sure this is not tumor/pathologic fracture
    • Consider previous and pre existing wounds
    • Consider placement of plate/implant or reduction tools in making the incision
    • Consider the size and the need for retraction
    • Consider skin bridge and blood supply
    • Consider making thick flaps to avoid damage to subcutaneous blood supply
    • Be careful in using tissue forceps and to avoid macerating the skin
    • How to close the wound
    • How many layers
    • Do we need a drain?
    • Do we need Ethibond? (what size)
    • Do we need SS wires?

  • Study plan for a pre op conference may look like this:

    For a Galeazzi fracture dislocation

- Must read
  - Hoppenfeld Orthopedic Exposures chapter on dorsal and volar approach to
    radial shaft
  - (plus pertinent anatomy)
  - Rockwood 8 chapter on radial shaft fracture
  - Rockwood 8 chapter on internal fixation
  - AO Volume chapter on radial shaft fixation
  - AO chapter on absolute/anatomic reduction
  - AO chapter on plating
  - AO chapter on templating

- Good to know
  - OKU Trauma 4 chapter on fractures of forearm
  - OKU 11 chapter on fractures of forearm
  - Wheeless online for pertinent journals
  - Updated journals for collateral readings

For a femoral shaft fracture

- Must read
  - Hoppenfeld Orthopedic Exposures chapter on approaches to femoral shaft
  - (plus pertinent anatomy)
  - Rockwood 8 chapter on femoral shaft fracture
  - Rockwood 8 chapter on internal fixation
  - AO Volume chapter on femoral shaft fixation
  - AO chapter on IMN  
  - AO chapter on relative stability (length axis rotation)
  - AO chapter on templating
  - Implant provider surgical technique

- Good to know
  - OKU Trauma 4 chapter on femur fractures
  - OKU 11 chapter on femur fractures
  - Wheeless online for pertinent journals
  - Updated journals for your collateral readings

For femoral neck fracture undergoing a THA

- Must read
  - Hoppenfeld Orthopedic Exposures chapter on approaches to hip
  - (plus pertinent anatomy)
  - Rockwood 8 chapter on femoral neck fracture
  - Campbell THA chapter (this chapter has a subsection for templating of THA
    by Capello)
  - Miller THA chapter (good source to understand alternate bearings)
  - Implant provider surgical technique

- Good to know
  - OKU Trauma 4 chapter on adult reconstruction
  - OKU 11 chapter on adult reconstructions
  - Wheeless online for pertinent journals
  - Updated journals for your collateral readings
  • Remember that the pediatric fracture classification and surgical indications are different from the adult
  • Rockwood 8 has an entire volume dedicated for pediatric fractures, it is comprehensive and would suffice
  • During the pre operative conference, write down notes during the discussion
    • The types of implants
    • Techniques
    • Patient positioning
    • Special preparations
    • Special equipment and instruments that needed to be prepared beforehand
  • Pre operative checklist
    • Before going home on your pre op/indications day make sure that
    • Implant providers are notified of the surgery, time slots of patients
    • Implant sizes are correct, laterality, autoclaved, necessary equipment are ready (ball tip pusher, femoral distractor, wire passer, straight pin ethibonds opsite hip pack wiscott marker etc)
    • Blood are cross matched the night prior and that you be informed if there are any mismatches
    • WGS/WGS/WGS!!! day prior to surgery (WGS are valid only for 24 hour, so do them in the afternoon)
    • Procedure explained to patient and relative
      • Complications from mildest to worst are explained
      • Remote possibility of death during surgery are explained
      • Patient and relative expectations are managed
      • Rehab protocols explained prior to surgery
      • Consent signed after this
      • Extremity for surgery marked

