New year's joke and jokers...

There was this female patient admitted to a local regional hospital for facial cellulitis. She is a k/c of diabetes mellitus and hypertension. On D2 of admission, a computer tomography was done and the doctor (? infectionist) had told the family that a great amount of pus /a.k.a abscess was noted in the face and debridement was needed. Unfortunately no plastic surgeon was around and a referral was needed. 2 place was offered - another regional hospital and a medical center(medical center > regional hospital > area hospital) . The family opted for regional hospital as there was bed available. The patient was seen in ED and later admitted to ward. In the ward, the atteneding physician/?surgeon saw the CT and told the family that massive pus is also noted and debridement is urgent and warranted but again they were unable to perform it. So the patient was again referred to the medical center. As no bed was available - the patient was placed in the observation ward in ED. However in the observation ward, the oncall CR told them that only a samll amount of pus was noted and no surgery was needed...

Facts of the day -
1.Physician/ Surgeon cannot read CT without the radiologist - the medical center had 24 hrs coverage of radiologist and the smaller hospital did not...

2.General surgeon trainning is not sufficient - I+D of face could not be done by a board certified surgeon(general)

3.The doctor cannot differential diagnose an abscess from a cellulitis -( or maybe too cold this few days - the doctor thought that the abscess will be iced and stoney hard on palpation...?)

well - there is still someone who earn something in this case - the ambulance driver... 2 referral cost the family at least NT 5k....

this happened to a friend's mother......last night.....

anyway  - happy new year....

Taiwan Medical Grad in Malaysia....

 

I met with one of my old classmate 2 days ago. GSW had been my classmate since med school. He is a Sarawakian. Unlike most of us who get into med school after high school. He was from govt school stream- completed form6 and work as a temporary teacher with the Ministry of Education. He had then come to Taiwan and study in the pre-U course . He gained his seat 1 ys later and I met him the first time in KMUH North Hostel. KMUH(Kaohsiung Medical College then....) North hostel still stand today,eventhough KMC had become KMU and many old building had been demolised and new one established....... He is much elder than me... A nice person , Christian who really care. He is just like a big brother to us. He was elected as North Hostel in charge during the old days... a nice person who helped the Malaysian to secure a place to stay...

After we completed med school. He worked in Pingtung Christian Hospital for a year and went back to serve the MOH. He was posted in Kuching GH then Sri Aman District Hospital. He served his time and open up a clinic there. His wife is a Taiwan Dentistry Grad and both of them shared the same building and practice. I met him once in Malaysia during my service. He had come to KL and I gave him a small tour around KL in my Kembara .... It was 6 yrs back....

He is a all rounded GP who served the Sri Aman Area. He had a successful practice ... I envy him really - if I had gone into private practice instead of coming back for my specialistship  - I might lead a life like him...... well, nothing much to regret....of 9 Malaysian in my class - 3 went back to served the mother land and I swayed away from what once I believed just to pursue my personal achievement....

 But Syabas GSW ..... keep up the good job....

 

the end of the year....

This is the end of the year....

I had spent less time on blogging for the last few months.... Domestic disturbance mainly but now I am better and hopefully would improved more...

I had done a lot this year... passed some exam and failed some - but more confident now... I am turning 39 next year and the learning process is still going on.... I am planning to swtich field next year - maybe joinning a resident program  but still the economic situation is so bad and my current hospital is doing well and stable. We had achieved most of our target(health insurance agency)  and gained some extra budget next year. Well, not a bad performance in this economic storm.... hopefully the bonus is big this year(we get our bonus on the chinese new year eve....)

My job is secured - we had a new locum ED doctor (Emergency medicine certified) . He was quite ambitious initially. Trying to ask as many shift as he could - the deputy superintendent even asked me if I could spare my Wed night shift to him. I gladly concurred and looking forward to enjoy life in 1-2009. However, my dream was blasted out lately. This locum doctor had done a few hanky-panky act and nurses from ED and ICU had complained vigorously... he had also stepped on my foot - moxifloxacin was prescribed for UTI ( my patient !!!!)... Well, one can be lacked of knowledge but most of the complaint was about his attitude. He is still on our locum list but definitely would the first to be stripped off....
Well... I would stick to my current schedule and grab as many cash as I could....

Farewell 2008....

1 arrow 2 hawks plan....

 

It was a hard mission for me…

I had 2 objectives to accomplished and hope to complete them in 1 shot…

The first objective was to attend the exam of Health Information Manager certification exam. The exam was organized by the Medical Informatics Society. The exam was fixed on the mid of the November. I had an advantage for the exam – 20 % of the examination was about medical term and another 20% about medical ethic and health insurance. I thought I need something to justify my position as a programmer in the hospital – I am not a computer science/engineering grad  , really inappropriate for me to such job...

On the same day the internal medicine society(SIM) was having it’s annual conference. I am still 2 credits short from my practicing license renewal. This 2 credits was specific credits that means only I needed to attend specific courses to get them – the sex and infection control credits. The sex credits was required as too many of sexual harassment occurred in the medical field recent few years. The infection control credits was required due to the avian influenza and SARS outbreak. The SIM annual conference had organized such course during the 2 days conference.

The challenge – the courses was held during the morning session. The sex issue in the morning(8:30am) and the infection control in the afternoon(3:30pm) in the National Taiwan University Hospital.(NTUH) The HIM exam was set at 2pm at the other end of Taipei City(Taipei Medical University). I made a call to the SIM and the SIM had claimed that they are not very strict about the entrée and exit time for the courses(we need to sign in and out during the course to make sure we actually sit in the classroom…). So I decided to rush and see if I could get the attend the examination and still collect the 2 credits. I came out with the 1 arrow 2 hawks plan…

I took the 1^st high speed train up north – it was the biggest Build-Operation-Transfer plan of Taiwan and the dream of 1 days traveling for North and South came true. The 6:36am train would arrived in Taipei by 8:15pm. The 1^st course started by 8:30am. The Taipei main station is a joined station of train , HSR rain, LRT. The NTU is LRT station away from the Taipei main station. I arrived at the station on time and hopped onto the train. I did some reading and the was shocked as I heard the train announcement. I was on the wrong train – the announcement said it would be stopping at all station and would arrived in Taipei by 8:30am… Definitely no my train. I jumped off the train and found that my train was actually at the other dock. I ran up the stairs and cross to the other dock and managed to get on the proper train 2 mins before it departed. Not a good start definitely and “I had a bad feeling about it”…

I slept during the journey and the train arrived on time. I found the LRT dock and get on the LRT and arrived at NTUH by 8:25am. I went to the registration and went to the class room at level 5. The next 2 hours was not that boring as I imagined. When I went off by 10:30am. I found that we did not need to sign out…good news. I could go back earlier. I collected some free gift – a VISA electron card from a local bank, a blood sugar machine(free of coz….)…I took the LRT again to the closest station near National Taipei University. I took a bus instead of a cab. Lots of time for me to spare.

I had lunch at one of the shop outside the university – there are always lots of restaurant/food stalls outside a university…. I had an hour to go through everything again…

A 50 questions MCQ paper. I did a count before I passed up my papers – 70+ .. The passmark was 70 and I think I could do it.. at 30mins, I handed out the paper and rushed back to NTUH… I managed to get to NTUH by 3:40pm and signed in.. I left the NTUH by 4:10pm and got to the HSR station by 4:20 pm. There was a long queue in front of the automated ticket selling machine and even a longer queue in front of the ticketing counter. I quickly glanced through the train timetable and I thought I should take the 4:45 train. There were 3 machines in front of the queue. A female worker was standing around it and trying to help out those with difficulty of operating the machines. There was this man in proper suit(coat with ties) who tried to buy a ticket with credit card and kept having error and retrying. He had however turned down the offer when the lady tried to help him…He had stand there for almost 10 mins and finally gave up…I observed the buying process and found that the credit card route took the longest time. I decided to use the ATM card instead but then I would lost the credit card insurance coverage – but what the hack ,time is gold ( I need to go back and look after my 2 kiddo)… I managed to get my ticket by 7 mins before the train departed.

The course was smooth – I got home in time…

 

I accomplished all my objectives….I got the 2 credits and I passed my examination(got my cert last week…)

Well what a day…next year I need to go for the analysist examination....

Light and dark - chapter 1

Finally I acted....

Ving and I had a good week together and we had a small disagreement over a small matter... she started again .....digging out the past and she acted violencely. I was due to work at noon and was unable to left her in the house. I told her she had 2 choice, one is to go north to a place where she might be healed and there other was go back to Malaysia... she opted the 2nd but went into amok after  she opted. I knew I had to do sometime at that point. I made some calls during the next 2 hrs... I managed to give her a sedation and knocked her out. She was sent to the psychiatric hospital and admitted.

That night was a chaotic night. She kept calling me , begging me to discharge her. She told me she saw lots of spirits around her and she was touched and harrassed by them. I was oncall and nothing could be done. She had also called a few members of the church. She finally told HX she wanted to go north instead of staying at the place.

The childrens slept with me at the hospital and I took a 1 hrs break sending them to school. By noon, I went to hospital and had a long chat with the psychiatrist. He had a long talk with Ving. As usual, Ving had rationalized her violence behavior - all she wanted was "pamper" from me.... I told her if she wanted to go home there should be no more violence in the future. However she had a 180 degree change of attitude during the ride back. She even wanted to be re-admitted when we reached home.... There was another existed issue. My dad was coming over. She was very tense about this as the unpleasent feeling of the past had haunted. She was wanted to leave during the period of stay of my father. She called up HX and wanted to go to Hebron Holistic Care Society.

