Rubber issue

 

The new Fe came with PC6 when we took her in. I had a flat tire noted after 2 weeks of driving and nail pricking had been karma for the new F since then. For the past 2 years, she had 5 patching session over the 59000+km drive.

The last one happened 4 weeks ago; when I glanced through the panel while stopping at the traffic light during my drive to the hospital for work and I found out that the left rear tyre psi had dropped 15%(20% dropped will cause the light to lit on). Definitely a leak and I had pulled over at the first petrol station available and pumped the pressure up. I saw a nail on the tyre during the pumping process.

I googled and found out that a tyre shop was still opened around my hospital at the late hour.

I had an early start that day and if the shop still opened when I arrived, I would not be late for the job that night.

The mechanic cum boss was an elderly uncle. He jacked up new Fe and removed the tyre. I told him that I just needed to patch it from outside instead of inner part as the tyre is due for change. He told me that he always patches from inside and if I requested to patch from outside, he would still remove the tyre from the hub as it was easier for him to access the leak part. Some old fashion guy still believe patching from inside of the tyre is better for the tyre.

I had a good look when he removed the tyre from the hub. The wear was way beyond the thread wear indicator and I need to changed it soon

I usually changed my tyres at around 40k and this was the longest distance I had travelled on a set of tyres.

I contacted my usual mechanic and told him that I needed a change. I opted for the PC7 but it was not available and he recommended PS4 which was same standard as PC7. The PC series was noted with better noise reduction than the PS but yet PS is better at control and grip.

The replacement was done 4 days later. The price was 2.5x of the Bibendum’s tyres I used previously on my Z. The control and grip was better than the PC6 but yet it was noisier as review. You gain some and you lose some...

Well, safety come first and since 20 inch tyre doesn’t come cheap and there would be another pain again 2 years later. 20 inch tyre ? I would think twice next time I buy a car….

game of balls

 

I had always hated testis pain who presented to ED. The examination includes an ultrasound which need the physician to touch the sensitive part of the patient. The difficulty is increased as the ball will be sliding as you glide the probe over the surface. If the testis is painful the patient would start to resist and the scanning is more hazardous. Without the power doppler mode, you can only diagnosed testicular torsion if no definite flow is noted and it would be too late by if you see this….

Someone had told me this story months ago; A middle-aged patient was seen few times for abdominal pain with each consultation separated by 12 hours apart; even though CT scan was done twice(enhancement and none enhancement) during the visits, he had still ended with ball removal.

The unless proven otherwise rule was not applied in the case where the pain was not proper diagnosed and patient was discharged. The patient was treated as urinary stone where radiation pain to testis was an acceptable symptom. The key in the case was no stone was noted by the scan and a negative UFEME was noted.

I had been more cautious lately and I met a few cases of ball pain lately where I performed ultrasound without hesitation.

It was an embarrassed moment for everyone, the physician, the chaperon and the patient. Especially the chaperon who mostly is the nurse or nursing aide available and most of them were female.

Frankly said, I hate doing it as flow noted in the ball does not exclude torsion as we had no power doppler mode on our ultrasound and there is a 50% chance a urological consult was unavailable. Our urology consult was supported by two inhouse staff and half of the time the consult was covered by visiting staff who was reluctant to come...

I crossed my finger on every discharge…

we are one.....

ML was sitting on the bench opposite the triage area holding her belly while I walked into the ED. I thought she would be my first patient but her name did not show up on my screen after I seen three patients. I asked around and found out that she was turned by K today morning and G last night as she was just discharged from ward few days ago.

ML was a female with a sorrow past. A schizo since her young age and victim of a fire incident leaving scar over her appearance. She was jobless since the accident and living on subsidy.

Her visit to our setting had increased markedly since last years as she developed liver cirrhosis and massive ascites which required frequent tapping. She had visited us on an irregular basis. Her psy stat plus her noncompliance to medication behavior had led her ascites to increase great speed.

She was turned down from time to time as she tapping request sometimes was too frequent.

Prior to her arrival yesterday, she was admitted to our ward and tapping was done 3 times during her 11 days stay. A good 20000cc was removed and you could she her walking past by our desk with a tea drink jumbo cup on her hand.

After K and G turned her down, I was in no position to help her even though I estimated 10000cc in her peritoneal cavity judging from her belly size.

She had wandered around the hospital since then and I had asked one of nursing staff to hint her that to come back tomorrow morning and someone would proceed the tapping for her if she do so.

She however ignored those advice and kept bothering us from time to time.

I stood the ground as it was not an emergency situation which demand urgent management. The integrity of the EP team is important if no medical emergency is involved. She had then shifted to the OPD and later referred to our department gain but yet the staff did not attend to her.

She was still hanging around the hospital when I went off by 10pm.

