Caged

 I was sunk in the 175 sofa when I saw the news showing a photocopy of the medical degree of one of my senior. The news was about a locum syndicate composed of non-licensed doctor roving around center and southern part of Taiwan. 5 were arrested and detained by Tainan Prosecutor Office. I called Lem and notified him about the news.

Most of the Malaysian graduated here passed our board examination and got our license within 1 year of our graduation. A few got it within 2-3 years and a handful of them are still trying their luck. My senior W is one of them. He was 2 years senior than me, he was deputy president Malaysia student association at the time I entered med school. Although he was not an outstanding student but he was a nice guy. I had not heard from him for a long time since my graduation. He was one of the unlucky one who did not passed his board examination. He managed to stay back in Taiwan by marrying a local girl.  

I had not heard from him for a long time. But lately, while I was surfing the net, I logged onto the medical registry website and entered the name of those unlucky Malaysian who are still trying their luck. Sadly – none of them made it.

The board examination was not an easy one for those who had graduated for years as it covered some of the ‘ basic’ subjects – biochem, physiology…. The examination was divided into 2 parts and later combined into 1 and recently separate into 2 parts again.

For those who did not pass, one of the main reasons was job. Most of them still secure a job elsewhere working ‘under-supervision’ or without- license. Working and studying at the same time is the major stress – especially doing night shift.(Specialty board examination is another story as what you are being tested are what you do daily)

It would be difficult for a guy to lead a life without job – especially when you are married and you don’t have a rich daddy.

In the past, there were quite a number of medical graduates without license working in hospital and clinic as they are some secluded places in Taiwan (my hospital is one of them) which have difficulty hiring doctor.

At the time I graduated (10+ yrs  ago), doctor without license could get a job in any department provided you are willing to work night shift (pay less of coz) and weekend. Later, some hospital had started to restrict the presence of such doctor in ED/OPD fearing of any medico-legal dispute. Although working in the ward, such doctors could still get a pay of more than RM 10+k(night shift ++ of coz.).

There are also a group peoples who are not medical graduate but work as doctors – most of them are ex-surgical assistants (no medical assistant here) who had worked for years in the OT and ED , they knew something in and out about medicine.

They were pay less nowadays – RM 300-500 per night shift. One could earn RM 5-7k per month doing night shift/weekend shift. They usually operate in group – few of them had license and they were the one who interviewed locum jobs. But later, the person who turned up during the shift was another one without license  -that was how some of them still got to work in some regional hospital or even govt. hospital. But this syndicate was fierce – they used fake licenses and certificates. That was the main reasons, they were detained by the prosecution.

 

But still, some hospital still hired them as resident doctors working in the ward and ICU. Well, after this incidence, I doubt any hospital would hire them…

But contrary to most of the public opinions, doctor never get jailed for malpractice (even someone life’s was involved) here in Taiwan. Most of them being convicted (for malpractice) were sentenced but usually put on probation with fine. However lately, one of my ex colleague (psychiatrist) was sentenced and jailed due to fraud (issuing false certificate for insanity).

Hope my senior won’t get something hard…

Addicts

I had seen lots of drug addict during my service with the MOH. But not in Taiwan, most of my colleagues do not have the awareness of such dangerous patient presented to us. Whenever I saw one, I would advised my staff to don double glove. Most of the drug addict cum HIV user would revealed themself without fear back in Malaysia. But in Taiwan, these group of peoples would try to hide the facts - deny deny and deny....

Most of the addicts around our area are also stilnox(zolpidem) abuser. They came to our clinic and asked for large supply of stilnox. They were given 2wks to 1 months supply but many of them returned before the time was due. They had many reasons - drug lost, I gave it to who and who.... Lately the narcotic drug control bureau had instructed us not to prescribed extra medication to those before their drug ran out.

I had this young man presented to ED for epigastric pain earlier this week. After the routine Q&A, I had concluded that he had acute gastritis and asked him how would the treatment to be ( you had to... some would not get healed if your treatment doesn't meet their expectation. eg - some like a jab, some want a IV....) He said he wanted an injection. Just when I was entering my order, the patient told met that the normal pain killer doesn't work on him as he had undergone "80+" times of surgery before(he is 23). I then asked him what kinda of pain killer he preferred - as I expected :narcotics. I told me I could help him and would give him a H2 blokcer parenterally as he had received 2 injection ( 1 is a prohibited drug - avapyra, the other as ketoprofen ) prior to his visit[he showed me a prescription during the Q&A. ]
Another drug addict trying to crave narcotic from us.