2 days later, I was post call and 3 of the church members had accompanied us up north. I was lucky to have good sleep. The drive was a long drive 340 + km and my heart was heavy... I need to let her go for the 1st time. She had never left the family since we came back to Taiwan. I had to left her in a place where I had never been to...

Ving was ok during the drive... the society was situated in a community. The community was formed with a few blocks of apartments and lots of terrace house. We took a wrong turn in the community and ended at the other end of it. We passed a temple and Ving started to act strangely. She said the place is filled with spirit and she no a suitable place to stay. We walked to the office and had lunch there. Ving had took double amount of what she could eat and finished it. We were joined by the pastor during the lunch. She finished her lunch and walked out from the office and claimed that she wanted to go home.....She sat at one of the bench outside the office. The pastor and wife talked with her and one of the spirit had spoken via her mouth. However this time no exorcist was done. The pastor asked the spirit with a firm voice and the spirit just went away.... We walked back to the office and chatted for 1+ hrs. Ving had regained herself and agree to stay there... 
A room was arranged in a terrace house opposite the pastor's home. We left the place after everything was set. We walked Ving back to the office and I hugged and kissed her before we left. Every steps was stoney hard for me... I broke out in tears when I walked to the car...
I drove all the way back by myself .... The pastor told me before I left :
1. I had sent her too late - I should have noticed and realized the matter earlier
2. The power of dark side had influenced her too depth  - It might take a long time to recover
3. She would be having recurrent episode and she would be hovering between 3 places - home, hospital and the society.

I had then 2 problems to face - 2 children without mother , My future shifts....

light and dark ... prelude

I am still denying what is happening around my family...

I slow down of blogging due to some domestic disturbance... However, what I considered as domestic disturbance was not just domestic only - it had something to do with light and dark side of life.

I had always considered Ving's disturbed emotionl as personality disorder and psychiatric related. However last month -I found out that the dark side had played a part in it and she had been influnced deeply.

It was an disagreement between us and the flame of fury was torching in our house. 1 pair of closed couple ( SH and HX) had come over to help to cool things down. SH and HX are both christian and deeply devoted. After cooling the things down, they had offered us a prayer and I did not resist it. During the prayer, Ving had gone into a trance, eventhough her voice tone was the same, however she had talked in the way different from the past. I had encountered such way of talking in the past and I thought Ving was in a hysteria state. She looked fatigue and kept yawning. She told the couple to start praying , claiming that she felt very discomfort when they pray. HX told me that she was possessed. She asked me how long had it been going on - I told her for years I had noticed her in such state but I thoughy she was hysteric. Nope - they told me this a state of being possessed.
That night - a short prayer was done and the "thing" seem to be exocised.

I was a little bit confused than but tried to accept what was going on in my family. I had gone through few serious discussion with HX,SH and some other core member of the church. Indeed, Ving was in a state of being influenced and something possessed.

I was confused about her state and bought severe books from tha amazon. The book "Hostage of Devil" by Martin Malachi had clearly described the process of being possessed. I was in a denying state but still opted to act - I had agreed to become a christian. I had no choice - my knowledge and experience had told me that there are 2 known effective way to chase such "thing" out - the chinese temple way and the way of christian. I had a wide knowledge of buddism(my parent is devoter of Nichirin Shoshu (Soka Gakai member)) and I was once deeply devoted to such teaching of Nichirin Shoshu but later defaulted as I dipped into it deeper.  The chinese temple way were risky - you don't know which would work and need to try here and there and I don't have the "american time" to do so and I don't what to hand over my wife to some medium or so to do it...Christianity had become my last resort.

Ving is specially gifted - she could see "things" and even kicked one of the things back in her childhood. She was interested in such spiritual matter since 6 months ago when she taken up Yoga and met this Yoga teacher. The teacher likes to go for fortune telling using rice. I knew the truth behind such ritual - most of the teller had a spirit beside them, the spirit would tell the teller what to say. I had a grand grand uncle who practice such ritual - he used poker card instead. He had told us that he knew what happen now and then but could never tell the future. He never got married and used what he earned on the same day. I could not stopped Ving as she told me after she been to such place. Since then, some spirit had gone into Ving's dream and build her a house inside her mind - the spirit had started to teach her to play tarrot card in her mind. The spirit had made her believed that she could be famous and rich after she learnt it and helped others with the trick.
One of the day during my night shift, Ving had left the children with one of the church member and drove out. I found out later when I called home. I tried to call Ving and she tearing and told me don't know she was - she told me she was in a graveyard. I tried to use th 3G mode but couldn't get any image as no 3G coverage over her side. Some of the church member had tried to drive around and find her and failed. Finally I decided to take both of the children to me in the hospital and asked the church members to stopped searching. 10 mins later, Ving had miraclelly returned to home. She was unable to recall where she had been to. The next day when I got home I opened the image recorder on Ving's car and found that it was blank - no recording during the period. According to the mileage she had traveled about 80kms.....She was in a trance state when I got home and I had talked with the evil things within - the evil things use "we" so it is things instead of thing. I doped her with aprazolam that night when she wanted to eat some instant noodle. ( she dislike the instant noodle in a hatred way ....it was not her...). When she woke up the other day - she was better and I knew drug could suppress them - but not chase them away permanently.

During one of the morning, I was talking with Ving and Ving told me that she had a dream about something evil going in our house and 1 pair of couple in black had come over to our house to help out. She said, I had agreed after they explained to me. The man had stepped on her foot and reassured her to calm down and the lady had gone into our house and yelling "Jackal, please come out " in a very soft way. Ving had asked me what "Jackal" means - and I told her that it is a kind of coyete like dog. She was described the scene and suddenly asked me if I wanted to join them in the real world ? I asked Ving - who was them and what they practiced. She said the them was the couple in dark and she don't know where were them , but told me if I nod my head - someone would come to our doorstep and lead the way. After I joined, we would be very rich and nothing needed to be worried in the future. I was shocked and knew that it was the temptation from the dark side. I resisted it and knew that she was talking again under influence.

2 more exorcist was done but however the things enter her again and again. A wrong approach was used as the church members had denied what Ving saw and told her that she would be ok if she believed in God. Ving's has used such approach as an excuse and resisted the act of saving her. She claimed that she felt no support at all and didn't like the way the church member talk. During this period, I had endured verbal and physical assault from Ving. However now I knew she was under influenced and tolerated her. However the physical assault was unbearable - she had left wounds and scar over my forearm and body.
HX had told me that after consulting with the visiting pastor( the church was lead by an elder instead ) the best way is to sent her away. She had mentioned a place where she had served before in the north. She told me the Reverend was a good person and she saw many who were possessed cured in such place.

I had do some search over the internet and did not want to sent Ving over there(www.hebron-kb.org) Ving was not psychotic nor Drug/alcohol abuser. Why should we sent her there ? Later I sought help with one of the visiting psychiatrist. He is deputy chief of staff of a local psychiatric hospital. He had offered help and promised to arrange a place for Ving if admission is needed.

It was a big gamble for me - to sent her where ? to cure her and let her go....

finally I acted....

 

hopefully someone "repair" him elsewhere...

It was a bad night - I managed to get a few hrs of sleep and was darn tired. When I got the call it was 6:00am. I went to the bathroom, brused my teeth and walked toward the ED. The patient was a male who looked familiar. When I sat down, I did the usual routine of asking his name. It was a strenous agony being a patient in Taiwan. A patient would need to said out his/her name few times during his visit to the hospital. The nurse, the doctor, the lab technician, the pharmacist would ask the patient's name before performing their duty. The hospital evaluation committee had stressed on this topic and it is a major field concerning patient safety.
The patient replied me, " I forgot" when I asked him the routine question. I had a bad feeling when I got the answer - the patient was either suffering from amnesia, a mxrxn or a trouble seeking A-hole. I asked him again politely and explained that I did so because the regulation required me to do so. He still answered " I don't know" and asked me why it took me so long to get to the ED. Another FxCxxxG A who thought he is the big daddy after paying up 250NT at the front desk.

 I was not in the mood of starting a fight. I apologized to him and told him that I need to brushed my teeth as I didn't want my bad breath to affect my patient.  I apologized again and told him that I respect his decision of unwilling to saying his name if he didn't want to do so....He than showed me his left thumb which suffered from a penetrating injury. After the examination I told him that he needed a tetanus injection. He asked me if he really needed it. I told him yes but he could refuse if he didn't want to do so. He accepted the jab and dressing. I was too tired but still wrote a "FxxK" word at the allergy hx column on the front page of the patient chart. ( This ritual was started by one of my ex-colleauge in our hospital, a very prestige orthopedic surgeon (Korean, who is also a FACS and FICS - he got the honor while working in our small and humble hospital, contributed a good amount of papers and he is currently semi retired. One of the good all rounded surgeon who could repair nerve, vessel and do some plastic job .....), but he wrote FK usually and I like to complete the 4 letters word instead.)

That guy was not drunk eventhough I could smell some alcohol scent from his breath.  Later the nurses told me he was nice during the waiting period and suddenly turn violence when I started the consultation. The nurses told me that he was a private ambulance driver and came to do some transfer in our hospital.  He had quit recently. Most of the private ambulances were operated by funeral home and most of them have relation with the mob. But it was not the reason I did want to give him a good lesson. I would be at his level if I do so and I did not want to make dirty my hand....