OR day

  • Arrive prior to consultants
  • Talk to the nurse that controls the traffic of patients coming in
  • Call the respective wards to check on all the patients scheduled for surgery that day
    • Prioritize the first table
    • Make sure nothing is amiss
    • Trouble shoot the deficiencies if you can
    • If you can’t, inform seniors ASAP
  • Mount to the negatoscope
    • X-rays
    • CT scan/MRI plates where applicable
    • Template
    • Surgical plan
  • Check that implant surgical assistant is present
  • Check patient’s implant
  • Check the power drills (are present, adequately charged and with back up batteries)
  • Check correct sizes have arrived (example Austin Moore all sizes in narrow and regular)
  • Secure hip post
  • Get yellow plastic for prep
  • Get towels, draw sheets and wadding sheet for padding the bony prominences
  • Secure pliers for removal of Steinman pin (when applicable)
  • Double check your ioban/opsite/skin markers (tailored according to patient’s needs, consultant’s request and cost effectivity)
  • Remind scrub nurse early on to secure equipment that you need (such as a good reduction clamp for an RU, straight reamers, vise grip, lamina spreader)
  • Ready K-wires. cerclage wires, straight needles (where applicable)
  • Call the RadTech (at the Radiology department OPD or ER) if you need an early shoot for the image intensifier or your want an x-ray prior to prep
  • Call the pathology department for a heads up if you are sending an RFS (the RFS form should be filled out day prior to surgery)
  • Do you need music? (some teams want music on the background-with a particular genre, some want utter silence). Hence, prepare a playlist just in case your team wants one
  • Know what the primary surgeon wants pre op(positioning, particulars of prepping), intra op (preferred instruments, preferred approach) and post op
  • Don’t forget to eat prior to surgery! you wouldn’t want to faint intra op

Surgery proper

  • You would know the flow of the surgery if you have studied the case
  • Some basic rules to follow:
    • Keep yourself sterile
    • Do not obstruct the primary surgeon, give him space to move and maneuver
    • Do not pass instruments/gauze in front of the surgeon’s field
    • Pay attention to what he is saying
  • Do we have to elevate the table
  • Do we have to reposition the lights?
  • Do we have to sit on a stool (for a forearm surgery)
  • Intra operative efficiency translates to decreased operative time which benefits the patient

Duty day

  • Come at 6 am - this would be enough time for trans out, for duty preparations, and for timely attendance at the conference
  • During trans out- it’s good to know the status of all patients of the team that has been operated on (and not just your own personal patients)
  • Don’t forget to write your patient’s name for on-call surgery at the ER board
  • For the on-call surgery remember the following
    • Pre operative orders day prior to surgery
    • Wound gram stain
    • Crossmatch the blood night prior to surgery
    • Make sure you have 1 or 2 units of blood available for the surgery
    • Make sure the pre op Hg is > 100
    • Make sure the patient is physiologically stable (no fever, no hypertension)
    • The patient is admitted less than 2 weeks
    • All materials for surgery were made ready the night before
    • Patient and family informed and educated about the planned surgery
    • Patient has a relative/guardian that will be there during the surgery
    • If all the above are ready before 12 noon, then you can inform the anesthesiologist, ER and ward nurses that the patient is ready for surgery
  • It is a MUST! that every duty resident knows every patient that comes in the ER
  • Triage- means that the resident would determine who is critical and who is not. Example: you are examining an “OPD” patient at the ER and a stretcher was wheeled in bearing another patient with a bloody leg. Politely excuse yourself, and administer appropriate initial resuscitations to the second patient.
  • Prioritize all open fractures and patients who are undergoing surgery under anesthesia
    • Order in the chart and indicate the patient for surgery
    • Make sure to write your own history and physical examination findings
    • Inform the chief resident regarding the surgery, make sure they have scrutinized the x-ray and that they agree with the proposed procedure
    • Inform and communicate with the anesthesiologist
    • Check that the wound gram stain has been sent (instances occurred when the whole team was waiting overnight for the patient to undergo surgery only to find out WGS has not been sent)
    • Blood typing done
    • Crossmatching done (also a common delay in performing surgery; crossmatching takes place within 30 mins to 2 hours and if you want to check the status of the crossmatch you can call the blood bank)
    • Explain the diagnosis and the need for surgery to the patient and to the relatives and make them sign the consent prior to the surgery (make sure they understand the possible complications)
    • Always always check the neurovascular status prior to surgery!! (especially if you are putting external fixators). Document your findings at the chart PRIOR to surgery
    • Hours before the actual procedure check your implants and instruments. The last thing you want is an inducted patient and the external fixators were unavailable. To avoid this, do a mental surgery and write down every instrument and implant you would need (example: rubber sheet, drill that is charged, back up drill in case this one does not work, drill bit, tap, T-chuck, set of fixator with schanz pins, couplings, long spanning rods, wrenches etc)
    • Just as you would during elective surgery, take your time to study the case and devise a surgical plan prior to going in
    • Incisions can make or break you, it can dictate how easy or difficult subsequent surgeries will be. Hence, properly plan the incision and have your plan verified by your senior
    • Closing the wound? Or not closing the wound? SS wires? Drains? think about these things before going in
    • And there is no such thing as a mini incision for an arthrotomy, a properly done arthrotomy has adequate exposure and visualization of the joint itself
  • There are only a few true orthopedic emergencies that should never be missed:
    • Cauda equina
    • Dislocation
    • Open fracture
    • Septic knee
    • Compartment syndrome
    • Talar/Femural neck/Spine fracture in multiple injuries

