New year eve again...

 

I couldn't remember what I did during the new year eve ..... was I watching  the count down in the house or was I on call ?
I read back my blog written on 2006/12/31 http://blog.xuite.net/lywuu.ving/dayinED/9564324..

I was working acutally... and the shift is just the same....

I am sicked - sorethroat with no fever...
The ED was filled up with MVA victims...
I met some rude family- a mother complaint that her drunkard son was irritated by us during the management. The person had drunk a large amount of ? wine or what ever with lot of alcohol in it as he was having a very bad mood. How did I know ? he was grumbling about his bad luck in the ED when his mother arrived....

Group of young boys and girls who took a joy ride down south and fell from their bikes. Some told me not to call their families; they were afraid that their family would be worried displeased...

Well, I am going off 12 more hrs later - by 6pm 2008/1/1, hope I could make it in one piece.....I am tired and it reminds me next year I might want to stay home during the new year eve....

Not my specialty...

 

These 2 piece of  ear shit, ear wax whichI removed from Yun's ears 3 days ago...Well, I tried very hard to stabilized my shaky hand during the process...

 finally she let me do it...she had resisted it many attempts and I had tried ear drops but in vain and I am reluctant to do it...I am so afraid I perforated her ear...

well - it had been there for few "years"...well, I admit I am not a good daddy...

NSP - 2

There are 2 grades of nurses in taiwan - "護理師"(registered nurse) and "護士"( nurse)[I got the translated english terms from the ministy of examination, however I found the terms inappropriate)... There is this nursing class in this vocational school which run for 3 years (equivalent to senior high school). One can sit for nurse examination when graduated from one this class. The post high school education had divided into 2 categories mainly - the 3 years college diploma and 4 years bachelor degree program. Both are eligible to sit for the registered nurse examination. The only different is the entry salary when one work in a hospital. To be a NSP, one would need to hold a nurse license, preferablely registered nurse qualification. The nurse are graded into N1, N2, N3, N4 like the medical resident system. However, one does not get promoted on a yearly basis. A nurse start at the level at N0 and advance according to the CME credit and passing of relevant evaluation. The N3 is a very tough level, the N2 would need to present a paper in a public evaluation session organized by the society of nursing. An NSP should be at least N3 when she is selected. Most of the managerial nursing post also start at this level.

NSP - 1

How do a specialist care 20+ patient without help from resident doctor/medical officer ?

Unlike some big hopsital with trainning post - small hospital could hardly get any medical officer to work with. Even in hospital with 500 beds like my ex-employer has, attracting resident doctor to join is a matter of luck. The trainning post in Taiwan are so available even the prestige university hospital couldn't hire enough resident doctor. Approximate 15 years ago, there was a few hospital which was rich enough to get some prestige specialist to work in but unable to attract resident doctor as no trainning post was available(the hospital was newly setup and pending evalution). What they did was getting nurse to act as para-resident. Those nurses were named as nursing specialist a.k.a NSP. Since then, the job of NSP had started to flourish.  My home univerisity hospital was very against such idea and refused to set up such post. Later as the univeristy hospital expanded and unable to recruit new resident, they gave in and started to hired/trained such nursing personel.

The job/duty of NSP varies, some acted like a true resident, some acted like medical secretary. Frankly said, some of their duties were beyond the legal duty as a nurse. However the lack of medical resident had made the demanding of NSP risen. Last year, the bill of NSP act was passed and the NSP had become legal. The nursing specialist however is unlike those clinical nursing specialist in the US. It is more similiar to nurse practitioner. The requirement is less - unlike their counter part in the US, they don't need a master degree. All they need is a training in a certified training facillity for 6 months and passed a national examination ( MCQ - no oral). There is currently 4 NSPs in our hospital and none of them were certified yet.....none of them work under me, frankly said, I had 5-10 patient at any time and I could handle them with no stress....

a very bad call...

I had this bad call recently...no many patient in the ED after 12 MN. The ward was quiet...I had just admitted a patient to ICU by midnight. A case of hypoglycemia coma due to insulin overdose. He was fully alert after glucose infusing but his brain CT had revealed subarachnoid hemorrhage.

At 2:30am, the combined ED from the south call( the ED, I had part time before while I was working in my ex-hospital...). A nurse at the other end of line. I was told that the male patient had an intracranial bleed and presented to their ED with Glassgow coma scale(GCS) of 7/15. They asked me if I could take over the case. I saw the admission board. I had already + 3 beds in my ICU but still 1 ventilator left(minus the one in ED). I said ok and advice them to intubate the patient as his GCS was only 7/15. I got this answer," well, the patient was better after his arrive and we don't think he need intubation now...". Another standard crap-shit answer- I did not insist any further, after all is their call as the patient was currently under their care. Asking a nurse to do a referral over the phone is a very rude thing, but that is what they have done most of the time...

By 3:00am, the patient arrived and he was moved to the active resuscitation area. I saw the brain CT scan - rt putaminal hemorrhage with minimal mid-line shift. The blood clot esmitated around 50cc. However my nurse told me the patient's GCS was only E1V1M2 and he was not intubated. The family did not came along with the ambulance. The nurse told me they drove and would arrive later. I intubated the patient stat and sent him for another scan. No mannitol was given, only some steroid and fluid in the combined ED. My nurse started to curse .... I pacified them while waiting for the further CT scan. Well, intubation for my team is kacang putih( eating peanut , i.e piece of cake), but for those staff in the combined ED down south - it might be a very stressful procedure. Lack of training and on hand experience made their situation worst. I been there before.... nothing to blame and covering their ass is our job : afterall those case landed in our hospital would increase our bussiness. If they are competent and capable those patient might not have to transfer or stabilized and transferred further up north to Kaohsiung.

The follow up scan was worst. The bleeding had increased and the midline shift was more prominent. The younger son had arrived then. I explained about the patient's grave condition to the family. I told him, surgery was needed for this kind of bleeding but even if the surgery is done successfully and the patient survive the surgery; they could be facing a vegetative patient. The younger son said he had could not make any decision and his elder brother was coming from Kaohsiung. I told him, before they made any decision, I would proceed with my current management but the patient is definitely going to die if no ops is done. The patient was sent to ICU and by the time he reached ICU, I got this call again from the combined ED. This time the doctor talked to me over the phone. He told me that he had a patient presented with SOB and diagnosed as acute pulmonary edema. He had given her a furosemide injection and put in a Foley catheter. He said she was better and wish to sent her over. At this moment, I had only 1 ventilator in the ED left. I hessitated for 1 seconds and told him ok. I accepted the patient. My nurse asked me about the case and was worried with my decision. I told my nurse, I never trust their diagnosis, we should see what was coming to hit us and decide. There were a few times, when we  turned down such referral, they still sent the patient over to us - because the patients were too ill to make it to Kaohsiung.

 I saw the ICH patient in ICU minutes later and his pupil had fully dilated. I informed the condition to my neurosurgeon and he told me if the patient's son agree for ops he would come over. Later, His elder son came and I told him about the situation. He said that they would consider the option and would told me later about their decision.