I just hate this kind of trouble seeking jester and would really like to give them a good whacking ( in my imagination of coz...)  Anyway - hope he is "repaired" by someone elsewhere at some point of his life....

ass in the hole.....

Another surprise....

well... It had been a year since my return to this hospital.... well, I think I consider my self lucky (despite the worsen astham...). I got an additional cash reward (my annual leave converted ..). I had another surprise 2 days ago.... I am the employee of the year .... well, still don't know about the benifit I could gain from it(definitely uncomparable as the cermelang award of the MOH...) but I am happy. Nothing to do with performance - the employee of the year were elected....won't happen next year - the electee would not be entitled the following year...

This is my 12th year since I joined the employee line up - never been nominated or choosen before. I remembered back in those days when I was still serving the MOH - my district medical officer had told us during a talk that don't even think about cermelang if you have not work under him for 5 years. And if any staff have wanted the award badly - please talk to him. In my memory - the cermelang award come with a 1 months basic pay and 1 wks leave( correct me if I am wrong....). I heard other workers in the office told me that the cermelang award are given out on rotation basis - everyone would have the chance to get the award if you worked long enough....

well, it reminds me to keep up the good job... Nope ..good attitude towards my colleague....

busy and exciting month....

It is one of the exicting month for me...

my eletronic SOAP program is running smooth and the e-medical order part would be function fully next months... I had a hard time with the head of pharmacy but managed to tackle all those "big problems" he stated. I am trying to shift my program from simple txt file to oracle database in the next few months and hope I would succeed. I am not sure frankly but I would try hard. We had a new MIS engineer at the moment - he is fresh and he is currently handling all the hardward.... but he would be taking over part of the software and database part later on...I am taking an exam next months - medical infomartic management personnel organized by the medi info society of Taiwan.

The ED is facing problem of locum doctor... currently the weekend is covered but locum doctor but in the future such practice would not be allowed. The hospital is trying to find someone but unsuccessful. Next month I would be doing 6 calls again and enjoying my vacation. We e were trying to workup a scheme but with the pay/hr at the moment I would be imposible for us to compromise.

I had a surprise this months... the management had converted my annual leave into cash ... I am happy with it, at least I got my annual leave here, my past employer did not provide us with any annual leave...

I had my asthma attack on and off but still hanging on.... I am lucky I am not a surgeon, or I would be losing my job - with such attack, I don't think I could operate ....well, you never know what would come in the future....

aint my field but I ....

I was doing my weekly goevt clinic specialist clinic at the town of lion....well, it was about 11:30am and I was about to wrap up my ppt file for my presentation(for the end of the month...)

the counter nurse recieved a call from one of the pt and I overheard the conversation. The patient was asking if ultrasound if available and the nurse said yes and told the patient the O+G specialist clinic would only commenced at 2pm...The conversation ended and later the another call came(appearantly from the same patient) and asked if ultrasound could be do stat ... The patient was worried about the child and asked if an ultrasound is available to clarify her anxiety.
The nurse came to me and asked me if I could perform O+G ultrasound .. I said yes and told her to let the patient come.

the 3 nurses in the clinic gave me a strange look - it was an internal medicine clinic and I am a physician. The nurse was surprised when I said yes....

Well, the patient came 10 mins later and I did a quick history check... G1P0 @ 26 wks, poor movement noted since last night. Well - 26 wks, nothing much could be done - if it is gone, it is gone....

The machine was in good shape - newly purchased..But the jelly was so watery... I managed to digged some "thicker" jelly from the old jelly bottle... The baby was fine . I located the heart beat and shown it to the mother... Reassured her and asked her to observed...

I walked out with a smile on my face, those nurses must be wandering where on the earth I learnt the ultrasound..... O+G is out of bound for many physician or surgeon - they would referred the patient to O+G clinic even for URI.. some of them don't event dare to prescribed medicine for pregnant mother. Our purchasing officer was pricked months ago and she had been asking around in the hospital for few days( it was weekend) if she needed a tetanus jab as she is preparing for pregnancy. I told her to go ahead for the immunization... thanz for the MOH service and training....

back to 9...

Well, our plan to intake a newcomer had failed. The offer was rejected and we were back to square one. The problem had become worst new months as the other locum doctor had quit. We would had to cover the weekend night shift by ourself...

I was "allocated" with 1 shift and next months, one of our ED colleague will be taking his routine 3 wks break. That would make my night shift count back to 9....

I am not sure what would happen later but I am prepared for the worst....Would I resign and get a new job ? Most probably not. I dont want to move again... 20+km upnorth is Kaohsiung and the hospital is 20km downsouth from my house. I am happy with the current living environment. Lots of peoples had told me (not my colleague, but the locals)that the education resource in the suburb is definitely uncomparable in the big city. Well,  I tend to denied it and I think self effort and parents role is important than tuition.

Deep in the heart, I am still worry that my child would be handicapped at the starting point as I did not provid her with the best school. But as I look at her performance, I think we were on the right track.

Sometimes I still dream of getting back to work with the MOH...but the dream is drifting away slowly...

illegal and misconduct

The typhoon had badly hit the northen and central part of Taiwan earlier this week. However the southern part was spared. Building collapsed , bridge sunked.. 20+ peoples lost their life...

I was not surprised but such news... 20+ yrs ago when I first arrived here. There were this busses which were called "wild chicken bus".  At that time, the only legal long distance bus service was manned by govt. However there were bussiness man who run the illegal bus service. They uses 40+ passengers big bus ferrying passengers from south to north and vice versa. The police could have stopped them easily but no action was taken as people reps such as legislator had involved in the activities. This country had been well known for favor....

The hotel which was washed away by flood in the hot spring region had been built without a license and did not have proper infrastructure of steel /cement. And later in the TV, those illegel operator had condemned the authority for asking them to take down there illegal building. They plead that the act may make dampen their income. All I could say is "WTF!!!".  There were 20 hotel/ L &B operator in that area and only 4 of them were legal. The rest of illegal and due to their irresponsible act of building without any environmental evaluation - the flood had taken away life.....

There were also a also a fire and rescue officer who had fallen into the flood while doing a search and rescue. Everything was recorded by the TV. 5 officers had used a rubber boat and tried to row in themself to nowhere in a flooded river. Part of the brigde was collaped and 3 cars had fallen. Only 1 body was found and 5 still missing. The families of the victims had condemned the search party that not enough effort was done. So I think the F and R department had tried to show their effort over air. The drift of current was so strong in the water and I don't think motorized boat could sail properly. Luckily the officer was saved 5 hrs later. I saw a scene of family "ordering" the party to search here and there just becoz they the fortune telling clamp had shown a 3 positive result. (One would pray and throw the fortune telling clamp , if the clamp

Xian's school...

Xian had gone to school and doing well....

We had tried in the past when Yun was still in the senior class. However he was unable to concentrate and willing to go into any class. He had become familiarized with the school and we think that sending him back to the same school would not make him learn properly. We sent him to another school instead. It was not far away from Yun's previous school. The teacher there was friendly and the senior teacher had tried to couch him on 1 by 1 basis starting from learning daily rules. He learnt fast and was able to coup with the stress of being restricted from doing this and that. The restriction was less intially and later the net was tightened. Our conversation had become more interesting. In the past, I am always the one who intiate the talk and it went like 1 ask and 1 answer. But now, he would come to me and start a topic, he asked and expecting answer from me. He would told me what to do and wished to join what I am doing... He had gone into the classroom and joined the others. He would finished his homework after class.

Well, I am not sure if he would be ready 1 year later for the primary school. But he had progressed so far. I am glad as I had expected the worst .

Ving got all the credits as she is the one who had looked after and care for Xian in the past....many peoples had told us that it is difficult to bring up such child, but we are considered lucky as Xian had progressed so much....

massive casualties scenario

  It was 8pm and I had just seen a pt with traumatic SAH and sending the patient up to ICU. When I placed my foot steps in the ED, the nurse told that the Emergency Dispatch Channel had just called and told us that there had been an MVA and unknown amount of patients are coming in…I did a curse and knew that the “unknown” meant a lot, uncountable, unable to estimate… the next few seconds the ED door just slide open and 2 patient was brought in a truck. I get out from the ED and walk toward the counter and instead of seeing the patient – I told the counter clerk  to intiate  “ code 333” ( that means massive casualties scenario)…

This is not my first real massive casualties scenario – and I had my surgeon around….I walked back to the ED and started to see the patient.

Everything was wrong. The ED medical sheet, the staff management, the admin – things should not have gone like that. Everything done in during the drill was not follow properly. But we were still able to managed the scenario….

There were total 23 patients – 2 were transferred under my request : a 6y/o girl with pulmonary contusion (> 50% pul hemorrhage noted) plus minimal pneumothorax. Another 24wker G1P0 with pelvic fracture. Without MRI , O+G, Paeds Surgeon, we just can’t take this 2…

The incident : there was a local temple which held prayer. After the prayer a gathering dinner was held along the roadside. A tent was set up and few tables were arranged in it. A lady had rammed her VIOS toward the tent and those peoples in the tent were injured.

