Grudge

There was this incident 2 days ago…. I overheard the conversation while I was called to the ward. I decided to dig the story and finally get a good picture.

There was this patient admitted by LEM 1+ weeks ago. A bed-ridden patient admitted for fever. No obvious infection focus was noted and the patient was admitted to the chest physician. Antibiotic was shifted from parenteral to oral as no obvious focus was noted. However the fever persisted and later parenteral antibiotic was restarted. About 1 week after the admission a swelling over the pustule was noted over a swelling at the right inguinal region and the testes appeared to be swollen. The surgeon was consulted and testes incarceration was impressed. However the family had declined surgery.

After the consultation the surgeon had however commented (the nurses had used the word “bombard” instead) in a very loud tone with his nursing specialist at another nursing counter regarding the consultation[?delay of noticing the infection focus]. The conversation was of course overheard by the chest physician. Later that day, the nurses had described that the chest physician had shown a very long face….

The comment was done purposely in a very high tone – the surgeon had apparently wanted the chest physician to hear it.

I had shared the story with Lem and he told me that their grudge had started many months ago. The chest physician had not only once commented about the management of the surgeon over medical condition, however the main insult started over a referral patient. The chest physician had a patient referred for surgery but did not transfer the patient to the service of the surgeon after the surgery. The surgeon had told his nursing specialist to ask about the transfer of the patient. However upon request, the chest physician had told her in a sarcastic way (by using Taiwanese) – “ you can clasp the patient over [with chop stick] as your side dishes”. This was an impolite way to say it…

No wander the surgeon wanted to humiliate him publicly at the nursing station.

Indeed, the chest physician is overloaded with patient – he had too many patients under his service. From time to time, he would have patients(especially nursing home resident) re-admitted after 1-2 days of discharge. One of my senior(Malaysian current head of internal medicine dept in another hospital) who had worked with him had warned me about him prior to his arrival – a calculative person who tends to avoid anything which is not profitable to him…. I had stopped to admit irrelevant patient to him months ago after re-admitting those patient and wiping his ass in the midnight ( inserting CVP to patient who was in shock since afternoon as the only thing he does was hydrating without CVP).

During yesterday morning meeting, the chest physician was still in a low mode –

I would be very upset seeing a patient died slowly with his scrotum gangrene slowly...

I hope their paying back game ends here....

struggle of the ro(o)ster

After a week of struggle, the rosters(Jan and Feb) was finally out. Lem had did a lot of discussion with me…. The situation was kinda complicated. The were so many restriction. 4 persons with 4 different scheme…

 

I had agreed with Lem that we settled the roster than negotiate with boss about the pay. Actually I am the only one who is going to get adjusted as Lem and Ong had their special request.

I am reluctant to do so as I had planned to leave mid at next year. But I would have to experience a cut of my working hour later as we need to squeeze enough work time for our new colleague.

The extra cash would help us in the future as I would be experiencing a great cut during my training…..

I would be planning a short break after the Chinese New years- a week vacation in Malaysia….

Well, I had put my faith in GOD…Let the LORD laid the pave and I shall trace it....

Mercy...

 

It was supposed to be a good call – the cold front hit us few days ago. Most of the locals would stay at home, no one is gonna get drunk and ride their bike recklessly ending up in ED. But I was wrong – the 1^st OHCA( out of hospital cardiac arrest) came by 3am. Resident in a local nursing home, one of our Chronic Obstructive Pulmonary disease patient who had just discharged from our ward few days ago. He was found unresponsive by the nursing aide and sent over to us for help. I saw the blanket – so thin , core body temperature was 33C…negligence leading to freezing to dXXth… Well, the family came 20+ mins later and asked me to stop…

The next OHCA came by 5+am, another no sign of life for don’t know how long…. I did the routine and certified the patient…

Life was so fragile and sometimes we live at the mercy of the LORD. Few days ago, Yun and Xian had slipped a ruler into the piano…. We called up the piano tuner(who is also the dealer who sold the piano to us) and shockingly found that he had passed away. I later checked the tuning record and found that he had missed his regular tuning few months ago and we were not aware of it.

His son came for the tuning and I asked him what had happened to his dad – he grinned and told me that he met an accident, I saw the peacefulness in his eyes……

Our life is at the mercy of the LORD…. No one could defy the faith – I had learnt something – to value life and value whatever I had at the moment. I knew I had to be humble and love giving. I had to try my best to be an example and leave a good memory to my children…

Reshuffling ?

It was a great leap for us…We finally got someone to join us… he was my ex-colleague. He is a trained plastic surgeon turned ED physician. He was a man of night shift and locum.

Virtually he could do as many shifts as we can provide. However as our present scheme of 10-14(day shift 10 hrs, night shfit 14 hrs), he was unable to do consecutive daily night shift – he lives up north and the buses had been his main transport in the past. He had wanted a shift to 12 -12 but both Lem and Ong had against the idea and I support the 12-12 only if everything is fair and square.

So at the moment he had to settle with it. Boss had asked us to adjust the shift and we are gladly to do so. Ong and Lem will be taking their vacation next 2 months and there are lots of empty shift to fill in.

Boss had offered him with 35% more of what I got. I did not feel upset as my term is to re-discuss my pay scheme if anyone comes in and shift change….

I am still waiting and currently I would comply and tried to sort out what ever empty shifts there are present.

