Crow mouth....

 

 

After years of practice, most of the physician would have some instinct/experience guessing diagnosis with only a small piece of history of findings. Most of the time you would be happy that you have gotten the correct diagnosis….

K was sitting with me at the desk and a 10 years old girl had sent to his side by the local rescue service. The complaint was right thigh deformity after fall during a basket ball game.

While the patient being sent for imaging, I had chatted with K and told him that most probably it would be cancer(osteosarcoma most probably) as the impact during a basket ball game is not strong enough to break a 10 years child’s femur.
Well, I regretted what I had said instantly and loaded the film once it showed up at the imaging list… Crow mouth I had…

K notified the orthopedic surgeon and after reviewing the image, the surgeon had told K to refer the patient as she would need to be managed by a multidiscipline team in a tertiary medical facility.

No one wanted to break the bad news, K had to tell the mother that the fracture is complicated and need to be managed by orthopedic surgeon who is specialized in that field.

I had regretted sharing my spot diagnosis….10 years old girl with a total hip amputation and a long course of chemotherapy waiting for her; even with such aggressive treatment she is still facing a 30% 5 years survival rate….

The incident had haunted me and I had paid my price during the level 3 IDPA competition 2 days later....

Trust no one.....

 

The central line insertion was definitely a heart pounding procedure for a medical trainee during the first few years of their training. The localization of the central vein is the most challenging part especially for patient with thick adipose tissue.

The introduction of ultrasound into ED practice had eased the process and raised the successful rate of central line catheterization.

Most of my young colleagues practice the actual ultrasound guided method, but I usually used the ultrasound to confirmed the position of vein and proceed with the procedure using the traditional method. We got a small amount of incentive if we use ultrasound to guide our catheterization. I am more confident during the venous puncture part as the imaging had given me a rough idea of the position and size of the vein. 

The catheterization was always a one man show until recent few years, the head of department had wanted the surgical aide to assist in the procedure as someone would need to hold the probe during the puncture. Well, as I did not use the probe during the puncture, frankly said, I am not very particular about having an assistant. However with an assistant, the secure with stitches part would usually be done by the aide and I would left the scenario early after fully insertion of the catheter.

I did remember in the past that one of my senior had told me that when the catheter is inserted down the guide wire, we would need to make sure that the tail of the wire is visualized and properly grabbed hold on so that the wire is not fully inserted into the center vein which might need a vascular surgery to extract out the wire.

I had always being cautious and would teach my staff that the tail of the wire needed to be secured by the operator before the catheter is fully inserted.

All of our surgical aides knew the rules as I had always insisted that part is clearly done.

However, few months ago, one of our junior colleague had met the worst case scenario above mentioned.

It was an easy femoral puncture and our junior colleague had left the table prematurely after the guide wire was being inserted. The insertion of catheter was left alone to our senior surgical aide. The wire was not secured before the catheter was inserted. When the aide noted the wire is not seen at the tail of the catheter; he got panic and removed the catheter immediately; the act had left the wire fully inside the femoral vein. What he should have done is to clamp the catheter with a forceps and remove the catheter hoping the wire would be removed with the catheter.

When notified, our junior colleague however was bold enough to do a small cut down with the aid from the senior surgical aide. The wire was noted and removed from the femoral vein without complication.

It was a heart pumping scenario which was compensated without a scratch.

When my junior colleague told me about the incident, both of us sighed and agreed that it was an narrow escape.

The surgical aide was senior enough and capable enough to perform many procedures ….but yet accident do happens..

My conclusion -----“Trust no one”

urn run - final leg and the price

 

The sip of cask strength did not give us a hangover. We had awakened up early and enjoyed a good continental breakfast at the restaurant of the hotel. From nasi lemak to roti canai and fried egg; It was perfect for a good start.

We packed everything and headed to the thousand buddha temple with the help of the google map. The temple was situated around the largest cemetery in KL. The huge cemetery held over 10000+ of graves. The cemetery was separated into different part which were managed by different organizations. 

We arrived at the temple and I found out that the temple had expanded; a few more new building  were constructed around the main temple.

We found the office and was greeted by a female staff. After signing a few documents and paying up the relevant fee; she had directed us we to the old columbarium for the pickup process.

There was another young female and a foreign worker waiting for us at the praying desk with the urn. The detail on the urn was verified by us and I proceeded with the final prayer before the journey.