By 3:40am, the SOB patient had arrived. She  was noted with mod SOB. She was a esophagus cancer victim s/p radiotherapy with gastrostomy done. I saw no physical sign which support the diagnosis of acute pulmonary edema when I examined her. The picture looked more like pneumonia to me. I grinned when I read the referral note - the doctor had given her furosemide but also infuse her with NS 1000cc !!!! Such a controvesial management....
The x-ray confirmed my diagnosis and she was sent to ICU. I did not intubat her as she was better on oxygen mask use.

At this moment, the ICH patient's elder son had told me that they wanted an operation. I called my neurosurgeon and informed him about the decision. 10 minutes later, the elder son came to me again said that they wanted a transfer. He said that the second son is currently working in Chang Gung Memorial hospital( one of the biggest hospital in Kaohsiung)  and wished to transfer there for ops. I gladly complied and called my neurosurgeon again. He was on his way then and told me not to worry about the change of decision. When I called the relevant hospital and was told no ICU bed was available. The ED physician had also spoken personnally that they should not go over as the patient would not recieved proper treatment.(fromt he conversation, I found that the second son was not working in CGMH after all, he work in one of the sister company only..).  After 10-15 mins of making phone call, the elder son had come to me and told me that they still want to try their chance there. I settled everything and was just about to take a nap, the nurse told me that the son had again changed his mind -  they wanted to go over to another big hospital in Kaohsiung. Again, I called the hospital and was told that no ICU bed was available as well. I informed the family and when the family was about to ask me to try for another hospital, I told them that our hospital was capable to manage such patient and I was not going to continue with the wild goose chase. If they wanted to transfer, they need to asked for ICU bed themself. They finally went to CGMH and tried their luck there. I doubt any ops would be done as no NSICU was available. The patient is gonna die as his BP was dropping before he left our hospital. The patient's son does not care actually - if they just wanted to make the event look nice: they had tried their best taking their father to a very big hospital....
Well, I hit the bed around 6:00am after I made a morning call for Ving and Yun....there was only 5 patient from 12am to 6am and I did not sleep....

fading job...anyone ?

There is a case conference every week in our hospital. Unlike those big big hospital which hold their respective department meeting/conferecent, we could only hold this combined case conference due to lack of doctors . The case conference usually follow with administration meeting. Last week, our deputy hospital director(admin) had told us that they planned to intake one of the part timer(who did locum for us during the weekend) to our team. In most of the rural hospital, doctors are reluctant to do night shift - especially ED shift. The law had required hospital with 100+ beds to have a 24 hrs operation ED. ED shift are stressful - paeds, surgery and medical....sometimes some O+G emergency may show up. In some hospital(as in ours), the ED doctor will need to cover the wards as well. A stressful job indeed. The pay is considered handsome in the rural area as one would be paid RM 100(non-taxable)/hr. A shift is around 12 to 14 hrs, so one would walk away with RM 1200-1400 per shift.But in the city, the pay is less and 1 night shift is around RM 500-800. A resident under trainning earn around RM 9k to 15k depending of the hospital they are working. A good side income indeed if those resident willing to do these locums. But as most of the training hospitals are situated in the city and the residents are supposed to report by 7:30am for morning meeting thence it would be difficult for them to do these locums in rural area and rushed back to their primary trainning hospital. Another factor which affect the availability of locum night shift ED doctors was trainning. Before the PGY1(post graduate year 1 ) training ERA, graduates start their specialty training as soon as they leave school - lack of exposure, now it is improving but not satisfactory yet though...the ED training was too short in Taiwan - 3 years only, I recalled weeks ago, there was this senior ED physician(professor grade ?) who replied a letter in the forum of the "Apple Daily"- He claimed that the ED physician training was 5-6 years and asked the public to trust their skill; all I wanted to say is 5-6 years my AXX...the bigger the hospital the more focus of its training in medical and surgery(not in the respective department but in ED itself) with the paediatrician and O+Glogist seen their relevant patients in this kinda of hospital ...to make the situation worst - such rural hospital would require night shift doctor to cover their wards as well...few were interested in such job in the past and now only some left... Those who moonlighting about this job could be classified into : 1. Residents who were very short of money 2. "Rover" - denied specialty training/examination : work in clinic/very small hosptial in the day light and doing night shift here and there .. 3.Specialist who was once in the 1st category but later unwilling to give up such skill and moonlighting once a while to see if he could still do it o 4.Specialist who was once in the 1st category and just returning favor / or don't know how to say no to their ex-night shift's hospital management. 5.Medical graduate without practicing license... They would need courage and extraordinary physical and mental endurance as deprivation of sleep is the major stress factor apart from the variety of patients. At the present moment, the resident pay is considered good compared to other occupation so only a handful of doctor wanted to join category 1. Those in catergory 2 are less nowaday and fading from the health care chain - do not have a wrong idea: these group of doctors usually make a very handsome income. Only a few left in category 3-4 as they came from category 1. The 5th category has the least member as the local health department has strictly enforcing the medical act. Just like Malaysia system, notifying the local health department while doing locum is a must and violating the rule maybe fined both the local health department and the general health insurance scheme. Notification should be done by the primary employer and the locum organization jointly so approval from your employer is needed to do locum here and there. All this restriction had made the locum bussiness worst. The part timer mentioned above is a "rover"... the management had asked me if I could adjust my current shift and I complied partially to their request....I was looking forward to it actually although my income may become less, but I might get rid of some night shifts. Unfortunately today, our offer was rejected and we were back to square 1... I am hoping one day, I could do only 1 night shift per week, my white hair is increasing in a great speed for the past 2 years....

the system.....

I don't like others interfere with my patient nor my treatment plan; but sometimes I can't resist them ..... Today the hospital the head of development section(HODS) had come to our resting room while I was having a chat with my colleague L....
He asked L if 2 of the patients could be transferred to ICU as the ICU a little bit empty..... The HODS is not a doctor but an administrative staff, why did he requested so ? ---> it is all about this hospital bussiness....

In the past when the General Insurance Scheme(GIS) just started - its budget was unlimited. All the hospitals treat their patient and claimed the fee from the GIS office. The GIS office then select some of the records and examined it in a very detail manner. If any drug/examination is inappropiate the GIS office would fine the hospital according to the ratio of the selection - if 1 records was selected from every 200 records then the fine = fee of inappropiate examination x 200. The hospital could appeal though but it would take months for the final decision to be made. At that time, if 3rd generation antibiotic was prescribed in  a small hospital there was always a 50:50 chance it would be deemed as inappropiate and appeal was needed to justified it's usage. So the small hospitall would tend to transferred critical patient to major hospital. And more transfer means the hospital was more incompetent thus jeopardising their name. The bigger hospital however enjoyed some better treatment - less fine and less appeal. Under this scheme, some of the smaller hospital could barely survived and shut down - this include some urban area and thos people who lived around would face the lack of medical resource as they had only 1 hospital around their area. The bigger hospital had developed into creature and consumed most of the budget. The GIS office has sufferred a great loss and the loss were filled by the government treasury. Finally the government decided to put an end and the GIS started the budget system....some sort like the British scheme. Each hospital were allocated a budget every quarter - if you get whatever you did as long as you don't exceed the limit, and if you did more than the budget you won't recieved more. So the hospital would like to do slightly over the target but not underdo it....
Due to the above scheme the hospital hired this HODS to push the bussiness a little bit....And from time to time, he would monitor our in out and "managed" our patient... I am just an employee: I need to comply to this strategy...