With 6 months left, I am not sure if I would want to fight for a big increment…

Shift was tough in the January as I would be doing 270 hrs ….

The discussion of shift did not go well initially as most of us did not want a change – however our colleague would be settled with our view at the moment.

I had prayed hard as I am really at the junction and the temptation of money is so great.... to stay and grab big cash or to train...

I praying very hard....

Resus and SHXT

A CPR/resuscitation scenario is always a thrill in most of the TV series/ movie, but in actual life, it isn’t. One of the main concern is SHXT and PXE ( feces and urine)… In about 1/4 of the case, patients(either with sign of life or not) are incontinence. You just have to tolerate the smell. The nurses wouldn’t try to clean up the mass if no sign of life was noted. The 30 mins scenario is sometimes a smell tolerance game.

Well, I had this middle-aged psychiatric patient sent over by the local asylum after she collapsed. A lady with BMI of >40…as usual she was intubated but I told my nurses that prep the ETT anyway, I said there is a 50/50 chance the tube is in the stomach.(but in fact, their record is 100% esophagus intubation…).

The patient arrived and as I had predicted – I had to re-intubate her…The nurse who came with the patient told me –she was seen in a hospital nearby for Acute gastroenteritis earlier that day. She was soaked in her own feces…I had to do my job…I certified her after 15mins later…

I remembered the film “silence of the lambs”, when Jodie Foster and Scott Glenn entered a Autopsy scene – they had applied some whitish cream over their upperlips to barricade the smell of the degraded corpse….Just wander where I could get those….(tiger balm won’t work…I tried it during my days in the casualty department as coroner)

the next wave....

one of my favorite movie....

I had finally finished the coding of drug… 450+ of them (it is really small amount compare to the 10000+ items of the National Taiwan University Hospital). The interface for the drug data managing and nurses drug dispensing are also readied. The nurse could just click the mouse and all the photos of drug for the patient would be shown on the monitor. The program is time specific, if the current time is 6:00pm , only the drug given on the time would be shown. The nurses won’t have to double check the drug with the pharmacist if they were unsure about the appearance of the drug.

However there are still 3 great challenges lying in front of the project. The 1^st is the photo, I got about 200 drugs with photo and the quality was unacceptable. I had coordinated with the art supervisor of the hospital and she agreed that she would get a desktop copy stand and take the photo for me. But I had to communicate with the pharmacist and get all the sample labeled and pass it over to her. Communicating with the head pharmacist is a problem as he had always been a stone head.

The 2^nd challenge is setting up the testing ground. I had did a preliminary discussion with both the matrons(we had 2 now- 1 for he critical unit and the new one is focusing on the ward)- the ICU would be the 1^st to run. But I would have to communicate with the attending physician and surgeon that all prescription would have to computerized –no more hand writing. Someone would definitely grumble….

The 3^rd challenge is to introduce the scanner and modify the dispensing trolley. Scanner and bar-coding are simple technical issue but the dispensing trolley is more complicated. Batteries, wireless LAN should be included and the MIS dept is currently still in limbo. They are still busy upgrading some of the window 2000 terminal to window 7 as I had upgraded my develop platform from VB 2005 to VB 2008…

An amateur trying to create a user friendly interface for an existing system .... I am alone and I felt like sailing into a series of giant waves – this would be the most gigantic wave ever, there are so many things that are new to me….

I hope I could make it through with FAITH…

 

 

we pay for them...

I had been trouble by those stimin seekers lately. I do not consider this bunch of suckers as addict as no craving is noted. They used stimin as “interlude” drug- to sedate themselves whenever they had no money to buy heroin. The benzodiazepam group of hypnotic had no effect on them (one of the reasons – almost everyone of them are heavy drinker and).

The oral route had is not adequate for them – they crushed and grinded it into find powder and injected it into their vein.

Some of them with history of pancreatitis would come in to ED complaining of epigastric pain and minutes after the injection given(I usually start with cimetidine), they would start to request for “Demerol”. I would usually told them to be patient and wait for the amylase level. If the level is elevated, I would admit him and give whatever to ease his pain. But unfortunately, 1/10 chance I would get a normal value. I would then politely told them, no one would ordered me to give any narcotic drug. After a few time, they would not come in if they saw me at the desk.

However lately, I had covered the Ortho OPD(surgeon gone for ops) and met his scum bag. He had still 6 pcs of stimin left and he came for asking more. I told him that the computer prohibit me to prescribe such drug to him as he had still medication left(I had to lie…). The scum bag had told me that he would bring his kids and asked to prescribed for the boy after he had spend 15mins begging, threatening and cursing in the clinic.

I was lucky the surgeon came back and I handed over the clinic back to him. The surgeon did not prescribed stimin for his child (thank god…)...

A stimin worth less than 20 NT but  it’s hypnotic effect which could get the addict through the craving stage make it priceless….and the health insurance paid for it( so sarcastic….)

 

crucial.....

Lem had given up his night shift….He told me after he negotiated with boss. Actually he had seen boss to submit his resignation. He had got an offer from one of our senior around the place he stayed. However when boss heard about the bad news, boss had asked to stay back – taking off all his night shift.

Well, if the request was brought up 12 months earlier, the management would have told Lem to find a job elsewhere….well, the situation had been so hazard…

Well, Lem had stayed back, for the moment…

The breaking ground ceremony of the new building would be held 2 days later….

