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.