Anyway, I had this patient  X who was not the critical but unstable was "requested" to the ICU as there were 2 empty patient..later another patient had some complication during a pigtail insertion for pleural effusion was sent into the ICU... By evening, there was this 80+ y/o female who presented to our ED for generalized discomfort who I noted with a full bladder on examination. A cathether was introduced and urinary tract infection with leukocytosis was noted. I admitted the patient to ward and on the way up - the lab informed me that her BUN was 165 mg/dl and Cr 14.1mg/dl respectively...I hailed the patient in front of the lift and sent her to ICU instead. No sign of hyperkalemia and pulmonary edema was noted. I had a discussion with the attending nephrologist and no emergency hemodialysis indicated.
While I was writing order in the ICU, one of the nurse grumbled,"see, why transfered patient X(my patient - which was requested....) to ICU, see now we are +1...". I got a little pissed off...I told the nurse, " well, our HODS did not know this patient coming and he don't know that I would admit another 4 patients into this ICU for the next 8 hrs..."(just kidding in a sarcastic way, where could I find 4 critical patient ? actually what I wanted to say was the HODS is not god and neither me...)   +1 bed means more loading, but need not grumble, I dislike such situation as well....Only 1 word I would said- Lazy and attack of mouth itchness syndrome....I blame no one but this system : It took good care of the local people but the local people never appreciate it....

just when you think you know all....

We had this 60+ y/o uremic patient few days ago...He had been hemodialysed for a few years. He was also a known case of Diabtes mellitus and recieving control with insulin. Few weeks ago, a small wound over his left hand was noted and he had been doing routine dressing in our hosptial. His wound had worsen and he was admitted later. On D2 of admission, his BP crushed and gangrenous change was noted over his left hand extending toward his forearm. I was just about to go off by 11:50am, and the orthopedic surgeon called me and asked me if I could put in a central line for him... I tried and failed over 2 site - the rt int jug and rt femoral. As he was going to OT urgently for an amputation - he was sent into OT stat after 2 trial. I got the vein but was unable to introduce the guide wire during my trial. The guidewire went in half way and could not advanced. I seldom came across such condition - femoral vein and internal jugular vein are both big vessel - I cant explain such condition.... The patient went into arrest in the OT while waiting for his amputation, he was intubated and resuscitated after few minutes of CPR. He recieved an Below elbow amputation and sent into ICU for care. The CVP was inserted by the anesthesiologist.... The next day, he was planned for hemodialysis and as his AV shunt was done over his left upperarm, he was unable to used his AV shunt - a double lumen catheter was needed. Our nephrologist needed to put in a double lumen catheter - he had chosen the rt femoral vein approach which I had failed 1 days ago. He tried and met the same problem. Twice he had got the vein but just unable to introduce the guide wire. He than requested a heparin + NS in an 20cc syringe and flushed the venocath before he introduce the guide wire for the 3rd time - well, he succeeded - he told me the vein is ok but due to coagulopathy, sometimes the clot will formed instantly when the guide wire was introduced...so heparin would do the trick.... Although I had done so many central line - I learnt something that day...

is life so hard....

It was this post call morning... I was covering for the ICU and ED. There was this 911 call and the ambulance sent in this patient who was shortness of breath. I was wandering around the counter and saw this ambulance arrived. I went out with the ED nurse and the EMT brought someone down from the ambulance. An almost naked male. The adult around 30+ years of age, was wearing a shorts only - uncommon outfit for winter. Eventhough the southern winter is much more warmer than the north but in the morning it would be roughly 20 degree C. I asked the EMT for the history while helping to move the patient into the ED. The EMT told me he was found beside his car. He had parked his car "nicely" along the roadside and lay on the ground just beside his car. The EMT also showed me an inhaler. The patient was wheezing loudly - you can hear his wheezed without using stethescope. With the inhaler found at the scene, the patient is most probably having an severe asthma attack. He is confused though. The SpO2 was 99% and he was not cyanosed. He had passed stool on his shorts - very uncommon findings for an asthma patient who is still breathing. I ordered a neb and asked for an IV line with parenteral solumedrol. I wanted to give him a trial before I intubate him. I asked the EMT again about the shirts or pants he was wearing and the EMT told me they did not notice any around. I went back to the patient and he was drowsy and some yellowish liquid was noted around his oral angle. While I was auscultating, one of the nurse told me she smelled something like agricultural chemical. I had a bad nose especially in the winter. I took a good sniff and noticed there was this smell which is unusual. I pinched the patient hard and asked him if he had drunk any chemicals - the patient nodded. I didn't bother to ask the name and brand of the chemical, he was too dyspneic and drowsy to answer me....I then took him to the active resuscitation area and intubated him under sedation. His pupil had later started to shrink and pin point pupil was noted. I then contacted the local police station and asked them to have a look in the car. A suicidal note was recovered later but no bottle was found. I called up his mother and told them. He had lived 150+km away and worked around our area. We informed his mother and confirmed he is asthma status but his mother denied any factor leading to his suicidal act. The rest of the story was simple - ICU care, extubated the day after, and transferred to his hometown...
After he was alert and recovered from SOB, his physician had asked him about the chenical he use. He wrote down a name but we was unable to find the brand name. There was lots of such chemical in the market; the local manufacture had self packed such chemical and no registration was done. This patient was lucky, atropine was given based on his symptom..
The suicidal rate had been climbing since the past 2 years - lots of peoples facing finacial constratin and opted for suicide. Some even take their children along...a tragedy in such an advance society....

would you be mad ?

It was not an easy call....I was entering the ED door and someone outside was shouting, "We need a trolley please !". I saw a person in a orange working suit - looked like a coast guard; there was a green car beside him. I met one of the ED nurse sending patient to ward while I was walking toward the ED that means there would be only 1 nurse available. I grabbed one of the trolley and pushed toward the green coast guard petrol car. The coast guard open the back door and pulled someone who was wet through out from the car. A middle-aged male who looked cyanosed. I asked the coast guard how did they found him while we were transferring him to the trolley. The coast guard said he had fallen into sea at the port. I took a quick glance and noticed he was not breathing nor moving. While we passed the counter I told the counter staff to broadcast a code 999.
The patient was rushed into the resus area and Lem joined me there. I grabbed the laryngoscope, ET tube and BVM and intubated him stat. I violate the standard Intubation Sequence - no bagging, no stylet, no jelly. With limited ED staff - I had developed this skill...some may critised my technique but I could get it in successfully with 1 trial most of time...Well, CPR was commenced and asystole was noted on the monitor. However the difficulty to get in a line, 3 nurse from the ward came to help and unable to get a line. The patient vein look just like those IVDU but no prominent needle mark noted. I tried the rt femoral vein with a long veno-cath and got it. Then I walked out from the resus room and asked about the history. There were 3 persons who claimed themselves as patient's friend and 3 coast guard member. They claimed that he was sitting beside the sea port and fallen into the sea. The coast guards told me that they rescue him instant and not more than 3 minutes was used. I asked about the journey and they said about 5 minutes. I estimated the time was 10 minutes o.n.o. The patient skin condition confirmed the history. The hand and foot skin was ok. The body temp was 32 degree C on arrival. Eventhough the patient was rescued instantly but the responsed was bad. The first ROSC was noticed at 10 mins and lasted only 20 seconds. The 2nd ROSC was noted at 20 minutes and lasted for 2 mins. Then everything was flat line..I concluded the resus at 52 min. The body was warm to 34 degree...and I was sweating eventhough it is winter now...We used the heat lamp to heat him - we do not have the warmer for IV fluid....
During the CPR, I overheard the arguement between the friends and the coast guards - one of the friend had questioned about the coast guards fast and rapid transport to the hospital without doing any CPR. The friends said," if you told me that you all cant do CPR then I would do it...", the coast guard was trying to pacify him. Later when the patient's brother arrived, he asked me if any CPR was done prior to arrival and I told him the facts," I don't know as I did not see what happen prior to arrival." The truth ? - definitely no...Who wanna do mouth to mouth resus to a stranger but in fact they could do only chest compression CPR.....I think there would be a scandal if this incident was brought to the media...
Most of the govt agencies in the area don't do CPR for the DOA patient. I had encountered few of them who did so for their victims. Reasons :  incompetent senior...The senior member of these agencies did not perform their duties properly - they just packed and sent....so it will be difficult for the junior to follow....