The management had offered pure ED job(means the ED physician does not need to cover the wards complaint) currently … I had smelled and got hint from the management that they had planned to post us to the ward as night shift doctor if they got a team to take over the ED ….well, it would be sayonara then. Some of the regional hospital had posted ad for night shift attending physician/surgeon for years and not one interview had been set up... the reason is simple, someone who had the capabilities to do general ward calls, could easily cover the ED job, so why get a job which paid 40% less.

Well, the situation is obvious – we are currently(maybe for the next few months to one year…) crucial to the department…I had asked Lem if he had asked for raise and he told me no- he felt sorry as boss had to take over his call…indeed boss did more night shift than me this month….

cut throat...

a boys and men dream item...nevery knew when it  will come in handy...

It was tiresome day…. Ong had gone back for his routine escape , I had a rest of 17 hrs before I returned to desk of ED. I did not had a good rest after the 30hrs shift: the shift was considered moderate with a sleep of 3 hrs. However I had to prepared for a talk in the school. It was not mine actually. Ving had planned for sharing experience regarding the hunger 30 activity organized by the worldvision with the children in the school. Initially the talk was limited to Xian and Yun class. Yun had invited the supervisor of the local worldvision office to present some film and talk to the children. My only part was to edit a short clip of DVD for them to present(extracted from the 2009 hunger 30 special). However Ving told me that she made a mistake and she was supposed to attend the “Rainbow mother education class” in another school. She was unable to make it to the morning session…..so I had to replace her for the talk.

I had to say yes as everyone was prepared for it….

6 hrs before I went off on Tuesday. Ving told me that the talk had expanded from 1 class/talk x 2…The whole second grade is coming …I was only 1/2 prepared….it was hell night as I had gone to sleep as 2:30 am and wake up by 6:am…

The talk was a success but I was over stressed…

I was hoping for a easy call…

The patient came in about 7pm – terminal stage esophagus cancer patient , complaining of shortness of breath and coughing blood. Cachetic and hypoxic, a taxi driver brought him in. No family around. I decided to tuck him into the ICU. I ordered some blood for transfusion and after a 20min trial, the nurses finally gave up and asked me to insert a central line. He was quite dyspneic but I was reluctant to intubate him. I inserted the internal jugular line at a sitting position(yeah, with me standing on a stoll!!!).

He seems ok when I sent him off, but 5 mins later, the ICU informed me that he had gone into arrest.

I rushed to the ICU and took over the resuscitation scene. The ABG was readied when I resumed the intubation position – darn, a mix respiratory and metabolic acidosis. I ordered a large dose of sodium bicarbonate. The intubation was smooth until I tried to pass the tube. There was a big clot of blood over the opening of larynx and I had a real bad feeling about it – blood clot or tumor????? I got the answer seconds later. I failed to push the tube through.

I hesitated for 2 seconds before I told the nurses to prepare a suture set and a scalpel. One of the nurse asked me , “?why ?”… the respiratory therapist answered for me- “we are going to do a tracheostomy”…yeap... did not want to do a cricothyroidectomy…there would be no one to sign a tracheostomy and the patient would stuck with the supposed temporary cricothyroidectomy for the rest of his time, if he is “unlucky” to make it….

It was another 2 minutes(seems for ever to me…it is my no 6….) before someone had scrubbed the patient and I placed my incision…the tracheostomy tube was inserted in less than 10 seconds….he was hooked onto the ventilator – within minutes, we got a pulse.

This is the first time, my tracheostomy patient survive through the CPR...

I saw him today – laying on the bed breathing smoothly…..

it was a milestone for me.....

 

out of the jam but stranded.....

 

Lem was in a good mood when I stepped in to the 175….That could only mean one thing – he had a good call last night. He had bad call most of the time being called every 15-30 minutes. I took a detour and was lucky that did not strand in the jam; I arrived 20 mins earlier. I had a good chat with Lem.

He broke out the bad news…of the 4 ED physician called up – none of them is coming. The senior one told boss that his wife disagreed because our hospital was too far away from Kaohsiung. The rest of the 3 junior ones said, they don’t want to cover the wards. Our dept supt had told Lem that the management had no plan of hiring any night shift locum at the moment… no plan my ass –even if there is any plan, they won’t be able to get anyone. Two larger hospitals up north had been advertizing for the past 5 years and not even an interview was done. One of it had been head hunting me for the past 3 years- the initial pay offered to me had increased 30% since the first approach.

I had been looking forward to the arrival of the new colleague and new roster but it seems that I am stranded...

karma.....

It was my third encounter with the so called principle minded obstetricians.

I had this 19 years old girl who presented to ED with massive per-vaginal bleeding. She was using a towel instead of a pad. Blood stain was noted from the pants…

I did a quick assessment – she was in early shock stage with stable BP but her heart rate was 110/min. A G1P0 at 9 weeks. She was not married and another young chap came in with her. She told me that the chap was not the father and the “real McCoy” was somewhere up north. As she was at this grey area of 19. I told her that I need to contact her parents.

In Taiwan, one is considered adult at the age of 20(civil law)  but would be responsible for his act(Criminal offense) at the age of 18 (as stated in the criminal law). So 19 is consider as minor and I need to do my job. She is aborigine and her guardian was the nanny. Nanny usually can't make any decision as most of them are not educated or japanese educated....I asked her if any other senior relatives was available and she gave me detail of her aunty.