Well, I think we can do better next time - smoother and patient could be managed more promoptly...a post mortem would be done recently...

massive casualties scenario

 

It was 8pm and I had just seen a pt with traumatic SAH and sending the patient up to ICU. When I placed my foot steps in the ED, the nurse told that the Emergency Dispatch Channel had just called and told us that there had been an MVA and unknown amount of patients are coming in…I did a curse and knew that the “unknown” meant a lot, uncountable, unable to estimate… the next few seconds the ED door just slide open and 2 patient was brought in a truck. I get out from the ED and walk toward the counter and instead of seeing the patient – I told the counter clerk  to intiate  “ code 333” ( that means massive casualties scenario)…

This is not my first real massive casualties scenario – and I had my surgeon around….I walked back to the ED and started to see the patient.

Everything was wrong. The ED medical sheet, the staff management, the admin – things should not have gone like that. Everything done in during the drill was not follow properly. But we were still able to managed the scenario….

There were total 23 patients – 2 were transferred under my request : a 6y/o girl with pulmonary contusion (> 50% pul hemorrhage noted) plus minimal pneumothorax. Another 24wker G1P0 with pelvic fracture. Without MRI , O+G, Paeds Surgeon, we just can’t take this 2…

The incident : there was a local temple which held prayer. After the prayer a gathering dinner was held along the roadside. A tent was set up and few tables were arranged in it. A lady had rammed her VIOS toward the tent and those peoples in the tent were injured.

A post-mortem regarding the response plan is definitely needed.....

Meeting , meeting, meeting and meeting....

I had attended 4 meetings yesterday... it was my post call day and  I went off by noon. It eaten up all my time and I had only a short time for my rounds...

The 1st one was the ICU review - weekly routine to review appropriateness of ICU admission and day of stay. The 2nd one was ED personnel meeting - an unusal one. Boss wanted to get someone considered unfit to our hospital. His intention is to train him and make him "fit". This doctor is currently doing locum in our ED - many thing could be mentioned regarding his "mis-"... I don't want to point any finger as everything I knew was hear-say. But life would be a great change if this appointment truely happen. Night shift would be less, I would need to take up some Weekend call, pay would be less as well...the key point is - no one is sure if he is interested as he gave different answer to the top people. I am sure if he join us, then my life would be better (minus the cut of pay of coz...)

the 3rd one was the pharmacy operation meeting. I am not officially in it but as the "electronic order system" I am responsible at the moment has some relation to the daily UD(unit dose distribution) operation. The order system generate a prescription whenever a drug is enter in the ordering sheet. The head of the pharmacy can be described as a person reluctant for change. He objected every options or changes we proposed.. "This cannot and that would be problem , their loading would be increase"....We had 2 meetings in the past and this is the final one before fully implementation could be done. I had a bad start as most of the problems complaint by the pharmacy were due to incompetent of nurses... I had to live with it as the ward chosen for the test ground were "problematic" unit... I agreed with the choice intially as the daily operation of the relevant ward was less but their out of shape conduct had complicated the process. The nurse didn't even look at the prescription before sending the prescription down...

The 4th one was the infection-control committee and again I am not on the list but I would need to seek a approval of extending the antibiotic review period from 3 to 7days. The current review system was set to control the use of antibiotic and currently we would need to order renew the antibiotic in a very frequent fashion. Nurse would have to go around asking doctors for prescription. It involved regarding the system I am working on as well....

I left the hospital by 1pm...so tired after a bad call...I had 3 more committee meeting coming up - the ICU, the medical ethic and the patient safety....

I hope to make some changes.....

Kam Dou Tak ? (like this also can ?)

It is a typhoon day... I don't know why, I had my shift during most of the typhoon days... well, had to live with it...

however the gusting wind did not depress me, but the news of the 3 new ISA detainee shocked me...

2 journalist( I considered blogging as journal writing...), 1 senior  state Exco member(I thinked she ranked as deputy menteri besar), I think one had been left out  - the true racist...... well, I sincerely hope for their early release......

where is the wind of change ?

a change ... wound it happen....

I had been following the news regarding 916 takeover ...

I grinned when I learnt that 1/5 of Malaysia Yang Berhormat had arrived in Taiwan for an agricultural trip.... Taiwan had no official relationship with Malaysia, both had only trade office as their representative.
Taiwan is definitely not a suitable place for our YB especially those muslim. Back in my school days, we had welcome the recognition team from Malaysia and most of the prof and official was muslim. They were not that particular about HALAL food. The only thing to watchout is pork. But I think if HALAL is considered seriously then only vegetarian food is suitable for them. We had taken the group to Hotel and specially requested HALAL food( 5 star Hotel , and money was really well spent...). There is a Muslim Restaurant run by local muslim in Kaohsiung and we had a good meal there...the reasons for our back bench YB to opt of a trip here - no visa is needed for 1 month visa to Taiwan....

I am looking forward for a change - I am fed up of the racist to accuse other people as racist. This racist who carried a title of datuk (ex senator as well )  had faced a disciplinary action by his own party but no action was taken by the police for such act eventhough peoples had lodged police report . In the past, lots of people were arrested under the internal security act ... I think he should be as well... I regard myself as a Malaysian and hope to be treated as Malaysian. In most of the developed country, the minority was given privellege and aid from the govt. But the minoirty such as Indian was not look after, I am not surprise ( but was shock instead) that our MIC senior persons was pulled down in the general election. There was once I thought the Indian was still hypnotized by such figure. I met those very very rich Indian and met the very very poor ones...

I remembered when I attended the state health medical officer training in one of the secluded resort in Kuala Gula. It was a very long drive from where I lived. Nice bird watching place and the bird watching site was in the middle of the sea (wood cottage build on the sea).
Most of the MOs were Malay and I am the only chinese. During a chat after meal, a senior Malay MO had told the other Malay MO to plan for their life. She claimed that the chinese are different from the point of view of financial management. She said that an average chinese family save every penny for their children college fund since birth. The Malays do not have to worry about such issue. She asked me weather it was true in my case. I nodded. And I looked around and saw those other MOs who gave an innocent look. But changes were noted; Chinese was given scholarship by JPA(public service department) to India to do medicine nowdays which was impossible during my time.

The govt kept telling Malaysian that the Malay is still unde par and needed to be looked after for ,thence scholarship, quota system for university admission are still being practice. But nowadays, the names of rich Malay I knew were more than those rich chinese....

Peoples were being fooled....look at the automobile discussion board of Malaysia. Looks, pickup and fuel consumption were main issue Malaysian talk about. Malaysian pay more than people in the developed country to buy car without airbag... for me airbag is a mininum entry requirement for car safety. Nowadays in Taiwan, car under 100k are being served with traction control and stability control, in Malaysian, such car would cost more than 200k - why ? becoz Proton need to be protected ! nope I don't think it is true - under the present tax scheme (that lead to sky high car price)  , the govt is the organization which benifit most from it. Malaysian were being punished for buying car with more safety feature and the punishment(tax) goes to the National treasury....

I pay a visit to a nice Malaysian lady who operate a L&B facillity up north lately. We had a chat after dinner. The couple had asked me why did I go back and did my time with the MOH (ministry of health). I told them that I am a patriot - I had been a patriot since my 1st step on this land; I tried very hard to prepared for the Malaysia doctor entry exam just because I wanted to serve my mother land(although I never went through it). Unfortunately thing did not work up that way - Later I realized that I need to provide a good quality life for my family...... I still love the mother land - but I could only make a good living here. Sometimes, I looked at Xian and Yun playing in the living room and thinked back of my decision giving up the chance of being a MU master grad( only 2 MU grad in my whole family ...)......I am happy that I made a choice....

Snake bite....

I was covering for the ED in the afternoon... the emergency dispatch center informed us that the 911 is sending over a snake bit patient, ETA (estimate arriving time) was 20 minutes. The ED was not busy then... A 14 y/o girl was sent in. 2 teacher accompanied her to the ED. She appeared frightened. Her left wrist was bandaged but not splint. The teacher told me that it was Green bamboo silk snake(青竹絲) - Trimeresurus stejnegeri. There were lots of snake in our area, especially in the mountain. We get a snake bite every 1 -2 months.

There were 2 kind of green snake in our region. 1 non-venomous and the other is venomous. The non-venomous carried a strong smell and it was name as smelly green mother ( 臭青母) aka King Rat Snake ( Elaphe carinata). The venomous one is this T. Stejnegeri and it produced hemorrhagic venom. The bite is less striking than the cobra (neuro-toxin) which may lead to respiratory failure. However the swelling of bitten region is frightening.

