discharge them all and admit them again next minute...

I was informed by the nursing station that I need to discharged my patient and re-admit them on 1/31 and 2/1. Just a change of name and registration.
The department of health requests middle-size hospital to reform its structure. Most the middle size hospital are around 250+ and owned by family/company. Anyway the reform include a certain element - the change of name, the signing a new contract with the insurance agency...
the old hospital would need to bed disbanded theorically. So all the patient would need to be discharged and re-admitted -> paper work again !!!!
So I wrote discharge summary and re-admission note and order for all of my patient ( 9 of them ), it took me few hours to complete the job....the whole hospital was busy over this paper work this 2 days....

Our hospital is one of the unique hospital in Taiwan. Only govt hospital is named according to the local town name. But our hospital was named with the local town name instead. A lot of peoples mistaken we are a govt hospital....so we still retain our old name but the new name according to the new naming system sound odds : it is like

   eg. Ipoh Medical Organization Ipoh hospital....

But who cares - as long as I get my salary on time....

I did not insist...

it was this evening when I just took over the shift...there was this call from the local a rescue dispatch channel - MVA with 3 victims ( 1 was Death on arrival).
We were prepared when the case arrived. The DOA was a young man with tattoo, there was another person on trolley who looks alert. But I did not see the 3rd victim. A local samseng came in and pointed at the DOA telling the registration desk that the DOA was XXX and the other was YYY.

The DOA was rushed into the resus room. My senior (fellow Malaysian, nephrologist)had just walked pass the ED, he took the other one and told me to concentrated on the DOA. There was blood spreaded all over the DOA scalp. As usual, CPR was commenced and I intubated him stat. As the nurse was trying to get a line, I did a primary survey over him. There was no wound over the scalp despite the blood. There was this mandible fracture and blood was coming out from his nose and ear...skull base fracture. The blood was pumping like spring as the ambu-bagging commenced. The nurses had to put a suction is his mouth for continue suction of the blood.  There was difficulty of getting a line. Needle mark was noted his ante-cubital area - an IVDU. The neurosurgeon came by with his NSP and both of them sworn that they knew the patient as his tattoo look familiar. The tatto was over his anterior chest and abdomen, 3 devilish head was noted.

There was subcutaneous emphysema and I inserted a chest tube over each side. Still PEA and no response. I ordered some blood but still no sign of it after 15mins. Then someone told me that the family had come. I left the patient to the team and approached this couple ( middle-aged, husband and wife). I asked them who they were, they told me that they were XXX's parents. I broke the news that the patient was noted with DOA and currently no responsed was noted. The mother cried ," I couldnt bare to see my son in this state" and almost collapsed. The father helped the mother to the seat where she could rest. I returned to the scene and continued with the CPR. It was 20+ min with no response despite all those tubes I inserted. But there was still no sign of my blood...
I finally gave up at 30+ mins. The lab technician came in and told me that he had doubt with the blood test and he wished to request for another sample but unfortunately he was too busy to call us...I almost burst out with the 6 letter work started with KN....I told him never mind. I then proceeded to the parents and broke the news...The mother fainted on the spot. After settling the mother,  I went back to the computer desk and look at the records. There was another victims and was managed by my senior. The 3rd casualty did not registered though.

While I was completing the entry of the DOA victim. There was this loud shouting outside the hospital. I went out and had a look. The father was shouting at the samseng with those KNNxxx words. Appearently the samseng had given the wrong name to the registration desk. The real XXX was standing alive outside the ED. The death victim was ZZZ instead. The mother was so happy seeing the son alive....well, I slipped away from the scene...part of my fault, never insist they take a real good look at the victim.

I got a call when I was back at the desk. The lab technician called me that he was not going to issued the CBC data at it look very weird. I asked him was it the hemoglobin value ? He said yes...I told him to just issued the report without asking him about the value. I had known that it would be very very low - indeed the report showed Hgb of 2.5g/dl. Still not the lowest - I had seen Hgb of 1.7 g/dl from a person walking a live. It was a young female with schizophrenia. I saw her many years ago. She had presented to ED with dizziness and she looked damn pale. I repeated that check twice. I did a very detail history taking later. Appearently the patient likes to poke her anal with chopstick and bleeding was noted.

1 hrs later, I broke the news to another mother, she came with her daughter and both of them looks so calm....well, imaging an IVDU could do to his family - not surprise with their response....

knowing your weakness...

ENT

There were a few coxsackie virus critical case lately causing a few lifes....one of the senior paediatric infectionist had gone to the media and claimed that the victim was seen by ENT surgeon instead of paediatrician leading to delay of treatment. The ENT society was fury about this statement and threaten to sue the infectionist, they claimed that they are capable of treating flu and could diagnosed coxsackie...

Indeed this is a very wrong concept here. A lots of parents who took their child with flu-like symptom to ENT OPD instead of paediatrician clinic. The ENT OPD had 2 "special skill" -
1.the throat washing
- the ENT surgeon would swab  some solution the throat after throat examination, I think some anesthesia is added ,because the pain is better after the swab(I tried it before during my college's days...).

2.nose washing
- washed you nose with some saline solution - may improved nasal congestion...

Well, I do believed the above 2 "skill/treatment" may eased the disomfort of flu-like symptom but it won't shorten the duration..
As for abilities of ENT surgeon - no doubt, some of the coxsackie virus infection present with nose,throat symptom, but to complete asess of such patient, a doctor might need to auscultate and search for rashes...key point : for a ENT trainee who have the chance of doing 1 months elective posting in paediatric ward - can they mastered the skill of cardiac auscultation / rash differential diagnosis ? I doubt it....but for income sake, they are defending themselve and protecting their income...a pity and over confident act...

