1 step nearer

Time : 9:00am
“Welcome to the Navy Seal CRT selection program the ACLS instructor course pretest…..”
I was sitting in the lecture hall in a medical center, anxiously waiting for the result of written test.. it was 30 minutes to my destiny . I was confidence this time though, unlike my last 2 trial. I finally realized I did not study well in the past – that was the cause of my failure in the past. For the past 1 week I had read thoroughly and downloaded questions from the ACLS joint committee website. I studied till late 2am and get a good 4 hrs sleep. Left house by 6:30am and grabbed myself a Mc Bagel with bacon and egg, latte and hit straight to the express way 88. It was Sunday and the traffic was light, I sprinted (speeding of coz…). I managed to reach the medical center (unlike Malaysia, medical center is the highest grade of hospital here) in 25 minutes. I glanced through my ‘arsenal’ again and headed to the lecture hall 20 minutes before the written test start.

my arsenal - the pocket booklet was borrowed from ED

When I answered the last few question, I was confidence – I did well, I had less than a handful of questions which I was not sure of the answer– rumors in the past said that you will need to answer 40 out of 50 questions correctly to pass the instructor written test.

I waited for the introduction lecture to conclude – this was my 3rd lectures in the past 3 years. I looked around- about 150+ came to sit for the exam – most of them were 4th year resident or fellow doing their subspecialty training. I was one of the ‘senior’ on board.
Well, the result came out 10 mins later than expected and I saw my name being marked by a glowing marker – that means I made it ……half of the participants were slashed. The rest of us were sent to a smaller lecture hall.
This was the 1st time I entered stage II. I was anxious – it won’t be easy …. Stage II comprised of 3 stations – the megacode , the airway and CPR as in the ACLS provider course evaluation. But the examiners (or committee members) were either ED director of medical center or Superintendent of some hospital. The marking would be very strict and the schedule had stated clearly “high quality BLS/CPR is required during the skill station…”

I am not worried with the megacode and airway station , afterall, that was what I did for a living. As for the BLS station, I mumbled, “definitely a Skillguide attaches to the Anne…” It had been at least 4 years since I lay my hand on an Anne with Skillguide.

Anne with Skillguide

Well, I was wrong… I was sent to the CPR station first – 30% of the rescue blow was not effective and in about 25% of the chest compression , my hand was not properly position. The intubation sequence was better but I forgot to say that I would wear glove and mask prior to the intubation. Before I left the station, I saw the examiner wrote down a 4 on my marking sheet – there were 8 items on the marking sheet and I got a 4 (later I found out 5 was the best)? I thought I was gone case, after all the effort and coming so far, I just couldn’t believe that I had blown it…
The next 40 mins was a stressful experience as I waited for my turn for the megacode station. I overheard about the scenario in the megacode station – mostly vfib or bradycardia case, I am familiarized with such cases. But after my poor performance in the previous 2 stations, I was too upset to be cheered up by those conversations. Finally I was called. I was sent to one of the station and managed to work my way out. Before the end, the examiner asked me why did I come for this test – I told him that I was BLS instructor back in Malaysia and wanted to be ACLS instructor here( short chat of coz)…. Before I stepped out – he told me to work hard in the future and we shall meet in few weeks time …. My heart was pumping badly while I walked toward the door. I was confused though, in an actual ACLS provider course, you would need to pass every station – no fail allowed.  But if I am the BLS examiner I would fail myself….
The final result was delayed as the BLS station was badly jammed( a 5 cycle of 30:2 is required).  I was too anxious to sit down for a proper lunch, I bought a red bean bread instead.
2 hrs later I finally saw the list again and my name was circled with red ink. I paid up the fee and took a seat in the lecture hall and was still unable to believe that I had survived the pretest. During the pretest summary, the examiners had commented that they had used the combined evaluation scheme ( total marks from all skill station ) to select the candidate instead of the original ACLS provider evaluation scheme. I was lucky….

60 was left after the pretest … 40% pass rate and in 3 weeks time, I would have to return and present what was assigned to me – still, some would be dropped out during this stage. If I make it again ( oh mighty God, please…), I would need to go for a 2 days demo course in May and later find a course and teach under supervision once before I received my instructor certificate…
I was NT 10000 poorer on my way home…......

life of wii...

I had been cautious with my computer since I came back to Taiwan. My computer had been attacked before but not once I need to “reinstall” the windows… I had not download any torrent until last 2 weeks… I had decided to cross the line and downloaded a few wii game… I had upgraded my wii firmware to 3.3j ( accidentally of coz, my kids want to play with the wii music and they just press the yes button when asked…)

To play most of the game in English – I downloaded the gecko and later found that I wanted to play to some game in English – but unfortunately, I had got the Jap version and I was reluctant to pay another NT 150 for a US version(no kidding , “P” version instead of “O” version of coz..)

I decided to join the life of BT. I downloaded a few and successfully run them with the gecko.