While the nurse was busy proceeding with my resuscitation orders, I called up the aunty and she told me that she would come over to sort things out. As we don’t have any O+G specialist at the moment, I had to transfer her. I called up my ex-hospital and one of the senior nurse took the call. She asked me to call her back 5 mins later. A question mark popped up above my vertex but I complied. Minutes later, I called up again and she told me that their obstetrician rejected the case stating that it is against his religious. I thanked her but cursed as I called up another hospital nearby. I finally sent the girl out before her vital sign crushed beyond my resuscitation abilities.

  
3rd encounters of such kind and I questioned about ethic of these so called “religious orientated principle upheld obstetrician”…. I believe most of these obstetricians are devoted to Buddhism, but their practices of “no-do” of any D&C is really way against the ethic of a doctor. In a case of incomplete abortion, the embryo is deemed to be aborted and the D&C(for the incomplete abortion) in a sense is a life saving measure. By not doing such procedure, such devoted doctor was actually endangering the lady’s life…endangering other people life – so that one would not create any karma ?  a queer concept….but my future O+G colleague is one of this kinda of person(my 2nd encounter….), I am lucky as the nearest O+G facilities are 20km away…

G-shocker....

I had been a G-shocker since my college days – inspired by my brother---- a truly techie(currently serving as  managing director of an European Firm in China) on his job and life. He had taught me a lot….

I was attracted with G-shock (durability and looks) since then. My first 2 G-shock watches had plastic belt. I lost my first one during my Malaysia housemanship and bought another one. However the plastic case started to wear off and piece by piece slogged off…. A disappointment as I thought it was very durable, I told me myself, next time, maybe a G-shock with metal case.

Years later, I saw interestring an ad over the net featuring a football player with mud and a Gentlemen in suit…both of them wearing the MTG tough solar series. I was attracted by the ad - everything I need, metal case G-shock with solar ….

I started to eye for one and it cost 8k…Later I picked up one in the Costco with the tag of 6+k…

worn off... but still look great....

The MTG series is just inferior to the highest grade MRG series… My watch was unfortunately the 1^st batches and later the battery become to degrade. I had the battery replace years later(during my Z EDS upgrade). It is currently still in service and running well… But the stainless belt made it appeared a little awkward when I wore it during my bicycle ride.

I had no idea at all initially as I recalled the problem with the resin/cloth watch band – smelly residual after you sweat heavily… The metal band was the only solution and “all” the metal bands are stainless steel/gold/alloy band are mostly silver or gold in color... Until lately I came across the Protrek series – The was this black titanium band (metal band which is black in color). It was easy to decide which feature I need : A double LCD model was my call as the compass would be simulate on the LCD. That left me the choice of PRG 80 and PRG 200…the differences : thickness 1.4cm vs 1.1cm … the 0.3cm cost about NT3k… I had struggled a bit initially but decided to take the PRG 80 YT.

the case is bigger then the MTG the black color give a false appearance that it is a resin band...

I had thought of buying a good mechanical watch and later pass it along the line, but watches are not for ever –what the heck let them buy the one they wish when they could afford….I still keep the Orient Quartz watch given by my father when I came over here for medical school – it is still running and I wear it whenever there is a formal function(MTG is just too “Tough”…), an nostalgic feel whenever I wear it...

East coast tour - the journey

The trip started late and according to the google map – the 120km drive would take about 3:30 hrs… well, the Z is definitely a good car to drive over the curvy mountain road. I managed to got there by 3 hrs. Could have done it by 2:30 but was a delay but a long queue during the journey.

We got to the hotel and hit the pool – the was the hot spring (41°C) pool and small swimming pool. Yun and Xian was darn happy with the 1+ hr dipping. We did not have dinner around the hotel area but took a ride to the train station not far away. There was this night market going on… we had some budget steak and hot plate noodle – very cheap but tasty one…

The D1 ended early as all of us were tired after the "dipping"…A hot spring spa really relax one nerve and muscle.

We got up early the next morning – the breakfast was awesome in contrast to the price.

xian with his toast.....

However I was worried that it would be a waste as the boat ride might be very rough.

It was an exciting day for me… everything needs to be on schedule… We had a boat at 9:30 to catch and I had to rely on the GPS to get there.

at the quay...

We arrived in time and the boat ride was bloody rough(just like the pirate ship ride in the fair park). Yun had vomited x 3 but Xian and Ving went through it.

before the ride turn ugly...

The rest of the journey was smooth and we reached the ocean hot spring by 4:30pm.

taking a rest and sips...

We had another “dip” again – hell of a experience….salty hot spring spa. We left the spa by 6:00pm and the sky was getting darker. The evening ride was so beautiful with the sun setting just beside us. There was where the torch light came in handy.

The 8km ride took us 1+hrs and we finally got had our mutton hot pot dinner…

waiting for the dinner....

The sea weed ice was another unforgettable treat….

ice..ice ...ais...ais....

By 10pm everyone had sunk into the bed….

East coast tour - gadget

 

I recalled my old high school days – my mother had a good old Raleigh bicycle.

similar model -when I rode it , it was 20+ years old...

It had night lamp powered by dynamo. A dynamo shaped like a small bottle and it make a loud ‘WoWoWo’ when it was engaged to the tire. It really slow one down…..The light was darn dim even the street lamp was brighter. However when it is a useful gadget when one go through a dark alley. During my form 5(senior middle 2) year, the dynamo generated lamp had guided me during the journey to and fro from my house to the school for the night SPM class.

