fever and bleeding...

 The Covid era was the darkest period of my entire practice. Donning PPE was a norm and the fear of contracting Covid had been haunting me until I was infected. However rules were still to be followed and the mask wearing rule in medical facilities was only lifted about 1 year ago. I was one of the don’t wear mask physicians in my department prior to the Covid era but things had changed and I don’t feel comfortable facing my patient without donning a mask nowadays…

It was a busy afternoon and the EMT had rushed in a elderly female  with conscious disturbance and collapsed during the transit. 

She was intubated with a LMA and no Lucas automated CPR machine was used since setting up the Lucas was not practical in the ambulance. The EMT did manual CPR during the transportation. After accepting the case, I did the routine with my team; changing the LMA to endotracheal tube and bla bla bla… The patient was a small frame skinny elderly female and she was febrile.

I proceeded to the family and did a brief history taking. She was fine until noon according to her daughter. She was staying alone and her daughter would bring her meals during noon and evening. When I reentered the resus room, I was stunned by the blood noted from the endotracheal tube. It was fresh blood noted from the ETT. Fever plus bleeding led me to think about the scene of some medical disaster movie; it was hemorrhagic fever until proven otherwise. 

I started to chase most of the staff from the resus area. There were only 2 staff left in the room. Patient airway was secured in a closed system while being intubated and ventilated. However we would need to perform suction to clear the tube and everyone exposed would be quarantined should the worst case scenario happened

I called up my infection controller asking her if any recommendation or advice that she could offer; and she told me that I do whatever I think is suitable and asked for lab tests that are relevant. 

I was pretty sure that her contact and exposure history was negative and the only hemorrhagic fever around our area that was possible was Dengue. I ordered a Dengue rapid test and proceeded with the resus until the usual 30mins limit. The fever and acidosis had hinted a septic state but yet the focus was unknown.

All our efforts were wasted, I called the time and told the family about my decision and asked them to wait for the lab result before I released the patient.

Everything was negative; there was no coagulopathy nor thrombocytopenia.  I released the patient and told the family that a PCR would be done for the serum to final confirmation of the Dengue status. 

The cause of blood in the ETT? Well, the culprit was most probably the LUCAS. The automated CPR machine provides consistent and good quality of CPR. God knows how many ribs had been broken by it. The patient was skinny; my final guess was an idiopathy injury due to the CPR machine and most probably she had pneumonia.

During the resus, I couldn't bare to think about having the whole team being quarantined. We are currently shortage of medical and nursing staff and it would be impossible to run the unit if such incident happens.

It was a good lesson for us that loosening of rules does not mean lowering our standard of precaution. Next time I would wear proper PPE before entering an resus scene….

Google Doc

 

Han stopped by the ED few weeks ago and tapped on my shoulder and said” you are deity of medicine, you save one of my patient…” (deity of medicine in Chinese doesn’t mean god but just another way of saying that your had good medical skill)

I was confused and asked him about which patient…

He given me a medical chart number and I looked up the chart on the spot.

The patient came to ED 2 months ago complaining about generalized discomfort. I noticed that he had tremor and it was not typical of intentional tremor. I did a workup including a brain CT. The image was something that I had never seen before. There was unusual calcification over white matter and I had googled over the net and found a match --- FAHR syndrome.

It was not a spot diagnosis for someone like me that was not neurology trained. However it was an acceptable match, a good correlation between imaging and history. I had discharged the patient and written down the diagnosis in the medical chart.

Patient had later come back to our ED and admitted for renal problem with conscious disturbance and later admitted to Han service.

He saw my note and ordered a calcium profile and corrected the problem and patient had regained conscious…

Well, I told him that I gotten the diagnosis from Google, he however told me he could get the diagnosis even if he had googled. I grinned and told Han that  Google save the patient not me….

Googling was all about keyword and patience. You hit the correct keyword and explored as many pages of result as possible. The Chatgpt and sometimes Google function in a similar way where it found the most relevant info for you. The manual way of course took more time but yet it is more effective but no efficient.  

I did not claim the credit but yet I am glad the patient become better.

the final leg.....Peking trip

 

We arrive at the airport by 1:30pm. We had taken a slow walk around the departing area. Shops with great restaurant that cost you a hand and a leg. That was one of the reasons we grabbed the meat pie of the way. While eating the pie, the anxiety surge all over me, I was still haunted by the connecting flight. 

The security was tight however the police patrolling the airport on a mini cart was carrying shotgun !!! ; the determination of keeping peace at no course beyond my doubt. 