The girl entered our ED at + 40 min. She was nausea and vomited in ED. It is common for patient to had GI upset following bite. But when I saw the vomitus, I was worried, She had vomited blood clot. 6 bite hole was noted over her left wrist around the ulna artery site. The wound was oozing when I took off the bandage. I asked my team to move fast and called my nephrologist cum toxicologist H down. He was preinformed about this case before her arrival. He was worried as well as the course was too fast. An allergy test was done to see if any allergy present. Usually if allergy is noted, the case would be transferred to a medical center and venom were given there. ( some venom was given actually but if any complication occured the family wont raise any arguement...). Luckily there was no allergy noted. But I had decided to give the anti-venom anyway even if allergy had occured. The hardest part was the girl was staying with her granny and her parents was in Taipei. I ordered 2 vial of anti-venom stat and admitted her to ICU. H checked the drug storage and found that we had 7 bottle of hemorrhagic anti-venom left. He told me to passover not to intake anymore similiar snake bite case as he expect a full dose of 8 vial of anti-venom would be needed. I concurred with his suggestion. A third vial was infused later in the ICU as hematuria was noted. Her parent was called and informed about her situation. I left the ED 2 hrs later and her forearm swelling had started to swell. I told the on call doctor to give a 3-4 more vials as needed. I arrived in the ICU the next day and found that she was transferred out to the nearest univeristy hospital under the request of her uncle. Later that day, the nurse would accompanied her over told me that the swelling had worsen later and the uncle had insisted a transfer. The transfer was done against advice. As the ED of university hospital had told us that no bed (not even a strecther) was available. Our nurse had to stay there for another extra 1 hour as no bed for her in the ED(she had to lay on our trolley) instead. However the nurse told me that a ortho consult was done stat and she was sent to OT stat as compartment syndrome was noted. I was worried when I heard such news - no fasciotomy should be done until haemostatic abnormalities have been corrected as recommened by the The Clinical Management of Snake Bites in the South East Asian Region(edited by WHO). Well, I called up the university hospital ICU today , and asked about her condition. Fasiotomy - yes , Oozing was noted for the first 2 days and now better total antivenom used 3 + 10 vial Yes - she is currently stable... Thank god, she is stable at the moment....13 vial of antivenom used , more than 8 as recommended. But the challange is not over yet as the venom would be re-released from soft tissue few days later and further bleeding maybe noted later. Frankly said, no patient had died in our hospital because of T.stejnegeri bite. Most of them recovered without complication, unlike bite by cobra where tissue necrosis would be noted.

I had a dicussion with H later and he told me that the snake might be a mutant variant and the venom is super toxic...

I was covering for the ED in the afternoon... the emergency dispatch center informed us that the 911 is sending over a snake bit patient, ETA (estimate arriving time) was 20 minutes.
The ED was not busy then... A 14 y/o girl was sent in. 2 teacher accompanied her to the ED. She appeared frightened. Her left wrist was bandaged but not splint. The teacher told me that it was Green bamboo silk snake(青竹絲) - Trimeresurus stejnegeri. There were lots of snake in our area, especially in the mountain. We get a snake bite every 1 -2 months. There were 2 kind of green snake in our region. 1 non-venomous and the other is venomous. The non-venomous carried a strong smell and it was name as smelly green mother ( 臭青母) aka King Rat Snake ( Elaphe carinata). The venomous one is this T. Stejnegeri and it produced hemorrhagic venom. The bite is less striking than the cobra (neuro-toxin) which may lead to respiratory failure. However the swelling of bitten region is frightening.
The girl was entered our ED at + 40 min. She had nausea and vomited in ED. It is common for patient to had GI upset following bite. But when I saw the vomitus, I was worried, She had vomited blood clot. 6 bite hole was noted over her left wrist around the ulna artery site. The wound was oozing when I took off the bandage. I asked my team to move fast and called my nephrologist cum toxicologist H down. He was preinformed about this case before her arrival. He was worried as well as the course was too fast. An allergy test was done to see if any allergy present. Usually if allergy is noted, the case would be transferred to a medical center and venom were given there. ( some venom was given actually but if any complication occured the family wont raise any arguement...). Luckily there was no allergy noted. But I had decided to give the anti-venom anyway even if allergy had occured. The hardest part was the girl was staying with her granny and her parents was in Taipei.
I ordered 2 vial of anti-venom stat and admitted her to ICU.  H checked the drug storage and found that we had 7 bottle of hemorrhagic anti-venom left. He told me to passover not to intake anymore similiar snake bite case as he expect a full dose of 8 vial of anti-venom would be needed. I concurred with his suggestion. A third vial was infused later in the ICU as hematuria was noted. Her parent was contacted and informed about her situation.
I left the ED 2 hrs later and her forearm swelling had started to worsen. I told the on call doctor to give  3-4 more vials pending her condition.

 I arrived in the ICU the next day and found that she was transferred out to the nearest univeristy hospital under the request of her uncle. Later that day, the nurse who accompanied her during the transfer told me that the swelling had worsen later and the uncle had insisted a transfer. The transfer was done against advice. As the ED of university hospital had told us that no bed (not even a strecther) was available. Our nurse had to stay there for another extra 1 hour as no bed for her in the ED(she had to lay on our trolley instead.) However the nurse told me that a ortho consult was done stat and she was sent to OT stat as compartment syndrome was noted. I was worried when I heard such news - no fasciotomy should be done until haemostatic abnormalities have been corrected as recommened by the The Clinical Management of Snake Bites in the South East Asian Region(edited by WHO).
Well, I called up the university hospital ICU today , and asked about her condition.
    Fasiotomy - yes , Oozing was noted for the first 2 days and now better
    total antivenom used 3 + 10 vial
    Yes - she is currently stable...

Thank god, she is stable at the moment....13 vial of antivenom used , more than 8 as recommended. But the challange is not over yet as the venom would be re-released from soft tissue few days later and further bleeding maybe noted later. Frankly said, no patient had died in our hospital because of T.stejnegeri bite. Most of them recovered without complication, unlike bite by cobra where tissue necrosis would be noted.

I hate snake ......

Orthopedic - 1

Before I left the O&G department, I had gone to the clerk in charge of the HO posting. I wanted to do orthopedic as I lack experience in such field. I was told the medical was very short and orthopedic was packed at the time. I told the clerk I preferred orthopedic and I found that when you asked properly and politely you would get what you want...so I joined the orthopedic department after I finished my medical. The orthopedic department was headed by a chinese, Mr Ong. There were lots of Mr instead of Dr in the department. Well, unlike the US system, the UK surgeon was known as Mr or Ms instead of Dr. Back in the old days, surgeon was not regarded as doctor - some of them were barber actually. So they did not carry the title of Dr. But later the title of Mr had become symbol of surgical specialist. Mr Ong was a pakar perunding kanan(Senior consultant) but he was retiring - I had worked under him for 2 wks.

Life in the orthopedic department was much more easy then the Surgical department. The HO calls for surgical deparmtent were decided by the amount of HO in the ward. If 3 HOs was posted in one ward - the HO do a call every 3 days. If 2 HOs then the call would be every odd day. If only 1 HO left - that means the HO do call every day( that means he/she stayed in the ward and cannot go home - and would be called anytime when something need to be attended to).
The HO in ortho do call every 3 days. 2 type of calls was noted - the A&E ward and the ortho ward. The ortho ward HO covered the OT, but unless it was a life threatening condition ( gangrenous limbs which needed urgent amputation) - no ops would be done in the night becoz the Head of Anesthesia department said his medical officer might make mistake when "Giving Gas" in the night.....
The A&E ward was actually the surgical ED. There ED was called the Accident and Emergency department (A&E department) in HTAR. The A&E department saw the medical case and minor trauma. For major trauma, the case would be admitted to the A&E ward straight and managed by relevant surgical or orthopedic MO/HO. There was a call room in the A&E ward: 2 beds : 1 for surgical HO and the other for the ortho HO.
The call was less hazard in the ortho - I was happy then and started my preparation for the MRCP part 1....

MVA - drive carefully and slow

I was doing my order renew with my the order program when I got a call from ED. The ED had "requested me" to go down and help a. I think it must be something not that big but not serious. Lem was managing the ED - nothing could knock him down. Lem was seeing another patient with scalp bleeding when I stepped into ED - he told me to attend to the DOA patient in the active resus area. I turned and dipped into the scene. MVA victim - superbike rider : lost control and collided toward the divider. Everything was there - ETT, CVP . large bore. CPR was done for 10 min when I took over. I did a quick secondary survery. Left flail chest and possible abdominal internal bleeding. I did a quick look abd sono while waiting for the chest tube preparation. While - minimal ascites was noted. I inserted the chest tube and pneumohemothorax was noted. Still return of spontaneos circulation(ROSC). It was 20 mins since CPR started. Blood transufed was done but no response was noted. I certified at 35 mins. Well, there was another poly trauma with open book type pelvic fracture managed by Lem while I was managing the DOA. Well - 4th major trauma since the beginning my 24 hrs shift. I had a bad feeling when doing the resus. I was prohibited to ride a bike during my high school days as my parents considered it as very dangerous. Indeed in Malaysia - motocycle is a very dangerous toys for your kids. I owned a bike during my college day. Frankly said - I hate those bike who like to show off their skill. Left- right - left like a viper in the traffic flow. The superbikes were prohibited in the past but later approved by the govt as there were so many of them riding illegally on the road. The road tax was high but still there are peoples who are willing to spend big money(big enough to buy a sedan) on a bike. The biker families came later and the wife denied what had happened to her husband, she sat on the bench in front of the ED. I remembered they was a phrase in one of the famous cantonese mob film - " one who walks (means being a mob), would definitely need to pay back in the future..." Well, not only drive slow but drive carefully.... I did not stay long in the ED as I still had to finished my ICU rounds. I stopped by ED before I went off, the ED was clear and the ED staff with Han(nephrologist, Mal) was there having a chat. I joined the chat. Han said,"all of us should drive slowly today." Everyone looked at Lem after Han commented. Lem was known as a fast driver in the hospital and he grinned. But I told myself - I should drive slower as well . I had been driving in a rough way lately.....next time maybe I would buy a Volvo instead....

horn failure

My Z's horn was finally fixed.... for now....

well, it had been disturbing me for months.... I had expected problems with my car before I bought it... The 7RV forum had stated clearly that owner may experienced the below problems :
1. Noise over absorber - a washer need to be added
2. Horn problems - horn failure noted on and off when lights is turn on
3. Interior lamp persistently on - unable to switch off  --> bad driving habbit misleading the car that an accident had occured : reset the battery and ok...
4. Cracking of fog lamp : ?due to temperature

The interior lamp problem was noted twice within the first 2 months. After that it was ok and nothing was replaced and I believed that it was my bad driving habbit. The horn problem was noted later - it occured once a while and I thought I didnt press on the right place( the forumer had concluded that the horn is hard to press...) but later (> 6months) I noticed that the horn failed from time to time when the light was switch on. I complaint to the service center everytime during my routine service but the was no fault noted and the horn behave itself in the service center. finally , when the sales rep came to me for my annual car insurance payment ( that means it had been 1 yr oledi !!!!) and I lost my patient. I sent my car back and the service center replaced this and that but the problem was still there. According the forum, such problem had been noted in Astra and Zafira and most of the horn problem was solved after the CIM was replaceed. I had requested as replacement CIM(Communication Interface module ) earlier but they told me wiring and cable need to be replaced first and if the horn still fails then they would replaced the CIM.