However to ride on a mountain road of an island, I need sometime brighter…

	the LED was truly brighter than the traditional lamp.... the front torch was powered with 3 AAA and the back lamp was powered by CR2032 button battery..

The experience was truly fascinating…. Ving was leading the team followed by Yun and Xian. I had to be last rider overseeing the team. Few more islands to ride and they would definitely be handy in the future….

unsure path...

I had chatted with few of the medical college undergrad months ago. The govt. has planned to shortened the medical school tenure from 7 years to 6 years. The 1^st stage of the project is to lengthen the training of current Post Graduate Year(PGY) program from 6 months to 1 years. I was the 1^st batch of PGY trainee – the initial training was 3 months (1 months posting in Medicine, Surgery and Community Medicine eacg). The training was not that solid as there was no general medicine and general surgery ward at the time. However I felt the medical ethic part was good. I got a certificate which stated that I had passed the PGY training. According to the Dept. of Health, if the PGY training length had changed in the future my training would be valid though.

 

The training was later lengthen… the worst part was it was incorporated into the specialty training – there were a lot of resident training program that lengthen from 3 years to 4 years due to the PGY training. However start from next year the training would be different. There 2011 batch of medical graduate would be enrolled into the PGY training for 1 year and they would start their resident training 1 year later. The juniors had told me that their salary would be fixed at 40k – 50k during the PGY period. A very bad news for the foreign student – the entry salary for a foreigner(white collar) should be 54k at least! So if no modified criteria are added, our junior would be unable to secure a job. If the training of ED is shortened from 4 years to 3 years, I would considere taking up a training post instead of a medical sub-specialty….

Actually the training environment is the most important part of the program – appropriate ward should be set up – proper exposure is warranted. Doctor’s eye were flooded with money: ENT surgeon claiming that they could handle myocarditis and meningitis and influenza with complication. (How many months did they rotate to peds wards? Murmur ? assessing pulse volume ? ) ED physician who had conducted limited delivery and I guess most of them won't have the guts to come forward facing a lady in labour on a public transport….well, on the paper the training seems to be advance but the basic skill is tracing backwards….a pity….

 

 

inbound ....

 

3 weekend call starting from now… 30hrs shift is considered as in-humane but still have to coup with it.

A few board certified ED physician had called up and the hospital is planning to get 2-3 of them. I am not shattered nor worry as life would become better. 2 more months to go before one of them reported in and the other would be coming in after the Chinese new year(CNY). CNY is definitely an important date as the annual bonus would be distributed before the eve. Most of the working people would leave after picking up the extra cash. Anyway, I would be getting an adjustment (increment to be exact) and shift would become less....

A little bit tired for me as I am riding quite a lot lately…..

Milestone...the 10th

It was one of the memorable week – a new member to the family tree line….My brother got his second child….Congratulation ….

Well, my parents would be happy … there is less than a handful of living member in the family – the number had increased to 10….a real milestone in the family log…

 

Slides

It was lecture week for me…I had done 2 lectures, one for the EMTs and one for the high school teachers. It is an extent of my first aid teaching life…back in SJAM I had tried very hard to fulfill the duty as a medical officer. The slide part was the hardest however after you complete one, it would be simple for me to present it. I found that picture and photo is one of the key to the success of lecture. As most of the students would fall asleep if the slide is fill with words(my very own experience). Back in those days where the google was not the “shrine of search”, I had had to scan the photo myself. However nowadays, most of the photo were “googleed” Only a few amount of the photo was taken(yeap with my SE cybershot). Life was more easier than however the photo searching task still took up most of my time… I had prepared 6 pcs of slide back in for the EMTs(it was a whole day course). I like to put in some “ bloody” photo as it could truly attract the audiences.

The slide preparation is really a technique that needed to build up. The background actually is the hardest part – choosing the background would depends on the lecture place. Use a white base if the room couldn’t be shaded. If a dark room is there than a blue base/dark color base is suitable. One of my college’s lecturer had taught us this basic concept (of using dark/blue base slide in the dark room), later I knew that dark/blue base slide could not be use in a brighter room (very blurrrrr).

I had learnt a lot all the way and trying to help Yun to build up the skill as well(that was school teaches a 4th grader...)

East coast tour - prelude

After the rearrangement of my shift – I would have 2 weekends to enjoy per months. I had always been a outdoor person and I want Yun and Xian to be so… Yun had changed a lot, I remembered few years back, whenever we go on a trip, she would ask me what kind of hotel(how many stars !!1) we would be staying in (in fact she still does, but she would omit the stars part). She had learnt the path of humble life slowly. There is 5 weekends this month and I was scheduled to do the 1st, 3rd and 5th weekend. I was planning for a bicycle trip, but I was greedier than ever- I planned for a Jin Men Island trip – one of the airlines had offered bicycle transportation. I was interested and “google” whatever info I got. It was a frustrated one as the the YJ 256s was 130cm long- 20cm longer that the upper limits.

Giant YJ 256(currently in service)

However I had the feeling of doing another round the island trip – so I switch my focus, there was this island just outside the east coast: GREEN ISLAND. It was a good choice the island is small- round trip was 20km. A boat trip from the pier takes about 50min. Everything seems fine so I planned a 3d2n trip. We would take off in the afternoon and put up a night in the famous east coast hot spring area. On D2 we would take the boat at noon and start our round the island trip. The planning phase was smooth; I got a 4 person room in the hot spring area with the price of 2880.

the Tong Mao Hotel.... chain	hot spring pool - swimming pool like...