    Always consider these as the differentials, and carefully rule these out before discharging the patient.

  • Always be thorough in reviewing your x-rays, always have a second look. Make sure patient’s complaints and physical exam coincides with the x-ray. When in doubt - ask! Write in the chart, that the patient has beed referred to — (name of senior surgeon)
  • Document your PE findings and x-ray findings; and itemize your plan for the patient.
  • For patients with mold, cast, open wound no matter how small, it’s always safe for the surgeon and the patient that the follow up date will be done on the earliest OPD day
  • Educate the patient on how to care for the wound. You would be surprised many would put powdered antibiotics or liniments or hot leaves on their wound which would result in undue morbidities. Take the time to explicitly tell them “bawal po mag lagay ng langis, lana or tuba tuba, o pinulbong amoxicillin…”
  • Take good pictures! You know it’s an open fracture, before opening the wound, ready your sterile draw sheet, elastic bandages, gloves, glass slides and pledgets. Two to three persons should be there. One to lift the limb. One to assemble the draw sheet and get the specimens. Another one to take good pictures. It should be on a green linen, with orientation views visualizing the joint above and the joint below taken on frontal, medial and lateral views, posterior views as appropriate. A separate close up views to better delineate the degree of damage. It is better if the limb is in alignment when the pictures are taken (example: an open fracture of the tibia, hold the big toe in neutral so that the distal fracture fragment is not externally rotated in the picture)
  • Again scrutinize all your x-rays when they arrive to you. Here are the usual x-ray mistakes:
    • X-rays not taken on true AP or true lateral
    • X-rays has one joint above but missed the joint below
    • Pelvis AP with not enough internal rotation of extremity
    • Over exposed or under exposed films
    • X-rays taken with a cast or a mold
    • Foreign body obscuring the view (buckle of the belts/coins/zippers etc)
    • Soaked diapers compromising the quality of your pelvis x-rays
    • Not requesting ancillary/special views (does the patient need a traction x-ray? pelvic inlet/pelvic outlet/radiocapitellar/Judet views/false profile etc?)
    • X-rays the part of the body that may have an associated injuries (example: fall from a height? check thoracolumbar, pelvis AP, both calcaneus)
    • At any point that an x-ray does not satisfy the above criteria repeat X-ray under your supervision
    • Again, the x-ray you let pass may be crucial for you in the future (think: morbidity, mortality, court summon) so it has to be done properly
    • Properly taken x-rays are vital part of good documentation

Research

Research is an integral part (not just of being an orthopedic surgeon) of being a doctor. We don’t want to be mere consumers of knowledge that has been accumulated before us. Instead, we want to improve on what is already known and contribute to those who will come after us. We want to contribute on how science evolves. This is a good motivating factor. So don’t wait for the deadline, work your way bit by bit over the months and you won’t be cramming come October or February when updates are being asked.