Later that night, a couple came by and the nurse had pulled me out from my bad dream. I saw the girl before , she was young, thin with tattoo. She showed me a few ampules of drugs( diphenhydramine and solaxin) and said that she could not inject her self. She had wanted us to put in a veno-cath for her as she couldn't get any vein by herself. Her vein was bad....another drug addict...I asked her for prescription and she told me she get the medication from a clinic(drug addict rehab clinic). I politely turned her down and told her that without any prescription we couldn't help her. They walked off and try their luck elsewhere. Most of the drug addicts use insulin needle and sometimes with the insulin needle it is hard to get the femoral vein. So "highway" user become less.

I still remembered back in my kiddi days the RTM would aired those documentary regarding dadah (malay term for narcotics drug) - those addicts would add lime juice to heroin powder and heat the mixture over candle/lantern. Recent I googled and found out that the lime juice would kept the heroin in the liquor form during the process. The liqour is then aspirated to a needle and injected to the vein.

sponge and syringe

Nowadays -those addicts had a new toy : zolpidem. There is no parenteral form of zolpidem, but some of our nurses had seen them crushing zolpidem pills and mixed it with normal saline then inject it into they veins. Those addicts had 'used' everyone they could to come to hospital and get zolpidem and buy it from them.

 

Mourn

 2 days ago… I got a call from my father – my cousin had passed away in Tibet Lassa. He had participated in a survey tour to Tibet organized by the Malaysia Tourism Association. He was feeling unwell few days before the departure – cough and some flu like symptom. However after some Chinese herb medication, he was better. He suffered from diarrhea when they reached Lassa. He was left alone in the hotel as he was feeling unwell. Later the tour returned to the hotel in the evening and they found him in a very ill state. He was admitted to local hospital and passed away that night.

I felt sorry about the incident. He most probably had acute mountain sickness and was not properly treated, he had had fever and might be treated as pneumonia (if he is suspected for pneumonia, I don’t think any doctor would gave him any viagra, decadron …..)

My uncle(his father) was closed to my parents. They are wealthy as my grandfather left a load of fortune for his sons( not daughter or else I might not ended here…). My cousin was sent to Canada for pre-U and he quit his study later as he suffered from stress. He came back to Malaysia and rested for a few years. He later worked in my uncle’s company( 1^st china tour organizer in Malaysia). He had led a quite life and never got marry. We played together during my young days but never get close. After my study here in Taiwan, our relation was merely head nodding….

I think my uncle and aunty suffered the most…...That’s life…..

 always in our memory.....

Wildfire ?

 

Shock I was when the news I have read (delirum I have)….A confirm case of H1N1 in Malaysia…

Oh… I was more shock reading this comment on the star http://thestar.com.my/news/story.asp?file=/2009/5/16/nation/3921825&sec=nation

“Entry and exit points in the country are being monitored. Designated hospitals are primed to treat patients suspected of having contracted the flu.

Quarantine procedures are in place. We have anti-virals to treat those confirmed to have A (H1N1).”

Entry and exit points in the country are not being monitored… or else the govt would have traced down all the passengers who sat within 3 rows of the patients instead of calling all those on the flight to report themselves…. The govt had not monitored them – those passengers should have filled up a form stating where they are residing in Malaysia…

No prophylaxis medication for those who are highly expose (sitting beside him) ?  I wander does the Govt have enough Tamiflu supply ?

Well.. 1 + months before I make my trip back to Malaysia..Darn, I just grabbed the NT 888 offered by Air Asia (TPE-KUL) 2 wks ago… Got to buy more tamiflu…might have to take it all the way during the stay back in Malaysia….

failed fan

When someone asked my opinion about buying a laptop, notebook… I would recommend a Thinkpad(no more IBM, now it is own by china base Lenovo…). Still, it is something very solid – Xian had not only once, stand on the laptop and still it still work fine.

My R40 was bought 5+ yrs ago and it is still working fine. 1+ months ago, I got this fan error message and hanged. I seek my answer out with GOOGLE and finally know that the CPU fan had failed.

I went to this Thinkpad service center in Kaohsiung and the engineer told me everything was fine, just the fan, the axial rod had broken BUT no replacement, its part had ceased production….. I had a bang over my head… I had asked around the other service center and found that the CPU is something unique.