I recorded the horn failure scene with my handphone and shown it to the service counter section chief and he told me that was of no use as the technician need to personally pressed the horn and the horn failed on the spot then a change of CIM would be done. I instantly fired back at him ...

My car was driven back by the car sale rep and the horn for a short while but behaved normally then - of coz no fault was found. A rewiring was done and the horn failed on me again 2 hrs after I got my car back. I finally called up the manager and told him if nothing further could be done I would call up the Taipei HQ and filed an official complaint. He told me to leave the car with the center and they would run a thorough check. I asked him if still no fault to be found then what - he told me he would replace the CIM and horn. I photocopy what I got over the net before I handed over my Z.

I lost my Z for 4 days and they told me no fault was found but they would change the CIM and horn for me. I got my Z back and found that the horn could be pressed easily ..... and no more horn failure when I turn on my light....

but some forumer told me not to be happy as there was someone who had CIM replaced and still problem recurred later...

Compare to other european car which offered similiar safety features - Opel car price is the cheapest .  But as other european car, due to different of weathing and driving condition, minor problems was noted from time to time - that is what a european car owner need to tolerate. I had colleague who wanted a Volvo XC 90 and called the deal off last minutes due to poor comment from friends.

I hope my CIM would last....

doctors.....

I had this call from one of the head nurse 2 days ago. It was 9+am and I was reading the newspaper in the house( I work 12-12). The head nurse asked me if I knew my patient JL's  son is a opthamologist(80 or maybe 90% of Taiwan doctors are specialist...). I gave her a negative answer. She then told me that his son had called and asked us if blood transfusion was being done... I told her that no - his Hgb was 8.9 mg% and it was gold enough for a bed-ridden old-aged male. The head nurse told me that she had given the same answer and the son had complied with a unsatisfied tone. The son further claimed that he had bought EPO and injected JL from time to time. I asked the head nurse if she had told the son that he was admitted because he had fever and urinary tract infection. The head nurse said yes and she told me that the son had her  that they had been controlling urinary tract infection with cranberry juice and requesed for a discharge stat if no blood transfusion is to be done . But the patient had fever .......

Well, I had met good and all-rounded doctors in Taiwan. But many of them are only good at their sub-specialty. I recalled that when I was doing my housemanship in my hometown. I had a called from a psychiatrist  asking a patient condition. She had asked a few "sharp" question and at the end told me to care the patient properly - she reminded me that she had done medical posting before....  well, this true for a malaysian medical officer - they rotated through those major posting... well, the taiwan trainning defer : doctor dipped themself into subspecialty too early.  There is this hospital F which is not far away from our hospital which practice a different kind of rules

   1.UGI bleeding would be transferred if the Gastroenterologist is not on call that night
   2.Pnuemonia would not be admitted if the Chest physician is not on call that night
   3.Patient with pneumothorax would be transferred as they had no chest surgeon
   4. Peadiatric referral to ED would be suggested to see OPD of OPD is available

   Reason of 1 and 2 : the GI man does not want to care pneumonia patient and the Chest physician does not want to care UGI bleeding.
  My comment : they seems to forget gastroenterologist and chest physician hold a general medical specialist diplomate...

Reason  for 3 : the ED physicians( an "s" mean all of the ED doctors...) do not want to insert a chest tube ( should the board of EP retract their diplomate ???!!!!) ...

Reason for 4: The ED physician would need a paeds consult before any child is admitted and most of the time - the pediatrician would transfer the case out....

Well, anyone do something about it ... I am still waiting,.......

ghostly scene....

It is now month of the spirit... Well, some would think that on call in such a night would be horrible - imaging taking the lift alone: you never know what is waiting outside the door when the door opens.....Sometimes I got the creep wandering from ward to ward...but I never meet anything "dirty" during my walk...

1 wks ago, I was in one of the spiritual scene ... it was an average night and I was debugging my VB program. Patients came every 15-30 mins and I could not have a good rest in the call room. I was walking to the toilet in ED and saw one of the nurse (SY) taking a nap.. It was prohibited for nurses to take a nap in the night as they are working on 3 shifts basis. As most of the ED nurses was married with kids, allowing a short nap during night shift has become a practice provided that the ED is not busy. I asked her if she had a busy day and she answered no and went back to sleep.

Few days ago, when I took a over the shift, another few nurses told me that SY had seen something that night. After I walked into toilet, she was awaken by 2 persons in black. They walked into the ED carrying "COFFIN" and placed the big box in front of the ED counter. One of the man in black asked SY to take a BP for him. When they left, they mumbled a few numbers. Well, SY later placed a few bets with the number but it came out in another sequence. So she did not hit anything...

well, I was lucky I did not witness that...frankly said, chinese are particular about seeing those things - one would get sick or face bad luck after seeing those spirit.

10 more days to go..... in the past, the months of the spirit is small month for most of the hospital - people refuse to get admitted or doing surgery. But this year -it is different: I dont see the reluctancy in the past...well, good for our boss and hopefully a good bonus next year...

Syabas.... Malaysia....

Sugar cane juice....

I had this case 2 weeks ago....

I was having a chat with Han(Nephrologist, Malaysian) about the Anwar Ibrahim case in the ICU. The ED informed us that they were sending a patient up. In our hospital, sending a patient is an urgent matter : no matter how busy the ICU are, the patient is sent up STAT. Due to lack of nurses in the ward and ED, it had become a non-written proctocol.  Pro and cons with such practice but the ICU nurses had gotten used to it...

the patient is a middle-aged female who look ill. The admission indication is Shock. Indeed, the SBP was 60+ in ED. I took a glanced at the CXR and the right side of the lung is WHITE !. That means it is either fluid or consolidation. The lady was found laying on the roadside and heavy alcohol scent was noted. The patient was admitted to Han's service and both of us was thinking either a traumatic hemothorax or massive pleural effusion. A bed-side sono was done and pleural effusion was confirmed. Han did a tap with a needle and the fluid look greenish... Well, empyema . Pig tail might not be suitable to drain it so we decided to place a chest tube.

I had a bad experience in the past, there was this empyema and the pus was pouring out like a spring when I inserted the chest tube. So this time I told the nurse what I expect and she concurred as she had met such situation before(she was a senior nurse...). We were lucky not to create a mass.... within minutes the bottle was full...but strangely unlike those pus that I had encountered it was odorless...

Both of us felt strange about the findings...the smear had revealed a G+ bacilli....She was started on Clindamycin and Ceftazidime. Later she was shifted to Imipenem.

1 wks later - the culture came back:
   The pleural effussion - Streptococcus Viridins
   Blood culture x II - Bacillus sp.

Well - she survived the shock and currently stable - there was still 20-30 cc of pus daily drain from the tube....

She was cirrhotic (alcohol related) and definitely immune compromised (afebrile on admission with WBC of 40000+)... I wandered if the she had mixed infection and the bacteria had degraded the smelly component and making the pus odorless ?

oh, was that sugar cane juice... I almost drool...but just like Lem said, " I am going back for dinner don't show me those appetite spoiling picture..."(of coz I showed it to him - he was the one who admitted the patient from ED...)	full and yet still pouring out....

Abductor....

It was hell night... I was called every 1 hrs ...

I had just seen a female with acute gastritis and just about to leave the ED to my call room; the nurse told me that 2 MVA victims were on their way. I sat back to my seat and resumed to my VB project.

The ambulance arrived 5 mins later. 2 very young couple came in. The EMTs told us that they were MVA victim. Car vs divider. I preceded with the examination. Both have seat belt injuries. No airbag on the car so no burn over the face.

I was right about the girl but wrong on the guy. The girl was only 16+ and the boy eventhough look young was 20. After the treatment I asked the girl for her parent telephone and told her that she is underaged and I needed to informed her guardians. She gave the no to me without any hessitation. My past experience was they mostly would beg not to inform the parents. I called the parent up and the phone was answered by the father - I told him about the incidence and the condition of her daughter. I got a ?angry hung up before I asked him if he would like to pick her up. The parents lived in Taipei and I don't think that they would come but I still hope that they would sent some relative nearby to do so. I called back and the mother answered the phone. She was polite and told me that she would call me back to decide about letting the daughter leave with the guy(boyfriend a.k.a abductor as far as I am concerned). The mother contacted the daughter(I knew as she answered the call inside the ED) and later called me and informed me that they were unable to picked the girl up and told me that to let her leave with the guy...