Xian was doing well lately and he started to find his way on this railed shooting game – the first one was Rayman rabbit TV party. Then he went on to try the House of the dead 2 & 3 returned ( old old game which I had played on PC before..). Playing it with a zapper is another exciting experience though. Later I found this latest release of House of the Dead… I spent a 1 weeks downloaded it with turtle speed. I finally “google” again and found out that I need to change some parameter and the speed finally caught up. I burned my House of the Dead: Overkill yesterday…

As the game stated – not only rated X, but XXX – the game was filled with 4 letter words starting with “F”…. the shooting scene was darn bloody (no option to change the blood to green…). But hell of an experience – the recoil and sound from the willmote was good. Need some IPSC shooting skill – reloading is one of the key factor….need to plan the reload properly…definitely not for Xian of coz...

Another game which I felt good was the “Call of duty: World at War” ( torrent of coz…) – unlike the House of the dead railed shooter, I need to go around with the nunchak (really gave me a nausea, but gotta hang on…) –  the feeling of shooting M1 Garand was good… Maybe I would buy a air riffle version of this M1 , later of coz…(cost about NT 20k….)

"fired" warrant

The new locum ED doctor had finally cast a rock over his own face this time… I managed to resuscitate a drowning case last weekend. The case was admitted to ICU and I was wandering if the case could make it … On Monday evening, I found that the case was transferred out. Later that night, the night shift nurse had told me the story behind… The male was identified as “No name Male”(we don’t use John Doe stuff here in Taiwan – it is either No name male or No name female”) on arrival. Later the family was contacted and came.

The wife was a foreigner and there were others who accompanied her. By 11+pm, few of the friends had come down to the ED and made a fuss over the ED stuff. One of them claimed,” this is the worst ICU in the County. “ She then complaint about being left outside the ICU waiting to sent towel and diapers to the patient for a long time. The family/friends were so impatient and later followed one of the night shift nurses(it was 11:00+ and the late night shift nurses started to come in) entering the ICU. They claimed that the nurses was chatting and let them waited outside the ICU for more than 10+ minutes. (I later asked around the staff and the staff told me that it was not true as they were changing stool for another patient, but that was not important) The lady than ‘show her power’ by saying, “ I knew the county health director very well , and we could transfer the case to any govt hospital in the county anytime. I would report the ICU incidence to the director personally.” If I was the doctor sitting in the ED, I would definitely stand out and apologized first and tried to pacify the family. Our locum ED doctor did stand up though but he mumbled,” Just go and do what ever you want, I am not doctor of this hospital…” Well, the other ED nurses were stunt by his word and reported to the management the next day. Well, I was interviewed by both the hospital superintendent and the deputy later– they asked if I knew about the matter. I told them what I knew. The management was definitely unpleased with such reaction and I think this locum board certified ED physician is gone case in the near future…. No violation of any professional ethic but his act signed his “fired” warrant.

Lem had discussed with me about future plan of ED ---- I told him we should get a 4th doctor and tried to covered all the shift – I told Lem I am willing to go back to the 180hrs(15shifts) life but there should be raise over our current pay….well, when I left the office, Lem had gone into a deep trance considering my words….a raise in this economic crisis? definitely joking...

Grand round..

I forgot when was my first grand rounds... it must be 10 + years back when I was doing my clerkship. Well, a large crowd of persons in white, lead by the resident and interns, then the chief resident and attending (surgeon/physician). The head of department would be surronded by the crowd. Just like a rally in the ward. The team would go from room to room. The residents would present the case and the head of department would glance through the chart. Q & As was definitely a must and most of the time, the junior one would be "electrified until you become 7 colours[Tin Tou Chat Choi]" (a good description by some Hongkong senior during my college days). When I returned to practice here , I had chance(actually force to) to attach to the college's teacher hospital(it had become unversity then) twice. The grand round had taken a shift - no more rally, the residents would prepare all the charts and the grand round was done in the conference room .... the resident would take turns present the case...the atmosphere was still tense though, but eventhough I was junior resident then but I was senior enough to skip the lashing. We had a general discussion session every thursday and all of the attendings would exchange our view about cases... but as the evaluation is closer , we had started our grand rounds as request. The 1st grand rounds ( last month) was just like old days - rally from room to room. But yesterday, the was some delay and the grand rounds started late - most of the attending was either in OT or seeing their OPD. So, our superintendent had a lonely grand rounds with the nurse specialist - they forfeited the rally and just completed the charting.... Maybe we would have another rally next month...

I will have and I have

2 MVA victim came to the ED at 7:50am…

The rider – young male sustained multiple abrasion over his limbs, the backseater(girl) was not that lucky. Her upperlips and lower chin had abrasion wound and her buccal side of lower lips was penetrated by her lower cannie tooth. We repaired her lips in the ED.

When I was entering the data to the computer, I saw the male was only 17 y/o and asked the male if he had a license – I did it purposely as I wanted to “educate” him “no license no ride concept”. Surprisingly he told me that,” I have”… ? WTF (nope, not World trade federation, the F is the letter word end with K), I asked, ”but your are only 17 y/o..”, he replied, “by the end of the year, I passed the exam – I will own a license…”

I almost had a seizure attack of my eyes(a.k.a eyes turn white…), and continue with my work….  