I had prepared 3 red packs just in case my parents wanted the prayer to be done by the monks. However my brother told me that it was not necessary. I left those red packs to the young female and asked her to share it with the foreign worker and the office lady staff.

I knew that both the female staff were orphans which was adopted by the temple as I heard the story about temple was running an orphanage and some of the orphan would stay back to serve the temple.

My brother had given me a surprise look when I placed the urn in the Ikea basket and fixed it securely with the safety belt around the backseat. I told him that I am not stupid enough to carry the urn on my lap for the whole journey. I had more than 20 years securing object on the backseat with safety belt…..

The drive was smooth and we had stopped over around the Pagoh R&R for lunch. The Malay mixed rice with the ayam masak merah was tasty and up to standard. After the brief stop we managed to arrive at Kulai around 1+pm.

We had met up with my sister in law who had arranged the cubical purchase at the P memorial park. A middle-aged male was assigned to us and we had headed to the columbarium for the relocation.

It was indeed a good spot with good view. There was this strange smell which was quite irritating during the drive from the office to the columbarium. I did not ask around but was aware that something was interfering the process, all I could do was prayed….

The position of the cubicle was just as promised, eye level and nicely located near the exit of the hall. I placed the urn and did the final ritual. The smell had gone away after the placement.

Everything was set and three of us had headed back home.

I enjoyed my dinner at a food court later that evening with my family; I discovered that nothing was below RM5; a decent meal with drinks would cost more than RM10. The price hike was steeper than I expected for the past few months.

The next day, I had driven my parents to the memorial park again after breakfast. It was time to let them see the effort we had put in for the past few months.

My parents expression told me that they were satisfied with our arrangement when they saw the final setting.

I waited for a while as they offered their chanting. I looked at the cloudy sky and flashed back what had happened many years ago. The final days of my grandfather, the funeral, the cremation….

Once, my dad had told me that he would like to move the urn to a better position if he could afford it; well, wish had come true finally…..

I had taken a flight that night from Senai airport to KLIA2 as my flight back to K city which operated by double A was scheduled at 8am the next day.

While passing the security check, the alarm rang and how careless I was to misplaced my Leatherman knife in my hand carry bag…..Worst of all, my parents had left the airport and only thing I could do was to surrender it to the Imigressen.

It had accompanied me for more than 10 years and travel with me thousands of miles across the continent. I got my final hit later when I reached KLIA2. The staff at  tune hotel at KLIA2 front desk had told me that I had wrongly booked the hotel at Aeropolis.

I mumbled the 4 letters word start with F and rebooked a room as I was too tired to move on….

While laying on bed after a refreshing hot bath, I had tried to think back what had happened; the pocket knife and room booking were the price that I had to pay for dealing with the dark side. The heavy smell was the final warning and I had ignored it and proceeded with the final ritual. There were so many obstacles during the tour; all of the tricks that aim to let my ancestor laying elsewhere was the work of the dark side.

I had fallen into Alam Bunian and awaken early after a few hours of deep sleep. I had done the final packing and headed toward KLIA2.

A smooth check in though but I did not lay my hand on the salted sesame pancake (Ham Jin Bang) as the stall was not open yet at that early hour (it had also closed early on the day of my arrival)

The rest of the journey was uneventful and I was greeted by Ving and Xian at the airport few hours later.

Apart from the money and time spent with a loss of precious belonging, I had never regret of taking a walk down the path….

urn run - the first leg

 

My anxiety had growth over the waiting period; my shifts were packed as usual as I need to do 20 shifts in 25 days before I hit the airport. I later found out that the window I had planned was within the  school holidays and it also collided with Hari Raya Haji. No wander the flight ticket was expensive and hard to book.

After reminder from my dad about the holiday matter 3 weeks before the journey. I had to discard my plan of doing a last minute hotel booking. The best choice was hotel around the Mid Valley Mega Mall. The drive should be 20 mins or less; I had wanted to get something nearer preferably breakfast not included but yet it was not a good area for some food apparently. I had to settle with the Cititel Hotel which came with breakfast. 

During the scarce off day Ving and I had gone to IKEA and bought a basket made with rotan. It would be my container to hold the urn during the drive. I had done some math and estimated that the basket could hold the urn properly and could be secured with the safety belt on the back seat without any difficulty.

