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.