We had checked in our luggage after we finished our meal and headed to the restriction area.

The first area was a baggage check with a long queue. After that we proceeded to the document area to stamped our passport. One locals in front of us was taken away by the senior officer and never return…I sweated as it happened in front of our eyes. It was not rumor after all…

It took us one and the half hour to hit the boarding area. We boarded the plane without difficulty and I started to stared at my watch.

According to the flight radar; the flight had delayed once to twice every week. Any delay of take off of more than 45 mins will jeopardize our chance of catching the connecting flight. We boarded the flight as scheduled but the plane was stranded on the runway for more than 30mins.

I had to cross my finger hoping the best as we had reached the upper limit of the delay.

I was too tired and slept through the flight. The plane did arrived on time however as my club mate had told me it would take a good 20 mins before it reach the gate.

The CP flight system was well designed as it had shown the gate of our connecting flight on my seat display well before the flight landed.

Bad news was the gate for our connecting flight was so far apart as I glanced it over the seat display. We had to go down to the base level and take a shuttle train to another satellite building. I doubt it we could make it as we only had 40min left. When the cabin door opened and as I had expected, there were a female ground staff waiting for us with a signboard. There were 2 groups of passengers taking the same connecting flight. The ground staff had specifically told us that no assess to any toilet on the way. We could only go for nature call once we board the connecting flight.

It was a fast walk for the next 25mins where we could only take a rest on the shuttle train. We managed to join the line up of boarding passenger when we reached the gate. I cheered in my heart while refraining my bladder sphincter during the queue for boarding

The senior member from another group had grumbled to the ground staff during the run that why can’t the flight wait for us as it was the same flight company we were taking. I answered the question for the ground staff, “the KHH airport had curfew from 0000-0630H and our last flight had to take off before 10:30pm so that we would not be directed elsewhere, moron” (the last word did not slip out from my mouth and I had used a polite tone).

We managed to board the flight and arrived at the airport by 2340H. We reached home after midnight and I was back to the desk for work the next day.

It was one of the daring trips that I had planned and we had completed the journey with hiccup as usual.

It was a short trip to Xiamen initially and later expanded to a 6D5N trip to the heart of my ancestor homeland. Spectacular experience for everyone for us. Especially for Xian; He had taken a leap of faith out from his greatest fear….

D5 and D6 and it aint over yet...

 

D5 was another walking day as we had roved around the 1^st rim and visited the art museum, St Joseph Church and the temple of heaven.

The art museum was something modern and it was well managed with great exhibition. 

The St Joseph Church was an establishment of faith where ruling party disagreed with. Old fashion catholic church which hold the ground for the great one. 

The temple of heaven was place for the emperor to pray for his citizens. A big garden that took us a long walk before we exit the area. We run out of water on the way and we were lucky to met a lady who sold drinks at the MRT entrance.

It was a long march day again for us.

We had seen mosque, church and museum around the city. We had walked through the alley of the commoner and the royals. Well, and amazing experience for me as I had read a load of Chinese novel related to the Qing Dynasty. We concluded our last meal with cattle spine firepot.

It was just an capital of a great country. Police patrolling the street without firearm, CCTV all over the street. One of the safest city in Asia, no doubt. I did not hand out any currency note during the whole journey; I was using touch and go; only foreigner and people from very rural area use note.

Bitter gourd with lemon was one of the drink that I had drunk a few times. The locals had taken the tea drink to another level.

The police were not helpful, I had tried to ask for direction a few times and most of the police officers told me that they don’t know and ask me to look it up over the net.

There was no night life around the first rim. It was silence after eleven; no supper joint nor night shop around the first rim. Frankly said, it was kinda bored but yet we were too tired after the day tour.

The last day was not planned and we had decided to take a look at the heaven peace square. We took the MRT which arrived at the area by eight and found out that it was crowded and no way we could get into the square by ten.

We had however taken a hike around entrance. The was a large shopping area before the square.

The tourists were citizens from all over the country. We met police around the area asking for ID card. The police use a loud hailer shouting as loud as he could; however when he saw our passport, he halted for a second and asked us to leave with a calmer tone. Yes, you cannot go around without your passport…ID was needed to enter every place of interest.

We eaten Mongolian xiumai[burning sale](I like xiumai and until that day, I had only eaten hongkong style….) and bought some meat pie before we headed back to our apartment. 