Somewhere in my heart I hope this incident to be brought up by the media....but frankly said, I don't want to be involved in any scandal so better keep quiet...

1 day in Taipei part 2- medical ethnic/law/quality CME credits

it was a 5:00 am and I woke up...I had poor quality sleep then..

I took a hot shower and left home by 5:40am...The express way was empty and I had smooth drive and reached the car park by 6:10am. The parking was free as I booked the ticket through the net and paid with credit card. The car park is 10 min drive from the air port and a shuttle bus tooke me there. I reached there by 6:30am, checked in and brought myself a breakfast.

very expensive breakfast.....RM 8....

By 7:10am, I was sitting in the flight - taking a good nap. The flight touched down by 8:05am and it was darn cold in Taipei and luckily I bought my jacket. I took a cab and hit the Taipei World Trade Centre by 8:30am.

nearby is the 101 building...	the entrance..

 

 I reported to the desk get my tag and headed for the conference room. I thought it would be very packed as lots of people like me who came for the credits...but I was right and wrong. There room was filled up before it started and lots of people standing, but not of them came for the credits - the topic was EBM for traditional medicine; lots of researcher and chinese sensai came instead..

Most of the doctors were very senior - they came for the credits, as it was Friday and most of the doctors were working it was not that crowded as I expected.

 

I took a lunch at the nearby restaurant and headed back to the center. I took a walk the medical supply exhibition and I found this counter which was hosted by Martrade...but it was empty, the officer in charge must have other bussiness going on elsewhere...

I took a lunch at the nearby restaurant and headed back to the center. I took a walk the medical supply exhibition and I found this counter which was hosted by Martrade...but it was empty, the officer in charge must have other bussiness going on elsewhere...

The afternoon topic was more related to my current practice - > terminal care for the ill. It was a good one. By 4:30pm, it was over and I rushed to the airport and missed the 5:00 pm flight by 5 mins. But the flight was filled up so nothing for me to regret. I wandered around the airport and get on the 6:15pm flight as planned. The flight took longer than it should be - the plane cruised in circle for the last 5 min before it landed. I was darn worried, look like my flight phobia was getting worse....we landed in 1 piece and I got home safely(of coz...there is why I am here writing this blog...)

It was like dreaming - my off day and I spent it on this wild goose chase for credits....but with 2 credits short from the target, I felt more secure now.....

1 day in Taipei part 1 - medical ethnic/law/quality CME credits

On the day I brought Yun to ED for her swelling forearm. I was called by our secretary...She told me that the CME system had changed asked me how many medical ethnic/law/quality CME credits that I had. She was unable to assess my database as I had change my password. She showed me a circular and I was not happy after reading it...All of the doctors are required to renew their Practice License(PL) by 2009-4 and I will need 18 of the mentioned credits to be eligible for renewal.

The PL is something like APC (anual practicing certificate) in Malaysia. Unlike the APC, the PL is valid for 6 years. For renewal, those with specialist qualification will need 300 credits which was recognized by each specialty body. For the rest of GP, they need 180 credits. The system has been imposed for a very long time, until the SARS period. There were some doctors who refused to serve and took leave(absconded to be precised) - they said they were not trained in the field of internal medicine .. Such unethical act had later lead to the development of PGY training system. The Health department had also imposed a 18 medical ethnic credits requirement for PL renewal aiming to re-educate the doctors.

It was SARS period when I came back here. My PL was due in 2009 and according to the rule my PL will auto-renew to a later date which will be same as my specialist certificate expired date( 6 years from the day I passed )which is 2012 - a long long time before I need to gather my 18 credits. Unlike other CME - the ethnic credits were very difficult to get. The session is usually 1.5 to 2 hrs per credits. Each session is only 1 credits only unlike other credits which are 2-3 hrs/5 credits. I though it was a long way to go and I had 7 credits for the past 4.5 years. Averagely one should have 3 credits per year...The latest rule however had changed and I had a death line of 1.5 years to get my 11 credits...a short time for me to go for a big load of credits...

It bothered me a little when I heard the news...and when I reached home and I arranged my stuff. I saw this letter from the medical associated which had arrived sometimes ago. I didn't bother to open it and I opened it and my  problem was solved. There was this annual conference on Fri, Sat, Sun and it offered 9 credits per 6 hrs in 1 days. But I will need to go to Taipei...I was off on Friday and what the heck...I decided to go...I will have 16 credits after this conference....

Common condition, but uncommon patient...

7 yrs old girl with rt forearm swelling after fell down in the school yesterday afternoon...

common history and obvious xray....I was the ED doctor but the patient was Yun.....

I was on working that day and due for home on next day noon; Ving called me and told me that Yun's wrist was swelling after she woke up from her afternoon nap. She was playing and tripped over ? bar. She is due for her 1st exam the next day and she went to played in the play ground during her recess time...I grumbled a little and asked detailly about her injury.... Ving told me that the swelling was over the "wrist" side and it was ok when she arrived home...I thought should not be any fracture, fracture at the wrist side mostly cause instant swelling. I told Ving to gave her some syrup panadol and ice-packing. The pain was better but the swelling did not improved.
The next day was her exam and I went off at noon. It was Tuesday and she was went off by 3:00pm. I  told Ving that I would go to the school and had a look of her injury. When I saw her she was preparing to take her afternoon nap. I nearly fainted - the swelling was not over the wrist but at the distal third of forearm and it looked deformed...definitely a fracture. I took a leave for her and brought her room. We changed and brought her back to my hospital. It was one of the longest drive - I was post 24 hrs shift and took a 30 min drive from hospital and now returning to there again.
As I had expected - the xray showed a fracture : luckily was a greenstick one...I brought her to the ortho OPD and referred her to my colleague. My colleague suggested a cast with a slight CMR(Closed manual reduction)...Yun was lucky as the next cast(which was much lighter and does not required a cutter for removal had just arrived 1 hrs ago). Water resist pad was also use to prevent itchness...I was dread tired that evening...but everything was worth....I considered Yun as very lucky - at least no pin required.

I recalled the fracture I had 30+ years ago..,...I was studying in Kindergarten. There were 3 of us. We placed ourself inside a hula hoop: and started to run. I fell and knocked over my left elbow.. instant swelling and I was brought to local hospital and later referred to Assunta hospital. An ops was done and closed reduction was made...I was put on cast for the next 1+ months...The cast was those traditional one, darn heavy and the itchness was so stressful....I am happy Yun did not have to undergo that...