I got a non-package room in the Green island, it cost 1600 with a great view.

great view.....

The most important part is – CLEAN(review from the net by some backpacker said so…). A package in Green Island would include a motor bike, snorkeling and meals. The hot spring stay was an excitement for Xian as he was looking forward to a play in the swimming pool… There was another challenge was us – night ride … There was this ocean water hot spring on the Green Island – only 11 countries in the world had such hot spring. We had planned to dip in it and the most suitable time to do so was in the evening. My plan was to reach the hot spring by 4-5pm and enjoyed the natural gift. However the hot spring is 8 km from the place we would be staying. That means we would have to ride in the dark. A good opportunity to expose the 3 young riders(have to count Ving in) to the night riding environment. The preparation was expensive – I had bought 4 LED torch light (650 each minus the rechargeable batteries). Back light was also neede(440 each). The results are astonishing as the brightness was truly amazing.($$$$$ of coz...) We took off as planned.....

President elect

I had always been playing XO(not cognac of coz, executive officer to be exact) during my whole life… most of the time, I was deputy: chairman or president or whatever. But not tonight….

I got a call from the President of Yun’s School Parent Teacher Association --  He told me that I am the president electee and congratulated me….So be it, I told myself….

da school....

Since last year, the principal and president of the PTA had invited me to take over the burden this year as the president was too busy with his own business. I was thinking of a sub-specialty training then and did not give them any positive answer. However as my shift was less and I think I could spare sometimes to do something for the school, I told the president and principal lately that if there is no one is interested, I would accept the post. (there is a election of coz, but since no one is interested then anyone who is not opposed to take over the post would definitely be elected)

Unlike other schools, the post of PTA president is a route to politics, unfortunately it was not true for our school.

Well, a foreigner as president of PTA, really queer for a local school …I recalled last year when I presented at the model student award ceremony. I was one of the guest of honor and the students(yes many of them) were shocked and frozen for a few seconds when seeing me offering my hand for a shake after I gave away the prizes. Guess, this is just not the local style…

One year of service and RM5000- I think I can make it….

President electee....

I had always been playing XO(not da cognac of coz, executive officer to be exact) during my whole life… most of the time, I was deputy: chairman or president or whatever. But not tonight….

I got a call from the President of Yun’s School Parent Teacher Association --  He told me that I am the president electee and congratulated me….So be it, I told myself….

 

da school....

Since last year, the principal and president of the PTA had invited me to take over the burden this year as the president was too busy with his own business. I was thinking of a sub-specialty training then and did not give them any positive answer. However as my shift was less and I think I could spare sometimes to do something for the school, I told the president and principal lately that if there is no one is interested, I would accept the post. (there is a election of coz, but since no one is interested then anyone who is not opposed to take over the post would definitely be elected)

Unlike other schools, the post of PTA president is a route to politics, unfortunately it was not true for our school.

Well, a foreigner as president of PTA, really queer for a local school …I recalled last year when I presented at the model student award ceremony. I was one of the guest of honor and the students(yes many of them) were shocked and frozen for a few seconds when seeing me offering my hand for a shake after I gave away the prizes. Guess, this is just not the local style…

One year of service and RM5000- I think I can make it….

 

 

Young trip planner

Yun and Xian had really grown up.. they are definitely not tracing my footsteps and I don’t want them to do so…

Xian is picking up a lot – he grew taller and very dedicated. Yun bought this book

a book by Naoko Takagi regarding her mother

 

Later when Xian started to read, he become interested with this lady’s works and he started to buy the whole series. One of them really caught Xian minds –

one person going to a trip...

 

This book described how the author travelled by herself. Xian had determined that he wanted travelled by himself at the age of 18. He ambitious is becoming a traveler. I was happy hearing his fantasy. I saw a boy grow up – it is so different from the experience I had.

 

He finally got his chance of to prepare for a trip. We are going to the Green Island on a bicycle trip this week – he had written a time table after asking me about the detail. I never had the chance to do it, but I enjoyed looking at him doing the planning. He was really excited as we would be putting a night in a hot spring hotel ( one of the favorite spot of Xian, as the book described a similiar place )

 

He also got his new toy lately – his own ipod touch, he doesn’t have to share the “touch” with Yun anymore. I had a mobile router with li-ion battery. Now the “touches” can get online anywhere…..

919 > 88 ...

It was another typhoon hit --- The 88 typhoon(Morakot, 8th of August) had hit us badly – leaving a flooded southern Taiwan. This year we had another worst one – the Fanapi which landed on the 19th of September.

It swept through the middle part of Taiwan but pouring an enormous amount of rain. Our hospital was almost flooded by it – according to the night shift staff, the water had flooded few cm below the doorstep. I was supposed to be working but my shift was changed so that I could attended the EMT’s CPR course in further south this Sunday(cancelled of coz after the typhoon, most the fireman was assigned to various place for the flood).

The rain/hr was greater than the Morak thus causing the flood. It was 15th of the 1Chinese calander (aka high tide day) and the estuary was flooded and unable to play it role of draining the flood.

the estuary was flooded....river had flooded the bridge and mud was left over after the flood.

 Lucky the rain did not continue and when I came to work the next day, the water had resolved leaving massive mud over the other side of the town. The part of town where our hospital was situated was spared from the mud. Darn lucky as everyone could come to work and no extra shift was needed.

