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....