Disaster exercise Final day

I got a good sleep and we arrived at the site at 9:30am

on the way to the airport, there was this piece of paper who flied and stucked itself over the windshield and wiper...it was "golden" paper for the death... what a bad start for the day...

...The drill started by 10:20am and ended by 11:30am. I was told by the sister in charge of my area that another doctor would join me in the afternoon during the final presentation. I was a  little pissed off - the doctor who would join us was from the govt hospital site, appearently, he was on the list but decided to appear on the final day only. For us not from the govt site - we did not enjoy such luxury --- from D1 I was there... we would told need to be there for the whole 3 days !!!

The national DMAT(southern region) team ... Medical tent : double layer..and fully equiped...	The national DMAT team in their uniform... they are based 170+ km away from this airport...

the is the last drill - we were given some matress and even strecther for transport... the right tent was the red zone - more severe patient... it was manned by the local DMAT team.

this was the small room we waited before we enter the scene..

The final presentation started earlier and it was over by 3:00pm - I was very tired then , even though I had a good call last night...

This was real action scene...

 

This was the XXX part - we were requested to gather around in row and "listen" opinion from 2 evaluating officer. One of them is a Colonel - deputy division commander, the other one was ED director from a prestige hospital. We looked like primary school students - standing under the sun for a good " lecture"...

Finally at the end of the day, I saw rainbow...what a day....

Disaster exercise D2

We were there by 9:30am as ordered. By 10am, we were informed that there was a change of plam. We would enter the scene by running in instead of sending in by ambulance. They had prepared a room for us - store room for airlines just beside the boarding gate. Luckily it was air-conditioned, evenif it is now autumn day but very windy around this area,but still southern part of this country could heat up to 29 degree at noon.

There was a drill in the morning and by 11:00am, the lunch box arrived. We took our portion and waited till afternoon for the 2nd round of drill.

	this is the medical tent for the moderate injured patient - no bedsheet, no mat for the patient to rest...
	more waiting time - you can see the famous buddist organization was also requested to participate...

 

There were patients for us to manage at the afternoon drill, but somehow the organising committee was not satisfy and called for a 3rd drill. It was 3:30 pm we were reluctant to do it...according the schedule there was only 4 drill prior to the final presentation. The last drill was over by 5:00pm and I reached hospital by 5:50pm barely made it to took over from my colleague. I was cursing on the way back as the committee had anounced that we would be havinv another drill tomorrow morning - according to the schedule, we would only need to report  by noon for the final presentation of D3.....

The stage	The tent for "black" bag....

The call for the night was extremely good - there was only 1 patient at 2:30pm from 12MN to morning 7am...I got a good sleep.

Disaster exercise D1

It was a good call for me, I got a good 3 hrs sleep...

We arrived at the scene at 9:30am....reported and took a seat the waiting lounge...
A short briefing was done and the leader frome each unit were called to the meeting room. As the doctor, I was supposed to be the leader but I "asked" one of my nurse to took the position...
The rest of us waiting at the lounge

	These were not flight passengers - I thought they were initially. They were local residents who was called to act as casuatlies(I heard they got pay a few hundred NT per day for the act).
	The briefing
	1 hrs post reporting - waiting...
	2 hrs and still waiting...

 

By 12:15 noon - the lunch box came...we took a lunch box and fill up my grumbling stomach. By 1:30pm. The drill started. We were asked to sit in the ambulance and waited for command to enter the scene. 16 ambulances from different unit waiting at a corner. The engines of all 16 ambulance were running producing enough pollution and what a waste of petrol. I slept in the car for 40 min and we were called.

we were standing in the air field, under the sun...	16 ambulances...I wander in an actual disaster could me mobilized so many ambulances in a short time ?

 

Later we were gahtered to the lounge again and change of plan was done after a short meeting(and waiting time for us of coz). By 4:00 pm, we were dismissed and I returned to my house in a very tired state...

Disaster exercise....Prelude

There was this worst earth quake in 1999 Nov 21st. Casualties and loss of properties beyond imagination..The govt had started to set up their disaster response system based on the US version. But thank god, it was never initiated. The most recent natural disaster was also an earthquake which hit the southern part of taiwan( approx. 70km from my house.) happened on 2006-12-26. I was doing my passing over in ED then.....Some building collapsed, and some life lost...

10 months later, the local govt had decided to do a drill for this earth quake scenario...I become part of it...my colleague was supposed to attend it but as he was sitting for his EM board exam, I took over his place instead. However the exercise was postponed twice and it will be officially done tomorrow. For the past 2 days, I had been to this airport which located at the southern part of Taiwan. It is actually not suitable to deo it in a small airport - but this airport is hardly use - 2 flight per week and sometimes flight postponed due to strong wind. Any small object in the run way might cause a disaster...Anyway, it was done there...

I went to the exercise with 2 nurses+ambulance+1driver. I was the in charge of the yellow area(mod-light injury). The exercise was organized by the county health department. But the army, the national DMAT(south) and regional DMAT were also involved. ...

It was a disaster for me though, the exercise was 70 km from my house, 50 km from my hospital. I will go to the hospital and joined the team and travel to the airport by hospital ambulance.

The schedule for me is terrible....:
Mon night on call
Tue AM - pre exercise 1    PM - pre-exercise 2
Wed AM- pre-exercise 3   PM - pre-exercise 4   night on call again
Thr   AM- pre-exercise 5   PM- official exercise (I will be 34 hrs at work when the exercise over...)

I hope tonight will be smooth...

Relief...

Examination...

My colleague went for this ED board exam lately....The result came out and he failed the written test..for the psat few months, he had been studied very hard. I felt sorry for him but it was a relief for him as it was his last trial..

There was no society for emergency medictiine 10+ years ago. Unlike the states or UK, the professional bodies are not named as Colleges. They are called the Society- but they function just like the Colleges for specialty. Most of the Societies practice the "closed system" rule, that means trainee will need to "served" in specific department of certain hospital before he is eligible to sit for exam. There were not much trainning position intially for EM. However it was unlikely to request those ED attending physician/trauma surgeon(who was trained in other specialty and later focus in EM) to go for the resident training program. So the Society of EM(SEM) had allowed those senior doctors who worked in ED for more than 2 years to sit for such exam, but there was a deathline for such exemption - year 2007. I returned to Taiwan in 2003 and I could not fulfil the criteria set. The only way I could sit for such exam was to joined a EM resident trainning program. I was thinking of such option earlier. But the life in ED was so unstable. Although I had the luxury to work 180hrs/month(15 working day),  but I could mostly get a straight 2 days weekend off once per months. As both the kiddo are going to school, spending weekend with them are crucial. In addition to this leave issue, I found that straight night shift for 3 days was my limits. I need few days to recovered from a straight 4 or 5 days night shift. ED life just not my cuppa of tea. That was why I chose to move back to physician life...

The EM resident training program is 3 years unlike the 6 years of British system. But the exposure for EM trainee is inadequate, there was this O+G and ENT, eye attachment, but the duration is short. The EM trainee were unable to master the skill. There was this rumor 1 years ago when my ex-colleague sit for the SEM exam --- The trainess from big hospital stayed in the same hotel 1 night before the exam and they switch questions(provided by their department). As I stressed - it was RUMORS....