Fire in the hole...

It had been my 3^rd week into the new roster – Life was much better as I spent so much time in the house. I was able to focus on my job; instead of manage the patient through telephone, I could able to see the patient personally. The feeling is good being responsible again. Expecting to go of in a not the tired state is crucial.

The adjustment was not fair though, as 3 of us did not get the same adjustment. It was the choice of the management and I couldn’t fight for my colleague at the time. It is definitely a delayed “fire in the hole” situation in the near future.

I am still considering a training post- I projected my view further : where would I be in the future ? I could think better in my current state....hopefully I could come up with one....

bitten...

It was a busy night, I had my dinner at 10:30 ->mutton fried rice.. Catch some sleep with q1h call. The Respiratory care ward nurse called me at 6:06 am telling me that there was a leak cuff and the patient was desaturating. I splashed my face with some cool water and took the lift(even though it was 3^rd floor but I was too tired). As I entered the ward and took a quick glance at the patient; I decided to reintubate her stat. The nurses showed me that introducer and asked me if I need it. I was still in my twilight zone and told her that I would do a direct one(simple reason – the tube is definitely not in the trachea as the patient was desaturating). When I removed the tube, I found that the patient was clenching her mouth very tightly and I was unable to introduce the blade, I started to wander if I had made a wrong judgement/decision at the time. I ordered 3cc of diprivan and proceeded with the trial by forcing the blade into the mouth. The attempts had leaded to bleeding of the gum and I found that there was a lot of granulation tissue around the gum.

I almost fainted when the nurse came back with the milky colour syringe in her hand but she also had a veno-cath in her hand. That means the patient had no parenteral line. Wow, now I had 2 problems, airway and venous assess……My fault as I had taken for granted that all patient laying in the respiratory care ward had a line. Well, blood had kept flowing out from the patient mouth while I bagged the patient…. I had to make a call of inserting a central line or try intubation… One of the nurses had run to the station and prepared for the central line insertion and I decided to take a chance to intubate again. I could barely insert the blade through the silt of tetanus-like clenching teeth but managed to get it. The best I could do was lifting the jaw up and exposing a window of slightly larger than 50sen coin. I saw the epiglottis though and decided to give a try…. I passed the tube into the mouth and did a slight adjustment of the curve(bad practice as you would have to contact the tube with the oral mucosa) – curving it into a U shape. I sighed when I noticed fogging in the tube as I passed the tube along. I had a feeling that my right index finger was bitten as I felt pain during the trial (bitten of coz…) and I was right, I noticed some blood in the glove and there was a shallow wound over the middle phalange upon examination. Well, the rest was simple – securing the tube, inserting a central line and packing the bleeding of the gum after sedating the patient.

The nurses had told me that the patient was lucky that I was on call or else the scenario would take extra times and messy… I grinned and told them that the patient times was not up yet, but deep in side me- I considered it was an act of god through my hand….. Had my skill become better ? I don’t think so but I think faith is the key to the success….

bitten...

It was a busy night, I had my dinner at 10:30 ->mutton fried rice.. Catch some sleep with q1h call from the ward. The Respiratory care ward nurse called me at 6:06 am telling me that there was a leak cuff and the patient was desaturating. I splashed my face with some cool water and took the lift(even though it was 3^rd floor but I was too tired). As I entered the ward and took a quick glance at the patient; I decided to reintubate her stat. The nurses showed me that introducer and asked me if I need it. I was still in my twilight zone and told her that I would do a direct one(simple reason – the tube is definitely not in the trachea as the patient was desaturating). When I removed the tube, I found that the patient was clenching her mouth very tightly and I was unable to introduce the blade, I started to wander if I had made a wrong judgement/decision at the time. I ordered 3cc of diprivan and proceeded with the trial by forcing the blade into the mouth. The attempts had leaded to bleeding of the gum and I found that there was a lot of granulation tissue around the gum.

I almost fainted when the nurse came back with the milky colour syringe in her hand but she also had a veno-cath in her hand. That means the patient had no parenteral line. Wow, now I had 2 problems, airway and venous assess……My fault as I had taken for granted that all patient laying in the respiratory care ward had a line. Well, blood had kept flowing out from the patient mouth while I bagged the patient…. I had to make a call of inserting a central line or try intubation… One of the nurses had run to the station and prepared for the central line insertion and I decided to take a chance to intubate again. I could barely insert the blade through the silt of tetanus-like clenching teeth but managed to get it. The best I could do was lifting the jaw up and exposing a window of slightly larger than 50sen coin. I saw the epiglottis though and decided to give a try…. I passed the tube into the mouth and did a slight adjustment of the curve(bad practice as you would have to contact the tube with the oral mucosa) – curving it into a U shape. I sighed when I noticed fogging in the tube as I passed the tube along. I had a feeling that my right index finger was bitten as I felt pain during the trial (bitten of coz…) and I was right, I noticed some blood in the glove and there was a shallow wound over the middle phalange upon examination. I did not bother with the tetanus injection as I got shot 5 years ago but true reason was I darn hate neddle....Well, the rest was simple – securing the tube, inserting a central line and packing the bleeding of the gum after sedating the patient.

The nurses had told me that the patient was lucky that I was on call or else the scenario would take extra times and messy… I grinned and told them that the patient times was not up yet, but deep in side me- I considered it was an act of god through my hand….. Had my skill become better ? I don’t think so but I think faith is the key to the success….

grace... truly amazing....