I was too tired and told my nurses that they could leave as they wishes. I went back to sleep and did not see them again...

I had seen too many of such cases. I am worried to be frank. I had a girl and a boy and I don't know if they would ended like anyone of them. Maybe I am too conservative or too old....How could parents let their 16+ yrs girl leave home 400+km travelling with a guy ? Where is the responsibility of parents  - providing food and lodging only ?

I always believe there are lots of good elements in the chinese culture , especially the teaching of Confucius. Where ever someone told me if my children are undergoing any special tuition for english; I told them that I am not worried about their English - I had traveled so far back to the chinese land and wanted my children to command such language (especially the classic chinese(Wen Yuan Wen)). They could learn so much from it. But now, I am worried if they could really adopt the concept and core value of such teaching.

A better tomorrow...

I finally told the administration I wanted a reduced in my night shift....

After the asthma attack, I had found that night night had become a stress for me...I went off at noon and hit my bed/sofa/ tilam  by 1:30 or 2pm. In the past, I would wake up by 4 or latest 5pm and feeling better. Now, waking at 5pm means feeling bad - dizziness, nausea and heavy steps.

I had been having mild asthmatic attack from time to time - but recent 1wks , I had a big one again. Although I could suppressed with symbicort and prn ventolin inhaler but the feeling is bad.

I finally walked into the deputy superintendent office and told him that I wanted to cut my shift from 8 to 6...that means I would have 2 weeks with only 1 shift. Life could be much better hopefully. But out of my expectation - the deputy superintedent was not surprised - he had been expecting my request ! Well, he told me that he would work the plan with Lem ( he had been director of emergency department for 1+ yrs now) and Big boss - most probably, Boss and Lem would share 1 shift each... Well, I am glad , at least I would have a better resting time and more daytime work so that I could spend more time in ICU...

Pay might not be less as I could take up more day shift. I should get almost the same pay eventhough the nigth shifts are cut

My progress note program is currently running well. The Order entering part is under developed and currently at the final steps of adjusting user interface.... I am considering of taking some exam such as MSITP... but my aim is in the Nov. - the Medical Informatic Adminstrator exam organized by Taiwan Association of Medical Informatic, I had a 15 marks advantage over the other examinee - there is a part : medical terminology which score 15 out of the 100.

Well, a change in my life and I hope it would be better...

Ving had gone to a fortune teller lately and according to him - I am at the peak of my carrier : I am happy to hear such phrase but I am worried as after the peak/plateau there would be down slope and hopefully not a long long way down....

never ending learning...

My past few calls were bad - interrupted sleep q1hly either by the wards or by ED patients. I seldom spent time watching TV lately - mostly busy with my program while waiting for data. The currently phase would be finalized by next week. I would have to meet with the nursing superintendent and head of pharmacy again next week. The progress note and passover note part were completed 3 weeks ago. Although some minor modification is neither - both of the them were running smooth. The order entering and prescription printing part are my current focus. The core was completed last week but after a brief discussion with the head of pharmacy, I was forced to re-write part of the script. The head of pharmacy requested and insisted that the 1st day UD dose would need to be stated on the prescription. Eg: IV Tagamet 1 amp Q8H is not enought it shoule be IV Tagemet 1 amp Q8H 1st day UD = 2 dose(if the order is prescrbed after 8 am).

2 tasks more before I could proceed with the test run in ICU. 1. The list of oral drug were not enter into the database. 2. The re-printing of prescription part need to be revised - serial no. needed for each print out prescription to facillitate the reprinting process. Why test run in the ICU ? well, I am one of the ICU attending physician - more easier for me to implement things. The ICU is a closed unit and manuplating is more simple. The most controversial part is the temporary telephone order. The nurse would need to key in the prescription on request via phone. The ICU nurses are more senior and able to carry out this job without problem. The ICU test run would last for 2 weeks and after the run and review. It would be implemented throughout the hospital. Then I shall move on to another project.

I enter a phase which I ever imaging  - writing computer program .Once, I thought becoming a physician is the last thing that I learnt to be.  But now, I knew more surprise I would get if I keep on the hard wark of learning.....

to helmet or not to helmet....

It was tiring morning..... I was post call and I got a phone from the combined ED down south..

"We had a case of head injury with SDH and we wished to transfer him to your ED", the doctor talked to me over the phone with Cantonese slang. (Hong Kong with ROC citizenship...). I agreed to his request as the ICU was quick empty ... I asked him what was the GCS and wheather the patient was intubated and this was the reply :" The GCS is 6 but he is breathing smoothly, so I don't think he need intubation at the moment...".

What a professional answer I got.... this was what the local people down south derserved. A special fund was set up to upgrade the service the ED service - the doctor was paid RM100/hr and these kind of doctor was hired....

The patient arrived 1 hrs later and there was a nasal airway in his nostril. I took a glance at the CT. The hemorrhage was minimal but there was severe midline shift. I told the family, ops was needed and I needed to intubate him stat.

The guy had short neck and small mouth - short than mine...I tried the oral approach and failed. I did a second look and still failed to visualized the vocal cord. I decided to go for the nasal path. I was lucky as the patient was still breathing heavily. I passed the tube successfully during my first trial. Well, he was up to the OT within 40 min . That is the advantage of a small hospital ... fast and efficient of clearing patient from ED.

I obtained the history and found out that the patient had fallen from his bicycle. He had gone to the famous Kenting beach town with his wife and children. They were doing a joy ride in the morning. Unfortunately the person who rent the bicycle did not provide helmet. He had fallen and knocked over his head... The history had reminded me about a news I saw 2 days earlier - a police who took part in a bicycle ride with his chief. The unfortuante policeman was cycling down a slope a loss control. He was riding with full gear but the speed was too fast and he sufferred from intracranial hemorrhage and cost him his life...

Well - better stick to my helmet(my head ...) and Strida(not the efficient but slow is safe...)   - I am doing my ride consistently and I dont want to end up like anyone of them....

Visual Basic Programming

It had been 3 wks since my last blog... well, I was stucked with a project... Few months ago, I was appointed as second chair to the patient safety committee. The was this issue about the passover of doctors requested by the evaluation board. I was learning visual basic then and I took over the responsibility to write a simple program for this passover procedure. The concept was simple - each attending doctor enter the passover note of relevent patient on the computer and the doctor on call log on to the computer and read the passover then print it out and signed it. The concept was adapted from one of the university hospital. Well, just enter, write into file and read it out and print.... Well, the program took me few months to complete and it was very raw ... the was this obsticle keeping our staff to using it - the biodata of pt - > entering the biodata is not a simple task for people who are not good at chinese input....so eventhough it was ready but it was never in use. Until the last attack visit by the local National Insurance Agency officer - the inspector complaint about different handwriting and not so up to date progress note. So I was thinking of writing a Progress Note Program .... this time, I would need to get access to the hospital database. So after a few discussion with the project manager (our hospital computer system is contracted to a software firm), we had worked out a solution. I was reluctant to do in the past because the hospital would be billed for every task done by the firm. 

 After 6 weeks of effort - the program is currently online.... The Nursing Specialist would benefit from it and hopefully some of the doctors would like it......The passover program was integrated to this program and currently on its 2nd days of test run...... I mastered several skill during the process - mapping drive, cutting a long sentence into different line and accessing database. I am learning as an apperentice programmer and trying to evolve...The health department had started to pushed the concept of "paperless" hospital but it is currently governed by the electronic medical record act - 11 hospital had entered the project but I doubt we should follow.... there is one requirement which is strict - each record enter would need to be transferred to the mainframe of health department - electronically signed and stamped with a date and time then sent back to the local hospital computer before it is saved. That means once the progress note/ order sheet/ nursing note / imaging or whatever could not be altered later..... well, which I dont think is executable at the moment.... My next project is currently the order entry system ... I had a deathline of 2 weeks and I intend to make it...

There are lots of books regarding basic of VB2005 but only few of its talked about advance technique, most of the time, I would need to browse the net to found a solution...

Proper passover

I was doing my rounds in the ward and got a phone call from my ortho colleague K - urgent call to the ICU...

The nurse was preparing O2 for the patient at the bedside. I positioned myself to the bed top and started to bagged her. I spot the oximetry reading was 80% when I reached the bedside. I knew the case - the nurse in the ward had called me last night - the family was complaining in a bad manner about a bruise over rt forearm....

The patient is a 70 y/o female who sufferred from a femur fracture and undergone surgery few days ago. She had also suffered from some brain tumor and undergone surgery few years back. Both her son were drunkard and a lady was hired to care for her in the ward. The son would come to the ward on and off under the influence of alcohol questioning the nurses this and that. Most of the time, the sons would calm down after explaination by doctors. The bruise was noted after removal of a venocath. I explained to the son and calmed him down. The patient had c/o abd pain and I attended to that. A frank epigastric pain with normal EKG. She was troubleb by such problem since post ops. A small dose of pethidine would make her sleep all the day and some respiratory depression was noted. So NSAID was given instead but after couple of shot she had this epigastric pain and peptic ulcer was impressed.