The meat pie was our lunch at the airport as our flight was scheduled around 4pm.

The trip concluded by noon when we hopped onto the mini van and headed to the airport.

And the thrilling part await us few thousand km away.....

D4 - the art of slicing

 The 3rd day was sleep till you awake day. As usual, I woke up early and started my planning about the next 2 days.

It was a shame that I was able to secure any ticket for the military museum. There were many place to visit but yet I opted for an easy one.

Peking is divided into rims; the first rim was the area surrounding the old palace and Sky Safety Square. Extending outward until you reached the outward of the bird nest stadium.

All I care about was food actually. To see and to eat till we drop.

We took the MRT headed to one of the PekingU station which once posted the Harry Porter Nine and Three Quarter Station. The decoration was gone but yet it basis structure was there. We then traveled to the cow street where most of the Muslims gathered around. We were lucky that the place was not crowded and we eaten the signature mutton puff and desert. The tour ended at a famous Muslim restaurant where we had another Peking Duck treat.

We travel back to the first rim and later patronized the bookstore and mall around our lodging site.

Xian was amazed by big shelf around the entrance. A huge collection of the leader publication. I think the only place that we could see such view is located in the states where the bolehland had no diplomat ties. The book was interesting and I had stopped by the medical area where I read their medical text book. Well, the content itself explained their standard….

However, I had bought some books for my nephew and niece during the tour. Very nice translated book in simplified Chinese which I could not get in ghost island.

We headed to the ghost street for a great firepot meal. Cheap and artistic was the word I could described. In my whole life, when I dipped a mutton slice into the shabu shabu firepot, I always get a shrinkage piece no matter how fast I pulled it out, should it be raw or medium. However, the special way of slicing the mutton had led to an enlarge piece of slice no matter how long I dipped it in the firepot. That is art...

The ghost street was actually a place where ancient people do underground business just like what you did in the dark web. However, it had transformed since the revolution. The ghost street was flooded with small lobster shop nowadays but yet the shabu shabu was still the best in my humble opinion.

While I chewed the desert bought from the cow street in the kitchen. I started to worried about our last leg of journey. Should I change our flight to noon so that we could have 3 hours of transit instead of 1.5 hours?

I decided not to gamble our luck and put my faith with the great one….

D3 - the Great Wall

 

The third day was the peak of the travel as we would follow the trail of our ancient defender at the Great Wall.

There were 3 spots to enter the Great Wall around Peking. I opted the MYT as apart from the Great Wall there is a Tobago ride. I had an excellent experience at the Sentosa island many years ago with the Tobago. MYT Great Wall had less visitor compare to the BDL Great Wall. The reason that I had chosen Great Wall run on the Monday was that all of the tourist spot was closed on Monday. It was a bad decision and lots of the tourist had done the same thing. As it was pre-school holiday and I thought I would still be safe and I was wrong. There were tons of families taking their children for early school holiday trip.

The push off was smooth and we had reached the two food joints as planned. One of them was named “Big lazy dragon”. Lazy dragon was a nick name for meat wrap. We bought 6 which should be enough to supplement our energy climbing the stairs. We stopped by a very small shop for breakfast. The price was darn cheap and we were eating among the locals. I had gone to the public toilet nearby and found that no door was installed in the toilet. It was like 15 + years ago when my parents told me about the doorless toilet in the kampung area when they visited mainland. Doorless toilet in Peking at this modern age ?

The breakfast price reflected its quality; cheap and nothing but cheap. Chain breakfast shop which was selling affordable breakfast to the locals. We were sitting among laborers and students. The bao, fried liver, meat loaf, soya was so so but yet it pacified your hungriness.

We were able to reach the gathering point on time and successfully get onto the bus. We met a bunch of kurang ajar kids who spilled their drink and hopped to another seat. Leaving us with one of the seats with stain of drinks waiting for to clean up. Yes, they were still locals who are rude, impolite and selfish. Although education had flourished over the years there were still people who is still caring only about themselves. Long way to go before it is considered as developed….

The journey took about 1.5 hours and at 9am we had reached the base of the Great wall. The cable car queue was very long and it took us 2.5hours wait before we reach the 5^th tower at 11am. We decided to skip the Tobago and ascended by foot to the 14^th tower where we would take another cable car back to the base.

The stairs were really not ergonomic and unfriendly. We stopped by the 7^th tower,  while we enjoyed the spectacular view, we walloped the lazy dragon and prepared for the final ascent. Although it was early summer, the breeze and temperature was darn relaxing.