I asked my brother for help and he said he can get some supply from some of the supplier. However during the waiting period, I found a ebay seller who sold such fan , a new one would cost me around RM280… Really sucks – quit a figure and I decided to buy it. While waiting for the seller for confirmation of stock. I came across another seller who sold a used one… just RM 50.. I bought it – anyway , if it failed, I could still buy a new one….

I got the fan

And started my work in our kitchen…

I had to read the guide from the net to open up my R40...the ASUS came in handy ...

as the engineer at the thinkpad center said - the inside was very clean...

I recomposed the R40 and Presto.. my R40 is running again...

Would I recommended anyone for a thinkpad again - definitely.... the feeling is still rock solid...well, maybe next time I would buy a harddisk and replace it...

some photo...

I finally got my USB bluetooth adapter and uploaded this photo... it was a nightmere but still I learnt something from it...

This was the swelling prepruce I mentioned weeks ago...

still shattered by the incident...

Dont Scroll down if you don't like any medical photo ( which part of it would cause your appetite...) 

 

 

 

well...3 days....many of us were lucky, no gangrene noted	only pressure ulcer noted ....after the reduction

 

Day of a ex- MOH staff...

 I had a change of shift yesterday…well, change of shift is definitely not a good sign. Usually the shift would be a bad one. But sometimes you just cant help it… Lem had gone for a course of Disaster management. So Instead of the 2pm-11am 22 hrs shift, I took over a 8am-8am shift. The ED staff combo was excellent one – head nurse plus assistant head nurse and a senior nurse, perfectly capable team. 3 MVA victims present at the opening and since then I did not go into the office. One of the MVA victims had a Galleazzi’s fracture and he did not want any further surgical treatment. Since our new orthopedic surgeon would be start working on 1^st of June. I had to do something. Just cant bare to put a splint and sent him out. I decided to do some – CMR (closed manual reduction). It was more than 5 yrs that I had done any. I sedate the patient with dormicum and pethidine and manual reduced the fracture and dislocation. A almost perfect one. While I was amazing with my skill – the patient had changed his mind and decided to admit and have plate implant later in the evening. A waste of effort. By noon, a female patient from nursing home came, underlying cervical cancer with massive vaginal bleeding. Holy spirit – when I read the referred letter from the nursing home, I had a transient vertigo.

There were no spotting on the diapers and I decided to a per-vaginal examination. I showed a bitter grin when the head nurse passed me the speculum – rusty crust over the blade. Can’t blame everything – it had been more than 8 yrs since our O+G specialist left. The last time the speculum was used was 1+ yrs ago ( yeap- you were right : me of coz…). The vaginal was filled with irregular tumor growth but no active bleeding was noted. I admitted the patient under my service later.

Well, for I sudden , I realized that the 4 yrs service with the MOH was not a waste. The other ED staff did show a unbelievable expression when I did those procedure….But that was not what I am chasing for – I finally achieved what I dream for when I first enter med school.

manual vs auto

I remembered back in my schooling days, most of the car had been manual... I took a ride once in my father's friend's car, it was a Volvo c automatic gearbox, you can felt the jerk and drag with every shift of gear. Later the trend had changed when I graduated. Automatic gear had become the main stream. In Taiwan - the condition is worst - there are countable cars under 2000cc with manual gear box. That is why the Proton Gen 2 can still survive here in Taiwan - some young chap who wanted to 'play' with the gear and have no money to buy a Subara hard skin shark ( synonym of Impreza) would make it the first choice.

I still remembered the feel of looking my dad driving a manual car - his last manual car was a Daihatsu Charade(993cc).

 small and fuel saving care - RM 13000+ during the old days...

 

I remembered the process of downshifting to 3rd gear while overtaking and shifted back to 4th gear later. Frankly said, I am not familiar with the manual car and tried to avoid driving any of them in the earlier days. After the I got my Z's - I had changed my view, I was thinking of getting a car with manual gearbox in the future. The Z's easytronic is great to drive as it had no clutch( still got the feeling of 'gear playing' and no need to worry about the clutch). The clutch is one of the nightmere - especially during 1st gear, if the clutch is releaesed too fast , you get this horrible jerk...

I finally saw some fanatic over the net lately. He is a high school physic teacher C who wanted to buy a Zafira 1.9 CDTI MT. We had only 2 version selling currently in Taiwan - the Z 1.8 easytronic and 1.9CDTI 6AT. He is currently driving an Hard Skin Shark STI (manual)... and he wanted a shift.

the Impreza STI rival was mitsubishi EVO series however the price of STI was way cheaper than the EVO and it had become one of street racing favorite.