I remembered we had this chat with the Consultant Radiologist of Perak at the time I served in Tanjung Malim KK. He came down to "lecture" us for doing Xray for death person. The MO from the hospital side was responsible for the post mortem. Some of the MO just ordered Xray (?skull) for those corpse and the radiographer was pissed off to do so and reported to the Consultant radiologist. He was unhappy with such incidents and came down to give us a good lesson...
It was a Friday evening, the consultant came down with his kids and wife on his car(appearently he was going to KL and claiming part of the mileage..) and give a talk for 15-20+ mins. He described us(doctors with no specialty) are called" Jack of all trade but master of none) in a very sarcastic way. way he talked made me felt that I was one who do not wan to advance...that was another story...

In my mind, an EM physician is more than that - he/she should be Jack of all trade and Master of many(if not all) trade...

shit in the hole

This is a patient who admitted for NKHS, septic shock , pyelonephritis....He was intubated intially and noted with acute renal e failure. Hemodialysis was considered for him once - but he managed to recovered and extubated. He was planned to be transferred out ICU when he was noted with fever again. A red patch with local heat was noted over his rt flank. The cellulitis than worsen and abscess was form. No I and D was done and it ruptured. Initially pus was noted then brownish substance came out form the hole - substance same as what came out from the ASS. He had went into respiratory failure last night due to sepsis and was intubated.
Well, a GS consult was done and no indication was ops now. The surgeon told us to put on a bag and treat it as a colostomy while waiting for his sepsis to subside...

putting on colostomy bag	closer look

Needle, needle...

I had this influenza vaccine on 4 days ago. All medical personnel is entitle to a free vaccination yearly. Few year back, when the SARS hit Taiwan hard, Influenza pneumonitis had been one of the major differential diagnosis and since then. The Dept of Health has offerred such vaccination to us to make the differential diagnosis narrower.

However, I had missed my shot since the beginning of the free offer. I had many reason - no definite protection, may have severe symptom.....etc. But the major reason is I am darn affraid of needle. I hate being pricked. Eventhough Ving had grumble over this matter with me many many times - I still refuse to take the jab.

This year, I changed my mind, I had this bad flu few months ago where I had this severe headache...I decided to take the shot this year.

Well, the injection technique of my nurse was good. Slight pain when I was pricked. I had this severe muscle ache and easy fatigue since then. Yesterday, we went to this shopping mall for few hrs, and I got home and unable to walk due to severe muscle ache(not over the injection site, but whole body) ....I hope it is worth the price.

CPR...

I went to this CPR course tody...

I was SJAM instructor during my service there - CPR was one of the main course I ran. 1 months ago, the nursing supervisor asked me if I am interested and I gladly complied.

The course was designed for Form 4 students. The education ministry has set the rule that all high scholl student should possesed CPR cert to graduate. So There were 140 students and I went there with 7 of my nurses. I did the main lecture and each one of us took 18 students for practical. It lasted for 3 hrs and the pay was NT 800 and a big cup of tea....

	The drinks -800cc cup of tea.(sweaten of coz..)
	Students doing the written test..

Paraquat survival..

This is one case that misleaded me...

This middle-aged female had presented to ED 1 week ago. She c/o sorethroat and running nose and others flu-like symptom. I took a look at the mouth and noted some blister and oral ulcer, the throat and tongue was also involved. She had mild fever as well and told me that she was seen in local clinic but in vain. I did a blood test and white count of 16000+ was noted. I admitted her under the impression of flu. 3 days ago I seen her again in ED and showed me a referred letter from a medical center. The cousin who came with her told me that the medical center said that she had no sign of agriculture chemical intoxication and was ok for her to get admitted back in a smaller hospital. I was confused while glancing through the referrel letter(it was not a referral letter - more like a lab result). The medical center ED did a cholinesterese test for her(it was normal).

I asked the whole history again and was irritated by it. Appearently, her oral ulcer has worsen the next day and the attending physician( my senior, nephrologist cum toxicologist cum infectionist ...a Malaysian as well) was suspicious about the history and asked her again"properly". She claimed that she had drunk some Paraquat ! 2 days before she was admitted. Due to her " paraquat" history - she was referred to medical center for further evaluation.
But I don't think the medical center ED buy her story - no urine paraquat test was done. I didn't buy story as well...I has seen lots of paraquat intoxication(mostly in Malaysia) - well, a very very very toxic chemical - there is only 1 survival I seen so far. A Malay Chap who had an arguement with his father about his girl friend. He took a bottle of paraquat and put it in the busket of his Honda cub and rode away. His father chased him from behind and rammed his bike to stopped him. Unfortunately, the bottle spilled and few drops went into his left eye, few drops into his mouths. He was admitted for 3 weeks and lost 1 eye sight with discharge with severe pulmonary fibrosis...This is the only survival.
I had met a few paraquat intoxication here - unlike the Malaysia paraquat which smelled like X%$@...  the paraquat here does not have a strong smell...
Back to the patient - she was then discharged from the medical center after the cholinesterese test was normal, and negative of urine paraquat test.  The oral ulcer has worsen..

D4 oral ulcer	chemical burn all over t

Me and my senior favor a corrosive injury rather than paraquat...

The cause of suicide  - Some misunderstanding with her family... This is one hell of the patient : she has this fulminant hepatitis few months ago complicated with acute respiratory failure intubated and ventilated , acute renal failure,  - she just got back from the gate of Hell/ (or maybe Heaven..) but chose to give it up due to some minor cause....

conjunctivitis

There is this conjunctivitis epidermic going around north and central Taiwan region. There is a few case here and there lately around my vincity. According to the Taiwan CDC - the causative agent is Coxsakie Virus.. but so what - the treatment is the same...prevention might be more important..

I had this red eye few weeks ago when we were cleaning our house - some dust has gone into my eyes and I had this allergic conjunctivits. I had to too some antihistamine to ease the itchness. And sicne then, my eyes itches easily from time to time.

I deeply pray I don't get infected....I am not worry about myself, but my 2 kids and Ving...

abscess..

The lung abscess ah mah came back for admission - due to fever and vomiting... I had done a CT for her, it looked better. I had re-started her on Tienem and no fever was noted. In fact, she had also had UTI - I think the fever is more due to the UTI. I had shifted down to Unasyn today after 3 days of Tienem..
My another lung abscess patient is better and the family had agreed on tracheostomy - I  would complete the 4 weeks Tienem course and transfer him to Respiratory care ward later.

The ah mah lung CT..

3 weeks ago prior to treatment	after treatment

 

Lung abscess...

It was 1 years ago ... I ended up with Lung abscess during my internal medicine board exam...I did ok....I was finally back to the lane of physician and ended up with 2 Lung abscess lately...

There is this Pan-Citizen Health Insurance Scheme here in Taiwan...People need only to pay a monthly fee and enjoy it...However for admission - there still need to pay 10% or RM17000 maximum of the In-patient medical fee. However if the patient is admitted more than 30 days, they will need to pay 20% and 60 days - 30%...I have this lung abscess patiente, who was lucky that she was not intubated. But she had been admitted for 50+ days and I had to discharge her under family request...today the family called me up and asked me if she need admission again as she was having mild fever. I told her that she should but as she had only been discharge for 7 days her medical fee payment will be set at 30%..   only if she admit after 14 days than her medical fee payment % will be 10% again....I hope she could hold until that day...