It was crawling speed for Ving and me accompanying the shortness of breath and leg soreness. How could the border guards tolerate such walk up and down as their daily routine? However it was hell of an experience to be part of the history…

Well, we landed back to the base at 3:30pm and we had a good sleep on the bus and by 5pm, we were walking back to the apartment.

On our way back, we had stopped by one of the famous Muslim firepot restaurant situated around the hotel. It was an expensive meal though. The meat and mutton were excellent and the slicing method was one of the signature features of the shabu-shabu.

Unlike the Japanese style shabu shabu which had influenced most the shop around ghost island. The Peking style shabu shabu utilized the old fire pot which was heated by charcoal. Just like the old fire pot that Malaysian use. No broth was used and only plain water inside the pot. The dipping which knowns as two eight source is a combination of sesame source and peanut butter using the ratio of 20%:80%. Mutton was dipped in the boiling water for 2-3 minutes; unlike the Japanese style shabu shabu where you dipped for seconds only.

A satisfied meal and we retreated to our apartment before night fall.

All I had read from the net/book were materialized in front of my eyes. I had completed the 2 major spots on the list.
It took me half a century to lay my foot on this land. It was so far away once…

The waiving of visa had brought the dream come true. My last visit about 10 years ago was an initial RM2k visa fee and 2 weeks of anxiety fearing the lost of passport while sending it to HKG for visa application.

Until now it was an amazing trip. While resting on the sofa sipping the Artic Ocean orange soda and staring blindly at the night scene; I thank the Great one for taking me all the way (with some hiccup of coz, but yet I am still grateful)….

Peking - old palace

 

The room although old but yet remarkable. I had a good night sleep and awaken up early at 5am. Everything was in order and the front desk staff was friendly enough to give them a 5 over 5.

We had pushed out by 7am and decided to take slow walk of 1km to a branch of a famous snack shop. The Protect Country Temple shop was one of the oldest breakfast shops in Peking. They sold a variety of food from main dish to desert. The taste was interesting and some of the food that I had never tasted before. However we were still reluctant to order this green bean juice which was one of the classic of Peking. It was made of fermented green bean leftover which smell and taste like spoiled food. It take "balls"  to take it

Price was acceptable but yet after my tongue being trained by food from the ghost island. I felt that it is just up to the standard. There were better food that I have tasted back in the ghost island.

However we had also taken away some meat roll and meat puff for lunch. We arrived at the meeting point and minutes later our guide came. A middle age lady who could speak English. She led us into the palace and started the tour. It was a 2.5hrs tour where we were introduced to history of the old palace. The tour ended by 11 and we started our own wandering around the palace.

The mainland treated it as old palace museum as compare to the one on the ghost island. Frankly said, the main exhibition is the building and not the collection. We were allowed to walk outside most of the building and only allow to walk into some of the building which was decorated as exhibition hall. We covered 80% of the assessable area by 3pm

Both of our lower limbs sore and we could barely walk back to the hotel which was another 2km walk….

As we hit our room by four plus, everyone of us was exhausted and we could only pace out for dinner after seven.

We headed to a mall and we had HALAL food for dinner. 2% of the resident are Muslim and some of the signature dishes is HALAL. We had Peking duck, Beile(prince) BBQ and other side order. Special meal and very salty compare to what I usually eat. On the way back, we had grabbed a load of sour milk as most of them were packed in a special small vase-like bottle and Ving just like it.

The TnG epayment was the best compare to Wechat payment. Straight forward authorization as simple as I use it in Boleh land. I was lucky enough to have some cash inside my PB account.

The area we were residing was previously knocked as Prince Gong Mansion. The residence was previously owned and built by a Duke who was the biggest bride collector in Qing dynasty. When the Duke was arrested and his property confiscated, the big house and land was awarded to the Prince Gong who later become the regent acting on behalf of the CiXi queen. The area was abolished during the CCP ruled and converted to a shopping area where a few shopping malls was erected around the area.  

The market was cold and only some shoppers were patronizing the area during Sunday night; it should be crowded with people but yet it wasn’t.

The 1^st day was filled with excitement and the second day was another day of thrill as we had to travel to the major bus terminal by 7am by MRT. With the help of Dianping app, I was able to find 2 shops to stop by before we hopped onto the tour bus. One for breakfast and the other for take away lunch at the Great Wall.

Could our legs which was filled by lactate survival another strenuous walk ?  I couldn’t bare to think about it….