somemore could be done...

I am sitting here in the govt clinic for specialist clinic session...life is boring here but the payment is good. Usually the patient no. are countable with fingers...

Unlike the klinik kesihatan(govt. Clinic) in Malaysia - it does not serve the local people well... I had this mother who brought her vomiting child to clinic few weeks ago. No injectable/suppository anti-emetics...I planned to refer her to our hospital which was 5 km away - but she refuse : money problem .... the govt clinic is free of charge...

I have this old lady with dizziness and headache today - her SBP was 240mmHg ( double checked !)... No NTG, no captopril and not even nifedipine(It is contra-indicated,I know...), all I had are those long acting once daily dosing antihypertensive, and the lady had taken her usual losartan and esidri in the morning.....I drove her over to the hospital and on the way she kept asking me about the payment....

Well, I think I would bring a small amount of medication - NTG, Captopril, Supp Domperidone next time...at least I could do something for them....

Nasogastric tube is for drug feeding only....

I had this old lady who was resuscitated from a DOA(death on arrival) situation... The admission diagnosis was Suffocation... I asked Lem how did it happen ? Lem told me she was a victim of stroke and an nasogastric tube was in use. But the family said they feed medication via the tube and "FEED" the lady through mouth. The lady was choked by this papaya !!! I had seen many case that suffered from aspiration pneumonia because family and patient refused nasogastric tube placement for dysphagia due to stroke, but such case was the first one I encountered....

Well -she was still E1VEM1 before I went off yesterday.....

175

175 had been part of my life since 12 years ago....There was once I thought that it had become history...now I am living with it again...

In the hospital, whenever there is a incident that needs the ED doctor - either a patient in ED , or procedures in the ward; 175 would be the answer and solution....

175 is the extension number of the call room. I was introduced to this room the first day I worked in this hospital. I had slept in the room 10 + days per months in the first 2 years. There was period of  6 months when I did 20 night shift per month. It ended when I gone home to served the MOH. When I came back, it was still there with some minor changes - a desk with chair was given.

the room was slightly smaller than the hostel room of Hospital Tengku Ampuan Rahimah. There was 2 double decker beds - there were 4 of us when I started to work there. We were all classmates... No TV nor refrigerator initially. 6 months later, one of the senior management staff came to the room and decided to give us a TV( 14") and a small fridge ( I mean small, the smallest - just like what you see in the motel. ). What could a resident grade doctor demand then? after all it would be good enough if there is a good bed to sunk in during the endless night shifts. The cleaner would come in daily to mob the floor with chlorine-added water. The condition become worst when I left. The management started to bring in more locums and no one care about the condition. There were a lots of staffs  - bags, overall coats, jackets, drinks , we don't know who left it and no one bother to dispose them...
When I came back from Malaysia  the 175 was in a greater mess .... but I could live with it as a bed, a TV and a fridge was enough for the stressful night...

175 was still there on my 2nd come back - but this time I had a desk in the attending physician office . But most of the time I would hang around in the 175 as Lem ( my classmate cum colleague. he had made head of ED then) was there and we could chat and watch TV together.

Recently we had a Surgeon reported for duty and the doctor's office is too small to add another table. The deputy hospital had asked politely if I could vacant my desk - I gladly complied as I did not spend much time there. Lem was also being asked to move out from the hostel(It was a building in the same row as my previous old residence) to vacant a room for the surgeon (he hardly sleep there so no harm..). So to compensate both of us - the hospital service manager had offered to refurnish the 175, he had given a lots of his innovation during the requesting session - at least Lem was the Head of Department ....

A thorough cleaning was promised and some  new furnitures. We tried to clean up most of the unwanted staff... and the cleaner came and did a good sweep. But the serviceman told me that no new furniture is being ordered and only the mattress would be replaced. Well - crap shit....all those staff discuss before were not being implemented. I was feeling upset and that night during my call, I had told the night shift nurses about the incident. One of the nurses suggested that we should have a sofa than...

I ended up drawing a design chart that night and passed over to Lem in the morning - he gladly agree with the setting and told me to carryon. The chart was passed over to the service manager and forwarded to the management then.... Few days later, there was a new change in 175 -> the upper decks of the beds were removed and we got a sofa. There was a locker for each of us ....when the rennovation was done the service manager said that we should make a signboard outside the room to warn there other staff  (the ambulance drivers and surgical assistants) to stay away....He said that strong word should be used. But I gave him another suggestion...and he accepted it...

Now the 175 is no more a call room - > it had become the ED physician's Office. Truely, it look like a office now - 2 bed with good matress , a sofa , a desk and internet connection. And also we had a bigger fridge...On call life in the hospital had never be so good before....

the young and the old

the accident happened in an early friday morning...

a bike rider had rammed a old lady...