I had another lucky and not so lucky patient - another lung abscess who was intubated - as he had been intubated for 21 days, his medical fee payment is 0%...he is now better but we were unable to wean him off the ventilator was noted. He will need a tracheostomy instead - yet another difficult situation...

Both of them were on Imipenem - imaging the cost of antibiotic...no drainage was done for them after discussion with family about the risk...

I am not frustrated - it could be worst in Malaysia...

 

1st step - ECO way to work...

day to work with train..
The train station was 10 min walk from my house. I planned to take the train to work earlier this year but never succeeded, mainly due to 2 reason : 1. the time is not that suitable , it is either too early or slightly late.     2.the size of my strida eventhough is small enough still exceed the limitation of luggage size allow in train.
But as the car saleman was due to deliver the car that afternoon, I took the train instead. It was 6:34am. I got up early by 5:55am. And took my Strida and it was a 5 min ride and 3 mins putting the Strida into the bag. A lots of Strida owner has successfully took their Strida onto the train without trouble despite the luggage size limitation provided the Strida is properly packed. So I packed it and bought a ticket. The train station officer did not stop me and let me through. I think it will be ok for me to take the train to work every Friday..so it was a good beginning.

The train ride was 43 mins, it stopped at every station. I took the last row seat and placed my Strida behind me. I read a novel and reached my destination by 7:17am. The station to my hospital was a 10 min ride.

Cons: I couldn't bring my laptop to work..but I will be buying a desktop for my office later....

	my Strida waiting for its 1st train ride
	non-express train with the basic seat..
	Strida resting at the back of the cart.

 

commitee....

I was “invited” to this patient safety committee as committee member few days ago. Well, “patient safety” has been a very important issue for the past few years….The hospital evaluation scheme(HES) has focus on this feature since the starting of the new evaluation scheme 2 years ago.

 

Well, a boring afternoon – most of the agenda need not to be discussed by whole bunch of member… It started by 12:30 noon and by 1:50pm I slipped and went to my OPD session. It dragged on till 2:40pm I heard.

 

But I was assigned to a specific issue – the past over record. Most of the past-over were done verbally in the past. Mostly MO to MO and sometime Specialist on call to Specialist on call. But now the HES required us to show record that past-over has been done. Well, more paper work again. The nursing director has told us that one of the big hospital is doing it over the  computer. There is this section in the intranet and MO will logged on and key in those patient that need to be “really” past over. The MO and specialist on call will than logged on to the net and tabbed on it meaning that they has seen the record.

 

Well, look like we need to do something similar…I will need to discussed with my cardiologist (still back in Penang and coming back today…he another invited committee member) and implement it within few weeks…

busy....

Nothing much happens after the assault incident. Busy as usual – the calls were bad, but I could still hang on. Then it was this 4 days continuous Mid-Autumn holidays, I had a break and a holiday far south. The weather was bad and I was wet most of the time. Back to work yesterday and I slept a solid 4 hrs without interruption.

 

I had 8 patients under my service now. 1 of them intubated and stranded in ICU, he is recovering from his pneumonia but I doubt he could be successfully weaned off from ventilator – he is too weak, albumin only 1.9….I am feeding him with some high cal/protein diet, hopefully he won’t ended up with trachestomy.

 

But my life is busy still – our cardiologist mother passed away last week and he is backed in Penang and will only come back on Saturday. I had to cover his OPD and this occupy some of my free time.

 

Next months, the earthquake drill will be on and they scrambled the drill into 3 days only. 4 pre-drill in 2 days ( AM+PM each) then 1 day for the Monkey show…

darkest day...

This was one of the darkest day for me.

I had a bad day intiailly – broken pipe in the house and was disturbing me…then that was this incident that happen during my call….

It was in the evening, there were this group of youngsters who came in to ED- the casualty was jumping. A 16 y/o girl with rt ankle swelling after a fall. She did not stand properly after a jump. Possible sprain I think. There was a crowd of patient then, a tall like young male who brought her in told me, “ lets take xray first …” His tone was not polite and I returned him, “ then what more exam did you want me to do – do you wanna teach me do thinks ?”. I was a little irritated by this guy – I haven’t examined her yet. I proceeded with the examination, then I ordered a xray. No fracture was noted and I chatted with the patient – she is staying in the hostel and the guy was the coach (national service man attached to school).

Since there was no fracture, I intended to discharge her - but as she was not adult yet(16y.o)...I need to inform her family -> at least tell them about her condition. The girl gave a mobile phone no. which belonged to her sister - but no one answer the phone. I asked her again, if she had any other contact no. she said she forgot - appearently another victim of parents divorce, or else she would give her father phone no. without me asking. I did not bother about ask but someone who look much older(early 20+) told me that he could contact teacher for me. He dialed a phone no. and passed me that phone -

 

teacher B : " now tell me what is the condition..."(still smiling tone)

Me:"well, no fracture and ......(explaination)...but I could not let her go yet, since she is under-aged I need to speak to her family"

teacher B :"I am very close to your boss(hospital director). just let her go..."

Me: "I cant, I need to do accordingly, and don't push me around in the name of my boss"(I was a little bit irritated)

teacher B :"you tried to give us a hard time.."(harsh tone")

Me:"No , I am just trying to do me job.."

teacher  B:"....(angry words..., tell me what is your name..., I am gonna come to you tomorrow.."

Me:" I am Dr XXX, I get off at noon...I did nothing wrong and you can come..."

 

The conversation ended as he was yelling and I just didn't like to hear it and passed it back to the senior person. Later I asked him if he could get the hostel supervisor and checked on her phone no. so I could call her parents - and that teacher called again and yelled some very bad words -again, I passed it back. I was so damn frustrated and the senior person told me that he is the trainne teacher and I asked him to sign a notification that he would responsible for her and let him brought the girl back to the school hostel.

 

About 1 hrs later, the teacher called again and this time, he told me he is definitely coming over to me and asked me to "wait" for me...I hanged up and called up my hospital director and told him about the situation - he told me to "watch my back". I didn't pay attention until the next day...at the moment - three person is involved - the coach(national service man attached to school) A, the trainee teacher C, the retired teacher B.

 

 

The A,B,C did come the next day(post call for me, I worked till noon) - and plus another 3 person, 1 is a currentl school teacher D, another 2 look like bully ( fat - fatter than me...)...They came and talked with my hospital director and service manager(he is the local who is somewhat influencial). But both of  them were not able to talk them out - I was busy in the ward then. Then my hospital director came and told me that he need me to go down - I actually told my hospital director that morning that I would face them - I started it and I should stop it...

My hospital director told me in a heavy tone,"I cant stopped them and they had promised me that not to use force if you faced them." I grinned and told myself - no force use my ass, they definitely would try to assault me. I was prepared - nope, not to retaliate of coz, to be bashed. This kinda people woukd not rest if no force is use - I would not fight back - but would try to cut the injury to minimal.