I had packed a simple luggage and booked the connecting flight from JB to KL 2 weeks before the journey.

Ving, dragon cat and I left home at 10am. It was a smooth drive and we reached the airport by 11am. I kissed Ving good bye and headed to the double A counter. The queue was long even with the frequent flyer lane.

I managed to check in my luggage after 40 min of lining up at the counter. The security and immigration check was fast though. In no time, I was patronizing the free duty shop and trying to get a cask strength whiskey for my brother.

My brother was lucky as I had managed to land my hand on a Omar Shirley Cask Strength produced by Nantou Distillery which he had sourcing for sometimes.

The boarding was smooth and I had fallen into dreamland as usual before the flight take off.

The Pak Nasir nasi lemak was tasty as usual; it had been 4 years since I had it. Not surprisingly, the ‘not enuf’ sensation had emerged when I swallowed the last piece of it.

Peace was with me as I closed my eyes and flashing back of what had happened since the CNY trip…Everything was in order and yet I had prepared for the worst as anything could go wrong especially when one is dealing with the dark side…..

The flight had landed uneventfully and I was greeted by my brother at the exit. 

We had had dinner at the Nine dragon ice shop where we had noodle and red bean ice campur(HK style of course). Nice meal but expensive though(no the price only, but later both of us had suffered from diarrhea the next day).

We had arrived late at the hotel  and enjoyed a sip from the whiskey which I purchased few hours earlier....

Misuse

 

I had this medical certificate request placed on my desk 2 weeks ago. I reviewed the medical chart grumbled a little while I figured how to write down the diagnosis.

There medical certificate here is something different than the Bolehland. During my service with the MOH, medical certificate a.k.a MC served as a permission for sick leave. It was very crucial for those people especially the laborer group. There were tons of reasons asking for one. It could allow them to take a day off either for rest or run some errant. The issuance of such MC had truly test the wisdom of the relevant MOs.

The medical certificate however was something more like a medical summary with a column for diagnosis and another column for comment. I had always been cautious to write down the diagnosis as it is an official document with possibility of landing into a medico-legal swamp.

The case of a bed-ridden patient who was brought into ED by ambulance for generalized weakness. I attended the patient 10 mins before the end of my shift. I reviewed the chart and found that the patient was seen in our ED the day before for head injury due to fall cause by weakness and poor intake.

The patient was alert on arrival with no sign of cerebral injury. I did not repeat the CT scan but order some blood test before I passed it to my colleague.

The patient was later discharged after 10+ hours of retaining in ED by the day shift physician. A diagnosis of R53.1 (Weakness ) was placed as diagnosis by the physician who discharged him.

The blood test came back normal and the reason of weakness was poor intake….

I was reluctant to issue the MC upon request but had to do so as my named was put under the attending physician column.

Few days later as young lady came and asked for my explanation about the diagnosis and content of the certificate. She identified herself as the daughter of the patient. Judging from her outlook, she appeared to live in urban area.

She had queried about the decision of discharging the patient. The conversation was not a comfortable one as she had a misconception regarding patient discharge. From her point of view which was based on common sense -> all patients discharge should be able to walk out from the hospital without aid. She had questioned our decision of letting a bed-ridden patient to leave the hospital.

She had expected a very detailed medical summary on the MC and asked us why we didn’t write any plan nor detailed instruction of discharge. She had barked on me claiming that she as scolded by my colleague who had discharged her father on that day.

I had asked around later and found out that an unpleasant conversation had occurred between the lady and my colleague. The daughter had requested an admission and was turned down; the reason of admission was that she was busy and she had wanted the hospital to act as an interim care node for temporary settlement. She was offended by the conversation and later she had come to us requesting medical certificate. After obtaining the certificate, she had utilized the diagnosis and the simple notation on the paper to query our decision; stupid but effective one.

The beat up and no retaliate strategy had worked out though and the daughter was in no ground to proceed as I had avoided the provocation by the relative.

The feeling was a strange one, I felt like a ghost being hit by a truck; no scratch over the body. However part of my soul was engulfed by something which I cannot describe.