When I arrived to work the next day by 9:30am, she was still wandering at the convenient store in front of our hospital; her belly was taken care of apparently.

Well, I logon to my account and found that G had settled her problem after midnight. Even though her problem was solved but yet she was still wandering around…. nothing to shout and comment as my decision to keep the integrity of our team was correct. No hard feeling of delaying the tapping.

too old ...

 

For a local hospital with 100+ beds, we were considered by the govt as small hospital. We are graded as community hospital - the lowest grade according to the standard of hospital evaluation scheme.

According to the diverting plan, we were not supposed to admit patient with severe respiratory infection caused virus. The plan was drawn after the SARS era to more efficiently managed such malignant wave of attack. Resources were directed to designated hospital so that patient would be care under the best team with adequate equipment.

The Covid rampage had however proven the insufficiency of the planning. There was always patient that was unable to transfer out.

Respiratory infection caused by virus had always carried a risk of worsening into acute respiratory distress syndrome or myocarditis and ECMO might be needed.

1+ years ago, a nurse who worked in a medical center grade hospital in K city had collapsed while she was going for trip to the east coast. She had collapsed in her car and later sent over to our setting where she was comatose and shock was noted. She had cardiogenic shock and ECMO was initiated in the ED. As her condition was poor and ECMO usage on the ambulance was not feasible. She had succumbed to the disease days later.

It was a difficult time for the whole team as the patient was placed on a venoarterial mode and a dedicated team was needed to the care for the patient. The day to day routine of the ICU was affected. The patient was young and families were hoping for miracle. It was a bad practice but as the patient was a medical staff; we did our best to pacify the family.

Since then, we had cautiously choose our patient but however some patient was difficult to turn down.

A father of our nursing aide had come to our ED presented with fever and cough and later proven as pneumonia caused by influenza virus. The patient was admitted as influenza pneumonia; it was considered as severe influenza disease and should be referred. However family wanted to stay back and we had admitted the patient.

The patient had deteriorated on D3 and one day after he was transferred to ICU, he was intubated due to ARDS. A referral was warranted as ECMO was needed due to poor oxygenation despite aggressive respiratory intervention. It was a Sunday and only one ECMO was available at the southern part of the island. Yeap, the last ECMO was in our setting.

The visiting cardiothoracic surgeon was available and he was summoned and patient was hooked on to the machine in no time.

We were lucky as only venovenous mode was needed as the patient did not had any cardiac failure condition.

The patient’s renal function had deteriorated few days later after being hooked onto the ECMO.

Our nephrologist was consulted and hemodialysis was planned and insertion of double lumen catheter was warranted.

Tan who covered the ICU had however gone back for a long trip in Penang and the ICU was partially covered by a junior neurologist and boss.

It was a difficulty decision to be made for the double lumen catheter insertion and Boss had come to us for opinion. The ECMO VV was inserted via the right side and a CVP was inserted over the left femoral vein leaving only the left internal jugular vein to be available.

A double lumen catheter from the left upper part was not a usual practice and the catheter would need to squeeze with the ECMO catheter along the superior vena cava when being passed through. Definitely not a good idea.

After some exchange of idea, we had decided to switch the CVP into the double lumen catheter with guide wire method and then a CVP would be inserted via the left internal jugular. Not a good practice as the possibility of contamination and infection would be high for doing so.

Boss had agreed and asked us to proceed with the procedure as no other option was available. I had to perform the procedure as my colleague had failed a pigtail recently and I understood his mental condition.

I was lucky as I had the senior surgical aide on shift that day. The changing was a smooth one and no massive oozing from the insertion point was noted.

The central line catheterization was however more difficult as I had to squeeze myself through a load of wire and tubing to get to the top side of the bed. No margin of error and I had done a scan prior to catheterization. The jugular vein was engorged and the neck was short. A short neck was a good sign as there is not much consideration for the point of insertion. No space was available to perform an ultrasound guided insertion as I was surrounded with tube and machine. A quick look and marking were all I could do.

I sighed upon completion of the procedure; I am a little too old for this kind of thrilling moment. I just couldn’t complaint about the judgement of my colleague about the catheter insertion; one tends to opt for the easiest path. The catheter was placed shallow than usual as I intended to avoid squeezing with the ECMO catheter. However at 14cm, there was still no flow noted and I had to retract it to 12cm and finally I got a slow but acceptable flow.

It had been 1 week since the thrilling event and even though he was still hooked onto the ECMO but yet his lung had much improvement judging from the xray.

I was still the youngest among the senior physicians. Most of the senior physicians were almost 70 and yet they are still keen on their job. In the past, Ving had asked me about retirement from time to time but recently we had acknowledged the facts, income is always the key to a comfortable life and retirement might not be an option for us in the near future…

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….