No LOL but still laugh of the day….

light and dark chapther 2

 I had a hard time when Ving was not home…. I had to pamper the 2 children. My dad came over and some friends helped me out. I adjusted my shift and took a balance between pay and spare time with the children.

I called Ving everyday as I was so worried about her. I did not known how long she would stay there… She recovered fast though. She had a clearer vision (not vision only, a real vision as described by Christian). She saw devil and things belong to the dark side. An arch angel(I guess, as she described he was very old and had very big wings) came to Ving’s bedside every night and told her something….she told me for the 1st time in her life, she see things "clearly". In the past, she had complaint to me that she always see thing in a hazy cloud but her vision check was normal. Now she told me she had clear vision.....

At the end of 3^rd week, she had prepared to come home… We went up north after sending my Dad to the airport … We stayed in a hot spring hotel that night and I had a long chat with her. She realized about her mission and wished to change her life in the future… I realized I had to change my life in the future as well : I am living with a prophet now - she had awaken from her sleep and she had recieved a so call mission. I finally knew that what I had undergone through in the past  is to prepare myself for helping her in this mission...

I was happy but worried and I was right when we came home….

it is democracy but unhealthy...

I was shock, when I learnt that the Perak Pakatan Government had fallen…. 3 of the defected Pakatan ADUN(state assemblyman) were Exco members and deputy speaker. That means these ADUN were rewarded with post after the election... I wandered what had “bought” them over. There is definitely some interest exchange(a.k.a money !!)  in this deal – the 2 Pakatan ADUN who turned independent will lost their exco portfolio definitely as they does not belong to the ruling party.

As for the “Rocket” women – a defection means end of her politic life … re-elected ? I don’t think is possible.

So it must be some big interest involved… For this 3 ADUN, I could hardly imaging how would they face the Perak Sultan as months ago, they were one of those who promised the Sultan they would form a stable govt…..

I agreed with the quote of ex-senior exco of Perak , Dato’ Ngeh: It’s an unhealthy democratic process.

Keto....

Our Chief of Admin approached me 2 days ago in the ED. She showed me a case note and asked me about the details of consultation. The case was a 5 yrs boy who had fever. He was seen by one of our locum doctor during the weekend. The boy had developed allergy after ketoprofen was given parenterally - yes "parenterally", his allergy was managed and discharge withour observation, the family was not happy with it of coz.....The family had come to our hospital the next day and asking for explaination. They had posted a few question : was the drug suitable ? , did the staff given an overdose and leading to the allergy ? I explained to the family and pacified the mother and she went home.
I had a discussion with our Chief of Admin - well, the management was in-appropriate definitely... ketoprofen was suposed to given intramuscularly and not parenterally. Luckily no anaphylaxis was noted. I told the Chief of Admin I would discuss with Lem and set up a protocol. Since my return to this hospital, I had pushed very hard about the ketoprofen IV issue. In the past, we had tended to give ketoprofen parenterally(including me) , but later we learnt that it was a very dangerous act  - indeed we had encountered various case who developed severe reaction. Now most of us are giving the drug intramuscularly but it would be difficult to restrict locum doctor if no written protocol is set.
This locum doctor is a ED certified physician who was previously trained in family medicine. He had stepped on several tails in our hospital. Han had a peritonitis case who was referred out instead of calling our own surgeon to manage it. I had case who was diagnosed as UTI and given moxifloxacin....But we have to tolerate him as locum doctor would need time to coup and get use with the tempo of the hospital.
After the discussion with the Chief of Admin, the nurse who overheard the discussion had come to me and told me that the locum doctor L had some opinion about my management... Opinion means "against" of coz... I asked them about the detail - he had told the family and nurse that I did not give "adequate" medicine to the paeds patient for URI...He likes to give multiple drug for antipyretic, and 2 antihistamine at least compare to my "all syrup" regimen. (usually 2 bottles - paracetamol and a multiple component antihistamine+ bromhexine+ antitussive mixture). That was what I gave my children....as the ancient taiwanese proverbs said, "there are endless children(other peoples of coz) to die"
I had this colleague back in my ex-hospital - he is a plastic surgeon turned ED physician. He is not internal medicine trained and his management for medicine case is criticized by most of the attending physician especially the cardiologist. However the chief of staff managed to "calm" everyone down with this - " since everyone of you are not satisfy with him , I will fire him then - but the left over of 15 ED night shift will be left over to you guys ..." . Since then no one made any complaint ....
Well, we had this similiar condition at the moment - our hospital superintendent had not only once hinted us that he wanted us to cover the weekend call - and we denied his pledge of coz...  nothing to shout about with this locum doctor at the moment....
I had reminded the ED nurses that no IV ketoprofen in the future - if any doctor orderded it make sure he pushes the drug himself....
maybe we should introduced Ketorolac - but it is far more expansive NT 10 vs NT 55....