Conferences

  • It is good practice to come 10 mins before 7am
  • Please don’t sleep during the conference
  • Is this a CPC conference? Take time to read the case one day prior and review the imaging when you arrive early morning at the conference, that way you will make the most out of the conference
  • Do you have a question? - Go ahead and ask, the conference is for us to learn
  • Are you the service in charge? - Then come 30 minutes prior, make sure that the projector has been set up, you have the right connectors, the laptop is working etc. Don’t wait for 7am to trouble shoot the technical problems. Kuya Boy is in his office beside the chapel you can always fetch him if you need anything.
  • Are you presenting? - Then again come 30 mins before 7am and you can dry run the presentation and trouble shoot the technicalities beforehand.

Food

This is an exciting part of POC residency!

If you are the one in-charge of the food, it need not be dragging, a bit of forethought can go a long way. Here’s a short list and my personal opinion (I usually pick our food and I have kept my previous and present teams happy so far):

  • Ajisen Ramen
  • Aristocrat
  • Army Navy
  • Bugis
    • Where I get my fix of laksa
    • Nice to order
      • Fish curry with roti
      • Nasi goreng
      • Fish soup
      • Hainanese chicken
      • Chicken rendang
  • Cajun
  • Capreal
  • Cold Storage
    • Salmon sashimi
  • Creamy Island
    • Famous angus beef burger goes well with a variety of soda (A&W Rootbeer, Canada Dry Ginger Ale, Dr Pepper)
  • Eat fresh
    • A spicier kind of Laksa
    • Rice toppings
    • Fruit shakes
  • Everything at Steak
  • Fernandos
    • Kalderatang kambing
  • Formosa
  • Greeka Kouzina
  • Iceberg
  • Jollibee
  • Jonas
    • Oyster cake
  • KFC
  • Kimpo
  • Le Ching
  • Lido
  • Liloan’ Liempo
    • Liempo
    • Lechon manok
  • Ling nam
  • Mann Hann
  • Max’s
  • McDonald’s
  • Meat Depot
  • Mikey’s
  • Monte Villa’s
  • Movenpick
  • Muang Thai
  • North Park
  • Octoboy
  • Oeda
  • Papa John’s
  • Pares sa Retiro
    • Campto soup
    • Pares
    • Bulalo
  • Pizza Hut
  • Rapsadoodle
  • Red Baron’s burger
  • Razon’s
    • Sizzling bulalo
    • Sisig
  • Rufo’s tapa
  • Serenitea
  • Sincerity
    • Fried chicken
  • Singapore street food
  • Sunshine fruit bar
    • Fresh fruits
    • Fresh fruit juices
    • Carmen’s best
  • Tapa King
  • Tazza Cafe
  • Tempura
  • Tien Ma
    • Xia long bao
    • Beef tendon with leeks
  • Tuen Muen roast
    • Roast duck
    • Soy chicken
    • White chicken
    • Cold cuts
    • Lechon macau
  • UCC Cafe
  • Whattatea
  • Yellow Cab
    • Dear Darla
    • Tomato soup
  • Zentea
  • Catch
  • Evernote
  • PBO e-logbook
  • Microsoft Powerpoint

Take good care of yourself

  • Eat when you have to
  • Exercise
  • Sleep
  • Live a life outside work
  • Engage your family, friends and social support system
  • Pursue a hobby
  • Dress well

Morbidities and mortalities

  • They will come and they will make us better and wiser surgeons
  • Learn from other’s mistake and not repeat it yourself