As a physician I questioned the abilities of ENT surgeon to properly managed paediatric patient who presented with flu - these kinda patient should not be their key income...many ENT surgeon just ended in OPD washing thraot/nose and not doing their proper part as a head,neck surgeon...

I recalled a senior emergency physician who claimed that the training of ED physician is very up todate in a forum of a newspaper...Well, they did not realize how weak they are - in the O+G and ortho/trauma field....similiar situation - over confident . .... I wander if they dare to raise their hand when a doctor is needed on a public transport...

Politics...

I don't like politics.....
 The general election was over last week...unfortunately my ex-boss did not make it, he lost by 9000+ votes. He is good guy dedicated to service the local community, but the election showed how cruel was the reality - out of the 20000+ votes in the local vicinity , he won by merely 600....half of the local residents did not support him...frankly said, I had the similiar feeling when I worked there - most of the VIP's medical charts were so thin - they hardly visit the hospital - only in an emergency situation they would come...

 Allegations and "Black mail" was sent to local health department. The head of psychiatric department was arrested and put under custody for issuing false medical certificate.  Staffs were under big stress. It is all because of politics...hope everything would be fine after the election...

Our ex-Health minister is another good example.....

local OPD

This was my second OPD session at the aborigine area* In the past, the aborigine areas were secluded place. Most of the doctors were unwilling to serve such part. Lack of doctors were the major obsticle however as the local aborigine speak their own language(believe me, it is sound just like malay, eg, " maburok" = mabuk..) and communication become another problem. The government had however setup another special scholarship for aborigine. The aborigine undergone a special examination(not the usual unified examination after high school) and selected into the program. After they graduated they would be sent back to the local health clinic and served there(10 years contract !).

In the past, lots of candidate was unable to graduate from med school - they were the elite among aborigine but still too far behind compare to the non-native elites. But things has changed - now many aborigine doctors had not only graduated and passed their license but also hold specialty in family medicine. But as hospital was not easily assessible from the aborigine area - the government had setup fund and sending specialist to this area. Our hospital were responsible to support 2 such clinic. The pay is good per session and the clinic is not that busy...

One of the clinic was near to our hospital a mere 10 mins drive...I been there last week and this week I am sent here to this clinic 26km away...The clinic is currently undergoing renovation and the clinic is temporarily shifted to the front hall of the local library.

I hope this would be another easy day for me...(I saw 2 patient last weeks...)

*Area is not a the accurate name ... it is supposed to be "Xian"(鄉), it is an administrative unit, something like a district in Malaysia. It's administrative head is elected and has a representative commitee(member also elected).

a better year ....

Our hospital hit the target set by the national health insurance bureau(NHIB)....a good news...but there is another impact coming on for this next few years...Due to the standard set down by the new hospital evaluation system - our current design could not coup with the standard and we will be building a new hospital and shifting to another part of the town. The new site location is better - more land, and it is just beside the main road. But the construction would eat up our profit and new staff shall be recruited - but no doctor prefered to work in this part of the country...

Well, I hope I made the right choice by coming back to work here...

 I heard this news from someone inside the NHIB, my ex-hospital did not make it to the regional hospital payment list eventhough they were rated as good during the hospital evaluation. According to the new evaluation system, all hospital will be rated as passed, good and excellent. Payment for each procedure/treatment would be graded into 3 class - the medical center grade, regional hospital grade and area hospital grade. In the past, hospital evaluated as regional hospital would be paid accordingly. But now, hospital would need to be ranked according to the evaluation score. Only certain % of hospitals rated as good would be pay according to the regional hospital grade. My ex-hospital was ranked only in the middle portion of the list. They might have nothing to loss - the budget allocated might still be the same and as payment pertreatment will be less , they would need to work harder to earn their previous load. But my ex-boss is running for Parliment seat lately and if he won the seat, things might change .....you just never know...

being tough...

It was a cold morning...I was preparing breakfast and watching the morning news on the TV. There was this running segment showing about "Ma country" health minister stranded in sex scandal...the Taiwanese use short form ---- "Ma country" could be Malawi and could also be Malaysia.... I quickly go to the door step and get the morning newspaper....I then glanced throught the news paper's international segment. The was this photo attached - a half naked lady sitting on the bed and a male standing...well, indeed it was Malaysia the news referring too...

A kinda shock for me....Big big news...a quick rising star in the Malaysian chinese politic circle - a little too fast I think. He was state excutive councilor (equivalent to state minister) for quick sometimes and suddenly he was in the cabinet as a minister without going through the position of parliment secretary and deputy minister. I am surprise he refuse to resign initially, such a big scandal.

2 years ago when I went back to Malaysia, I paid a visit to my old St.John HQ and chatted with my ex-area commander(now state commander). He told me that the Heamodialysis centesr they were running were about to shut down as this minister strongly required them to get a part time/ preferably full time doctor to station in their Haemodialysis centers("s" means more than 5 !)..I was their choice before I left and they had invited me to join, but I was dedicated to get my specialistship so I turned down their offer. He described a very embarrassing gathering with the minister showing a "hard rock" face during a offical function of haemodialysis center. A tough man with a strict manner...

After he declared his resignation in the evening, I read the interview published on the Sin Chiew net ... He is still "tough" - he claimed that he was caught because he was unlucky and because he used the same room in the same hotel ..... I am glad he was unlucky and have to step down....  a man setting some stiff standard for others but blamed his bad luck for being caught doing something wrong - what a politician...