 

 We had a sole Zafira B OPC(2.0 turbo , 6MT) currently roving in the northern part of Taiwan.

The blue color is unique to the OPCs series... and all the OPC car has a manual gearbox

This OPC was introduced as both a verification car and demo car but later sold to this lucky owner at an unknown price. As for the C,  I had never seen anyone wanted a manual car so badly, he is willing to pay the price but unfortunately the GM dearler turned him down........After this incident, I had begun to think about my future car ( day dreaming of coz... My Z is only 1 +yrs old...) it should not be an auto. Inspite of waiting a kickdown by stepping hard on the oil pedal, a 2 stroke of downshifting from 5th gear would make my Z roar like a lion and sprint..... hell of an experience, I remembered the sales who acompanied us for a testdrive. He had encouraged me to drive with M mode but I was too afraid to try it out at the time. Now 90% of my driving is Manual mode ( the 10 % - talking over the phone, eating ....). However buying an european car with RM200000 is considered too luxurios for me....

I saw this Exora lately - nice car, but it seems really underpower. It is selling at almost the price of WISH (minus the surchage Proton Protecting Tax of coz, WISH 2.0 is selling about 70K RM here) and yet WISH is 2.0 and Exora is 1.6. And this Campro CPS although highly praise by some is just some old technology... Well, Proton need to work harder , frankly speaking, I think the 1.6 MT version of Exora could still be a good car ....    But back to safety issue - how safe is Exora ???? NCAP 4 stars ? I think we should wait and find out when it is really tested and verified by the Euro NCAP. The Exora could not hit the Europe market as his competitor would be the Zafira 1.6...

tripped wire

I got this call from the MIS staff around midnight (few weeks ago)... The MIS staff (the hospital did not give him the title of engineer....) is a young chap who lived around Fangliao... Local boy who graduated in this computer science. His job is mainly networking and hardware maintanence...
He asked me if I had upgraded my program today because the nurse had complaint to him that the they could not prescript any drug..... I did someupgrade but it had nothing to do with the prescirption system.
I said I would log into the hospital and sees what happen. I tried failed to log onto the hospital server...the server must had been down I mumbled when I called up the MIS staff. He acknowledged the problem and went to the hospital. 20 mins later he called  me up and told me the problem had been solved. Apperantly the cleaner had tripped over the wire of our UPS and the server was down...
Well, we really need to shape up our MIS dept and the cleaner as well... 

New threat....

The outbreak of H1N1 had disturbed our hospital although no case had been reported here in Taiwan. Many of us still remember the terrible period of SARS. I returned to work here during that critical period. I was most junior doctor when I joined the practice and I was assigned to ED and seen those fever patient.

 H1N1 under the electronic microscope...

 The OPD turned down any feverish patient and asked them to seen in the ED. I covered the daytime ED and I was the one who felt the heat most. The febrile patient was brought to the negative pressure room( it was not a standard one, no pre-room...) and I had to wear some gear (again not a standard one, I had an isolation gown which supposed to be disposable and due to lack of supply I need to re-use it. I worn a disposable rain coat (gown) outside my isolation gown for more protection. N95 mask is a must though plus a proctection face shield which I bought from a local hardware shop.) I had to tolerate it as I had nothing to complaint. We got 2 cases of SARS. They were transferred out as probably case and later confirmed as SARS. One of them had died (an old lady who was intubated for pneumonia - ) and the other recovered well(not intubated).  The SARS was a nightmere to Taiwanese medical personnels and we did not understand the virus initialy. There were still many of thems who survived and lived with with poor lung function. Some had died and these peoples had given us precious experience to warn us about such disease. We had learnt how to protect ourself and now is the time to make use of it....
We had a house discussion last week and we had gone through our plan again. Sadly, many of the unit/staff had forgetten the SOP and we would had to retrain them again.

I am not worried at the moment as Taiwan still free of any cases. But I had did some preparation - I had enough tamiflu for 4 of us in the house(NT 90 per capsule and darn expensive...).

 

I had some supply of N95 and surgical mask.... And I am starting to wear surgical mask on the job ( I hate it...it compromise the breathing and I think it is impolite ...the patient don't even know how's his attending physician look likes...)