 

I met them, and greeted politely and apologized stat - but B was not satisfy - he said apologized is not enough and told me that he would like a room and have a talk. While me walk toward the room - one of the 2 bully charged toward me and kicked me on my rt knee. A small kick and I fell on the instant ( just like those football player who was tackle...) and sat on the floor and pretend looked painfully.... Well, no one came forward to gave me another tackle( actually our service manager restrained them from further attack). Even I am prepared for the asasult, I still felt very bad, not the pain but just the feeling ... I then get up and walked into a room with them - B started to yelled and claimed that I am unethical and some bad words - I apologized and them seem not that satify - and I was fed up and told them - I said if not enough, then I kneed la...and they stopped me from doing that and go away..

 

It was a bad experience for me - I was assaulted and I had to played like a person who had done a lot of wrong things. But, I had all the evidence, I had a medical report, I had a recording of the yelling and now is my chance to call the ball. But I won't use it - maybe later. Police report or complaining to the school might irritate them and further jeopardized the hospital....as the chinese proverb : you experienced one incident and you gained more wisdom - I am cool now, I might need to be more polite and don't "bashed" patient/family with words.. But, I would still insist on speaking to the family for under-aged patient...

PS:

1.the school is the local high school.....

2. I really like to report to the police about this KNNACB retired teacher(he was the former school PT head.) but to create such trouble to my boss in the future[legal suit, as he was the witness as well] - I will think infinite time before I do it...

3.Curse that KNNAOCB  teacher trainee and NSM coach - they should have call the current PT head instead of that retired Old ASS kisser/Fucker.

 

working in the house ?

Back to work after a 3 days off...I did a short round for my patient on Sunday and settle some of the problems, so I need to a minor catchup only. I enjoyed weekend and off but when you come back to work, need to catch up on my patient condition. It is a stress if lots of admission. I got only 5 patients under my service at the moment. And the best part working in this hospital is I could assess the hospital management system from my house remotely. I could assess almost everything(even the xray/CTs), minus the TPR sheet of course. But I just couldn't work as SOHO no matter how good is the system, is against the law to order anything without seeing the patient.....

 Well...is a stress to place patient under my service, not only need to responsible to the patient but also answer to their family...so far I have met no malignant family...

I has started to don a lab coat nowadys - too many things to carry along: steths, sanford, penlight .... However instead of the usualy long one for attending physician, I use the short one (mostly worn by medical officer/resident). I just couldn't bear the heat - the long ones are mostly thick one, the short one has think and thin version. Luckily it is autumn now...I sweat less...

tired

Calls were bad lately - even when the ED was cool, I was bothered by the ward from time to time.. my last call was worse, I came to work in the evening instead of noon - boss when to Canada to settle his daughter's college matter and I took over his ED shift. It was still a 24 hrs job but I started at 6pm. It lots of different from 12-12 shift, you just can't simply sleep first to prepare youself for call starting from 6pm. So I was darn tired after this 24 hrs shift. I slept by 10pm yesterday when I reached home.
I still felt tired today and I can't rest properly tomorrow after my shift - my LCD TV would be installed by noon tomorrow and when I reached home - I would need to re-arranged the TV table and those cable from TiVo, DVD player, X-box......

Actually it is a tiring month - my work is disturbed by this earth quake disaster exercise - 2 weeks from now. Disaster medicine was one of my interest and when my deputy pengarah asked me about attend it, I gladly complied. I hope to learn some from this exercise. Next year, I will be sitting for the disaster medicine specialist exam - it is not an official specialty recognized by the local govt- but I considered it as a personal interest..

drill...

This months will be more busier than last months…

 

I got to attend a earth quake disaster drill organized by the local county authority…The drill will be attended by the county chief so it is considered as one of the large “show”. There will be 4 predrill and final show will be 3 weeks from today. I am one of the 3 medical officer who will be in-charged of the sick bay….Well, more working hours this months.

 

 

 

This part of Taiwan is considered as one of the least earth quake region. However months ago, the was a big earth quake which had a magnitude of 6.0+ on the Richter scale. Only a few casualties but it made the local govt. panic. So a “show” is put up.

 

 

 

I had been to similar show before – not that realistic. I don’t see how it could improved the medical shortage around this area. The nearest DMAT is 100km away from the point. I think it will be wise if the a local DMAT could be set up. But again – doctor shortage is the key element.

 

 

 

Well.. more report on such event – the 1^st pre-drill is scheduled on this Friday….

happy birthday - my beloved country...

it is the great day again...

I had been telling Ving that one of the 831 I would like to stand at the merdaka square joinning the crowd for the glorious moment - Ving just told me to stop dreaming...indeed, it become more difficult for me to fulfill my dream...there were always something disturbed my merdeka square journey...now, with Yun going to primary school it had become impossible - in fact this is day 2 of her primary school....I was thinking to enjoy a day off but Ving told me that better go working and earn some cash (46" LCD here I come...)

The end of my 1st months as a physician - a completely different life as a ED physician. More responsibility - now no more hit and throw patient to other people service...Patients are placed under my name, I got a table in the attending physician office(in fact I still spent most of time at the old call room : 175). 175 was the ext no of the ED call room, I had been this room since 11 years ago. There is a TV and now, I got a internet line here...So I felt more comfortable here than the office..Did I enjoy the life ? I am adjusting myself actually, but the 2.5 days weekend off cheer my life up. Spent every weekend with the family is something enjoying.

Today, while I was doing the ICU round, my cardiologist walked in and I greeted him "morning". Surprisingly, he spoke the word" merdeka". I grinned at him and raised my right arm and answered" merdeka" - well, at least it cure my home sick...half of the doctors in this hospital are Malaysian - all of us love the country....happy birthday Malaysia...

A patient who helped me with my viva...

This is middle-aged male who presented to ED with palpitation...average Taiwan aborigine.

 

 

 

I first saw him during my 1 years of practice, I was in charged of the emergency department then. Below is his EKG...

 

 

 

 

 

My spot diagnosis was PSVT then- usual antiarrythymia drug was given and he was discharged later. He had multiple episode of attack and most of the doctors in our hospital saw him. Sometimes - procainame works, sometimes verapamil work, however his symptom was settled most of the times in the ED. Until one day, he was seen and managed by our cardiologist and he was diagnosed as WPW syndrome. I smacked my head when I saw the cardiologist's note written at the front page of his case note - I missed it...A little embarass for a graduate from my college - during the our school days, there was this topic special on this WPW syndrom, an old professor who was very specialised in it. Well, so the verapamil was off from the antiarrythymic arsenal for him. I recalled there was 1 time when I had tried every drug I had ( minus adenosine - it was still a rare drug then). So I took my risk of giving him a dose of verapamil and successfully reverted him to sinus. But some of the doctors still refuse to do so and few times he was referred to a bigger hospital and got admitted.

 

For the past 10 years, he had seen in our hospital for 200+ times. The cardiologist had suggested him to go for EPS and ablation but he refuse. To make things worst - he had bad veins. There was a few times when I need to insert a int jugular line for him.

 

 

 

Today he came again...now he had developed atrial fibrillation - he had presented with the same old symptom - palpitation. However the EKG shows atrial fibrillation with short run VT...I load him with 300mg of amiodarone parenterally and his rhythm was reverted to sinus after 20min...he was discharged again.

 

 

 

This patient had saved me during my viva of the internal medicine examination. The examiner displayed an ECG through the projector and I did spot diagnosis - WPW.