It was difference from emptiness resulting from a successful striking back. Frankly said, I don’t like both of the feeling; but I need to make a choice…

urn run - prep

Lack of man power had been haunting the medical field for the past 8 months. Since the loosening of Covid control; hospitals around the island had been flooded with patients. Wards were full and admitted patients had been backlogged and kept in the ED. The major element leading to such condition was the lack of nursing staffs. The wave of resignation had swept through the island and we ward were closed down. We had similar problem and a whole floor was shut down. My name was marked on our roster for 22 times instead of the usual 15. Any straight leave would land me on a very long streak of continual shift. It was inevitable for me to tolerate such hardship should I decided to proceed with the mission.

K was the roster master and he would do everything to satisfy our need; thence the deciding factor would be availability of the flight.

Price was not much a difference as I was buying the ticket on a very close date.

Not much choice to choose from however it still took me 10 days to make the final decision.

I had consulted my parents about the ritual of moving when I finally get all the info and completed the relocation site selection. My parents had been followers of Soka Gakai for a long time and my bro was currently with Tzi Chi. I had asked them if they wanted to bring some local followers up for chanting/praying and they had told me it was not necessary. I had hesitated for a while about performing the ritual all by myself. I had experience facing the dark side but yet performing the ritual alone? It would be my first time for such ritual; not sure if I could handle the price to be paid....

The date was fixed eventually and I had planned to rent a car, put up one night in KL, proceed the relocation on D2 and returned to KL on D3 for final preparation of taking flight back on D4. I was still confused about getting someone accompanied me for the whole process.

The great one had however answered to my call; when I informed my bro about my decision and date of return. He told me that he would be back during that period and would pick me up in KL and complete the mission together.

The process had actually stretched over few weeks before everything was finalized. The uneasy sense cause by uncertainty was an agonizing event for me. Disturbance and unrest were diluted by stress resulted from overworking.

I did not feel any relief when I booked the flight ticket. There were so many events to worry about; the extraction process, the 380km journey, the return flight from Senai to KLIA and much more. I knew I would have to put my faith upon the Great one to take me through the process.

urn run - the first step

I had fragmented information about the temple and location of the urn. The Jalan Kerayong had 2 entry; one around the palace and the other around the old airport. All I know was the name of the temple and the number on the rack (3033 or 3303). I need to identify if the urn was still there before I proceed further.

The 1^st part was simple, just Googled and I had the address and phone number. The street view confirmed that it was truly the site I last visited 5 years ago. I Whatsapped the number as indicated from the FB. I got a late reply asking me to provide the information about the urn's cubical.

All I knew was the name of my grandfather and the cubical position of 3033 or 3303. It took the admin a few days before she replied me that no name similar was noted at both the position. However she showed a two letter name name which she thought might be relevant to what I described. I grinned when I saw the name; the surname was the same but the name was “進” instead of the “进” which I sent. It was traditional Chinese vs simplified Chinese; my bad for not knowing some of the young Malaysian Chinese did not learnt traditional Chinese.

It was the first step of starting the journey. A further inquiry about the procedure and payment needed was done and I proceeded to the next step.

Sourcing the relocation site was not an easy job as I had set down a requirement which I considered as crucial.

The cubical would have to be at eye level; so that when we visit the columbarium we could have a good view without torturing our neck or back. The sourcing job had to be trusted to my sister in law. She had visited two of the memorial park around Kulai. Movie clips and photos were taken to aid our selection process. For the N memorial park, most of the cubical were purchased and only a few leftover. The new one was undergoing construction and could only be available by the end of the year. The leftovers were either to high( 4 meter up !) or located at a very strange position. 

The P memorial park had however provided us with more choice but most the cubical were meant for couple with larger space to contain 2 urns. We were considered lucky as there was still some cubical that met my condition.

The price was however a little bit weird; a 25% discount would be given if you paid by installment. If the cubical was to be used before the installment end; the full amount would need to be paid up immediately upon the cubical usage. In our case as we need to use it stat, the price would be RM26k. I was satisfied with the result and my bro had agreed with my choice. Prior to the payment, the staff had however offered a 40% discount to my sister in law and we had taken up the offer with grace.

The procedure had however involved 2 police reports to be done prior to the shifting of my grandfather urn. One would be done in KL and the other would be done in Kulai. The ashes was considered as remnant of the deceased and would be treated as control item; the police would need to monitor such process according to the law. The temple side told me that the police reporting would be done by them and my sister in law would make the report with the Kulai police station 1 day prior to the relocation.

Everything was set though and I would need to fix the day of travel….