I gave her a low dose of pethidine and some cimetidine.... no more calls about her that night...
And now, she was laying in front of me waiting for her intubation... K told me that she look drowsy and gasping for air was noted in the morning so he rushed her to the ICU stat.... She was confused and not fully comatose. She was biting and took me some strengthed to open her mouth. I managed to intubate her in 1 trial and sedated her with some propofol...

The SpO2 was quickily elevated to 100% after a few bagging... that ruled out pulmomary embolism but the heart rate worried me... it was 180-200/min on the monitor since I lay my eyes on it... the BP had crushed to 60/40mmHg after the intubation. I double checked the tube and the patient and nothing suspicious. By the time the hospital director and cardiologist was beside the patient. I proceeded with a internal jugular CVP and the reading was 12cmH20 - her skin turgor was poor though...

An EKG 12L was done and ischemia was noted. The rhythm was atrial fibrillation with rapid ventricular response. I decided to shock her as the BP was still lowish even after dopamine use. The cardiologist concurred with my decision and proceeded with the cardioversion starting with 30J(biphasic,sync). No response after the 1st shock and the current was increased to 50J (she was obese...). The 2nd shock resulted in asystole and chest compression was commenced.This was the 1st time I had an asystole after a sync cardioversion.... We managed to kicked back the heart within 1 mins and we got a call from the lab.... the sugar was 34mg% only.... what the @#$%^^&&***,(it had been 30min since I started to managed her...)  I mummbled while ordering 4amp of 50% of GW.....  she regained conscious after the sugar injection but her vital sign did not stabilized. She started to have fever and we had started her on dobutamine and steroid... Now, multifactorial leading to her failure... When I probed back to the history ... a sugar check was done in earlier that day in the morning which revealed 69mg% : the lady caring her had offered to feed her but she had only eaten some and vomited moments later - this event was not reported to the doctor nor managed further after the vomiting.... one of the crucial point. No proper passoever about the sugar reading was done during the passover to the ICU nurse....her hypoglycemia maybe due to poor feeding and finally worsen by sepsis....

She was still there this morning during my rounds - we treated her as septic shock with EGDT regimen. Her BP was ok and now the urine ... only 300cc for the past 22hrs...

Lesson of the day - sugar check !!!!!!!

patients.....

I had bad attack after the bike ride last Friday .... After the clinic session, I went home and felt very tired... The afternoon nap did some help but I had this shortness of breath again in the night... Ving drove me back to the hospital and I took the O2 tank home. The O2 tank re-energized me... but the rest of the weekend was not stable... I did not stopped my prednisolone and continue it to D10... By Wednesday I was better and I stopped my prednisolone use. I did a ride again - but with cautious. I did 3km over 20 min... The fatigue sensation was there but better. No more attack requiring any neb use. I did my 4km ride today and hopefully no more attack....

I had to give up the 3km run in Taipei... a sorry for Yun but she could understand it....

Well, a great experience for me ... .I am glad I am trained as a physician. Eventhough there were helpless moment during the attack but I knew what was the extend and what would come next - imaging a public who knew nothing about asthma.... the stress was not only on the patient , but on the families as well.

Lesson learned : " Be a patient and learn to care more for your patient.....  "

almost had it - part 4

What did I had ?
 
The symptom was so severe that I almost got admitted to the ICU...  The tachypnea was worsen partially due to my obesity ... time to lose weight....

Looking back to the course of disease, I think something had triggered the attack and it was not only a pure exerbation. I might had an viral infection that triggered it. The recovering was dramatic and I am back to my normal self now.

For the past few years, I had on and off attack during the winter and at one time, the symptom was so bad that I had shortness of breath on climbing stairs. But the symptom was better after the winter. This episode of attack was out of my expectation. I did not see it coming and was hit very badly. But I still believe that it was karma - time to pay and I am lucky that the price was not that high...

A narrow escape for me - I valued every smooth breath I take now.... the sensation of enjoying every breath is so good....

I had tappered off most of the drug and currently on long term inhaled steroid use only... I had this developed peptic ulcer due to oral steroid use and I stopped them yesterday.

I did a 6km ride today and tolerated it well; I use inhaler prior to the ride just to prevent any exercise induced asthma attack. The fatigue of body ( ? due to hypoxia) was still noted, just like a hang over after a heavy drinking night...

My challange come next week - the 3km run with Yun in Taipei ... Yes, it was planned 1 months ago and at one moment, I think I couldn't make it but now, back to preparation ....

Almost had it - part 3....

The sleep was bad.... chest tigthness and tachypnea....I was confused as I had never had similiar attack before. I was only slightly improved and I not really better. It was Friday and my round to the land of the lion govt clinic...

The "land of lion" govt clinic is located down south 40 km away from the southern tip of Taiwan. The clinic is currently under construction and the clinic is temporariy relocated to the local library. No air con was installed and it was good damn hot that day... My symptom had worsen again after a while, I took a couple of inhaler but it only relieved for a few minutes.... I need to take a few sigh from time to time to relieve my shortness of breath.

I finally reached home by noon and did not feel better. I told Ving that I might need to get re-admitted later that afternoon. Ving was very very worried... I was in a dilemma then - some O2 use may eased my discomfort but admission would panicked Ving... By now, I had reliazed that I had tappered my steroid too fast... I had only use methyprednisolone 40mg q8h for 2 days and changed to oral dose of 20mg tid on D3....Way to fast, during an acute attack - 1mg/kg is recommended and I am 90+kg : a use of at least 30-40 mg tid is needed....plus I did not use any oral ventolin nor theophylline tab... I gave in by 8pm.... I took a drive to the hospital - I saw the panicked and terrified look on Ving's face, when I told her I need to get admitted ... she offered to drive me but I denied - it was too late for her to drive such a to and fro distance....
I reaced the hospital by 9pm and got admitted... The chest physician was running the night clinic and he admitted me... he hit me with everything ... IV methyprednisolone, oral aminophylline and ventolin plus regular neb....
I slept better that night - thanz to the O2 use...but I did not get better. I was still breathless and need to sigh on and off to get some new air.
All the side effect of noted
 Headache and flushing - aminophylline + ventolin
 Mouth dryness - ventolin
 Dizziness - antihistamine
 Gastric discomfort - steroid
 Palpitation - aminophylline + ventolin

I just laid on the bed and put on my O2 whenever I sleep.... Ving came with the kid on D2 and brought me some food .... Once a while ( for mintues to hours), I could feel that I could breath smoothly and I thought I was better, but it was just for a while.
By D3(Sunday) - I was better and I discharged myself in the evening. Better means improved but not fully recovered. By this time - I started to wander about my condition - would I recover fully or I would have to go on prn O2 or lifelong oral tab ????? I just can't bare to think about my condition in the future...all I considered was - can I do the shift on Monday ?

I decided to do the shift ... at least I could use O2 when needed...and I was restless and having poor sleep due to the oral medication...

I wandered around the hospital with unsteady gait and inserted 2 CVPs with my trembling hand.... and put on my O2 nasal prong whenever I lay on the sofa of 175...

Amazingly the SOB sensation went off and I was almost well when I get off by 6pm Tuesday .... it didn't happen like a snap but I felt almost normal when I reached home....

I knew I had my life back and had an near escape from the gate of HELL....

almost had it ... part 2

I was better in the morning...
my SpO2 had returned to 99-100% and I had felt better....I discharged on the next day due to 2 reasons:

- there was a night ED shift waiting for me...
- I had felt better..

so I discharged by noon and did my call...

There were severe things that were notable...

1. the ward room was too small - I had a twin sharing room... but it was still consider very small..

2. I am a attending physician in the hospital and I don't have the priviledeg to get a single room - yet another fair and square and justice dilemma - the hospital is almost full and you just cant ask patient to without a proper reason...

3.There was no clock in the room - very unconvienent

4. The vital sign check was not that routine...

5. Never do enchaned CT in a patient with shortness of breath - very very dangerous - trust me , I experienced that.
When the nurse inject the contrast medium (I had ordered a 2nd gen non-ionic medicum), I told her to inject me with subcutaneous epinephrine first before she bagged me ... and you know what ? she asked me why ? ????? and what the FFFFFFFxxxxxKKKKKKK, one of the crucial steps of managing anaphylactic shock - I knew if she follow the ABC, I would have get the epinephrine jab hrs later when someone recalls it.......luckily I it did not happened. But I got this palpitation during the procedure - imaging the effect of aminophylline + neb + contrast medium.... I almost had it again...stupid stupid move to do CT at that time - but I was so worry that I had any gastric disorder...

6.It was a good way to loss weight - 3kg in 2 days...

7.Sanitized the toilet thoroughly before you sit on it... I got this UTI on D2...crap and strain sensation over my bladder.

8. 6 injection over my upper limbs...
I got the 1st one over left hand dorsal site - removed when I thought I was better
the 2nd one was the Arterial blood gas over the antecubital area- luckily 1 jab..
the 3rd was over the left intern vein(cephalic)( missed !!! and I had got good vein )...
the 4th over right dorsal hand - 1 shot
the 6th was over left intern vein( yes...left side again) and ruptured!!!
the 6th is over rt antecutibal area a 20G for IV contrast medium..
well, 6 pricks in 2 days....what a record for me...

right antecubital	rt metacarpal arez
left antecubital	left cephalic vein

well.... I went home and got a not that good sleep and ...there was still part 3......