The old lady was almost 80 and she had poor eyesight, poor hearing - her job : kalung guni (refer http://en.wikipedia.org/wiki/Karung_guni)...she was later sent into our ED by the local rescue ambulance. She was alert on arrival, holding her rt lower leg and yelling at how pain she was...her right face was severe swollen and she look terrible...her BP was stable and I did the usual assessment. There was definitely a facial bone fracture and probably some intracranial bleed. Chest and abdomen was clear and the lower leg closed fracture could wait...but the face swelling worried me; she was very thin ~ 30kg max, and the skin was so lax and the space between the skin and bone are spacios. If the swelling/hematoma expands, the airway might be compromised and I would need to intubate her...I told the family on my first explaination about her condition.
Although she had no neurological deficit, the brain CT confirmed my suspiscion of intracranial bleed - some SAH and frontal ICH - nothing much needed. But her BP crushed ( SBP was 70mmHg) on returning to my resus area. I was thinking of demerol effect, but I had given her only 25mg intramuscularly. I did a second assessment and yet no suggestion of any chest nor abdomen contusion. I flushed in some fluid and the BP return to satisfiable level. But I was cautious and did a chest and abdomen CT. The CT was clear and I sent her up to ICU as the family agreed to be treated in our hospital. The families were local peoples and the old lady had a major trauma 3 years ago (pelvic fracture and ICH) and recovered well after treatment in our hospital.
The BP was not good on arrival in the ED. The SBP was again 70+ mmHg. I inserted a CVP via the rt side of neck. The swelling of neck was noted now. The CVP level was -2 cmH2O and I ordered a fluid challenge and proceeded to the weekly morning meeting.
It was not long before I was called back to ICU to intubate her. The nurses were ambubagging her and got into the position stat. I glanced at the monitor before I did my trial. The HR was 50/min...she was crushing alright. The swelling had extended to her neck - airway compression had happned. I regreted that I did not intubate her earleier. The following process was more shocking. I had difficulty to get a good view as the facial swelling had made the mouth opening part difficult. Then I noticed freshed blood had flooded her mouth. After suction I could still get a good look at the vocal cord. There a swelling under the epiglottis. "Damn !", I yelled in my heart - 2nd time I regret that I did not intubat her earlier. I did a second look and waited. She was still gasping and the instant she sipped her air, I noticed the opening of vocal cord and successfully put the tube in...Now, the question : where the heck the blood come from ? I did a thorough check this time - there were multiple laceration in the mouth - the tongue base, the upper and lower gums...The BP was unmeasurable at the time. I ordered a lot units of blood...The BP was so bad and I don't think it would be appropriate to sent her to OT. I decided to do it ine the ICU.
I summoned the surgical assistant and 2 nurses(one of the OT) and we did it in at the side. The surgery took about 1 hours and we finally patch up all the wound. But blood was still pouring from the nose...
I finally make up the story : the old lady had swallowed all the blood until she went into hypovolemic shock. She was comatose finally after all this was doneo, although I got a good BP then...I went off by noon.
Before I took my supper that night, I called the ICU and found that her BP was again unmeasurable and nothing was done. I ordered more blood and went to sleep. If was an off day for me but I called the ICU and found that her BP was stablized again after the blood transfusion. The bleeding from the nose was less but she was still comatose.
I saw her again at noon on Monday. Her BP was stable but no urine was noted. The worst had happened. She had acute renal failure after the shock episode. She was comatose still. Her BP started to crushed again since that day and we lost her last night...

The young bike rider was sent to ED later after the old lady was sent to ICU. A young man who bared a backpack with a tennis raquet in it. He had 2 earing over his rt ear. Petrol smell over him. He had some abrasion wound and contusion but nothing serious. I treated him and adviced him to called up his parents. He refused initially but later called his mother after we insisted. The conversation did not go well - the young man hung up and told us that his mother refuse to come...The way he told his mother about the incident was rude - he said he had an accident and knocked someone, but refuse to give any further detail.  We later sent him to the toilet to washed away the gasoline. He left his phone in the ED and it rang. I answered the phone and it was his mother on the other end of the line. The mother was calmed and I told her what had happened and asked her to come over as the old lady was in a critical condition(she was not intubated then....). The young man later returned to the ED and rested on one of the bed. The nurses chatted with him and found out that he was a 4th year English faculty undergraduate; he was planned to the Annual Spring Shout Festiva Concert in Kenting....He asked me what was the statue of the patient - usually  I would told the person who knocked the victim - against the ethics. I would told them that I could not reveal the detail but if he wanted to know more he can stand among the families and listen to what I said. I told that the old lady was in critical condition(what a crap, one should be in critical condition to be admitted to  ICU !). He then mumbled to himself - I hope I could just attend another Annual Spring Shout Festiva Concert before I am jailed...all of us in the ED shaked our head after hearing his words...My thought was - it was a 3 days off (Fri to Sun) and he should have go back to gather with his parents instead of attending this concert....When I told Ving about this incident - I got shock again; Ving said the young man thinking is positive - freedom is what he is seeking....I think I am really old . I felt a little deserted - not belonging to this generation anymore, none of the feature on that young man I wanted to be present on my children. I wanted them to be "good" - lots of people asked me about teaching my children English but I would politely tell them that I am not in a rush. Maybe later I said. But deeply I felt that I had come so far to this soil and it happens to be one of the origin of chinese studies. A good master of chinese would let them learn the core of chinese ethics and hopefully for my children would grow up and become one of the model people I look up to...