Well….after a 2+ months silence…finally catch the feeling back to blogging.. It was one of my toughest period but still manage to get past the darkest hour… I had seen lies, deception, undergone depression and was truly lost. But at the end of the day, Lord had shown it mercy and guided me through the valley of death(no kidding…. I was blind and found), maybe one day I could share the story but not at the moment…

 

Well, starting from this week, my shift had been greatly reduced…Mon-Tue shift is now 20/24(depends on Lem). Wednesday – only night shift(18-8,14 hrs !!!). But I had to do alternate weekend call(Sat-Sun 24/30 hrs) – nothing to complaint as I had currently doing it for the past few months. I all started 3 weeks ago; I had initiated a daring negotiation which seems to be an impossible mission --- but I got what I expected… my pocket did not get lighter despite the cut of working hours.. in this kinda of hours, where most of my peers were enduring a cut, I considered myself as lucky….

Well, more time to spend with the family and better rest...

post intubation tetanus jab....

A short break follow by a stressful week….I had been back to Malaysia for my holidays(to be exact, I did not have a good rest…) and came back 2X fatigue than ever. A few events had occurred but the track was not affected. Everything was working fine... It was long but not physically stressful shift; after 20hrs in the blue working suit, a nurse in the respiratory ward had called me….A patient’s endotracheal tube seem to slogged off and I told her that I would come up and had a look.

Indeed, there was noise from the tube and I thought the nurse was right. One of the nurses took out a long stylet and asked me if I wanted to replace the tube with it…I was in a good mood than and told her that a 50% chance I would pass the tube into the oesophagus if I did it with the long stylet. I told her I would do a direct intubation. She ran to the station and prepared a tube for me. From 10m away, I saw her passing a “brown” stylet into the tube. Well, I grumbled to myself, ”since when we had this brown stylet?, MS golden plum should have informed me and Lem earlier[we were the major ‘intubator’….]…” (Ms golden plum is our purchaser cum store keeper). The intubation was smooth and when I removed the stylet, I was shocked when I saw the stylet...…..

 

 

 

Well, it was “rusted”….lucky I was as it did not “break” during the removal or else I would need to call the chest physician for bronchoscopic removal…

close up look....
 

Well, I had later informed the matron and acting head nurse later called me up and explained that the stylet was in that state when the store keeper given the tube to them….Well, I told her that I would look the matter up and pay a visit to Ms golden plum and she told me that the ward had applied the stylet 2 yrs ago…really Crap and Meat SXXT….I had shared this incident with Ong and this was this joke of the week response, “ Well, a jab of tetanus toxoid will be enough after the intubation…”

 

tough ride..

CM had left us and we had our roster out… so many LUBANG(hole, in malay) left over, Lem had did the roster and filled out whatever we can. The rest is up to boss and he managed to fill up the vacant. It is a tough ride, for everyone. A 24 hrs is truly not acceptable and healthy, I had to do 2 weekend shift but nothing to complain as I had a long vacation ( is 8 days long ?), I had left over 2 shift for them.

The worst is the coming august when Lem and Ong had to go off. The were 4 days of overlapping and it would be tough challenge.. no obligation for me to cover them up but I did tell Lem that I am gonna do 1 weekend only next months – enough for the “lending a hand” story. It had been more than 1 year doing a favor and the management had taken the favor as granted and placing me routinely on 2 weekend call. Well, there were ED physician who come to us for application with a rocket high pay request. (almost 2x what we are getting…) No way the management going to accept the terms, but our working environment is truly more demanding than others – Apart form ED, we had to cover the ward/ICU, only 1 doctor at a time and the nearest hospital(my ex-) night shift come with a acquiescence 3 hrs sleep and it is 20 km nearer to KHH… I I am not sure , very tired about the present situation – hope for a change in the near future…

Staying in but not admitted...

There was this 8 y/o girl who suffered from fever. No cough nor running nose was noted initially. She was seen by her family physician and ? common cold was impressed. Syrup acetaminophen was prescribed. Her fever had worsen and prn voltaren use was warranted to ease the fever. 4 days later non productive cough was noted and her fever was still stationary with no improvement. On Day 5, decrease air entry was noted over her rt lower chest and she was brought to ED where a chest xray was taken. The chest xray revealed right lower lobe lobar pneumonia and she was admitted. Parenteral augmentin and oral erythromycin was prescribed; fever had subsided on D2 and she was discharged well on D7. A simple history but a stress for me….Yun was the patient.

I had accompanied her in the hospital during and after my calls for the past 1 week. Yun had been admitted multiple times since her birth. Roseola, viral fever, bacterial tonsillitis, febrile convulsion…. And now pneumonia. I had no explanation – just a act of god, some people never get admitted but some suffered from wave and wave of disease. Yun was a healthy girl in general, but fever was a nightmare for all of us. Her fever was so difficult to control in the past. Acetaminophen(full dose of 15mg/kg) q6h and voltaren supp q6hrly. We really had a hard time with Yun as she got admitted on a yearly basis, most of the time was before her birthday. Well, she had overcome her major fear during the admission, she learnt to drink grinded pill with yogurt during this admission. A great leap for her as her body resisted of taking any medication except syrup…. Well, nice to see your child taking their step one at a time (or maybe a great leap)…

I had some thought during the stays in the hospital. The hospital had too much space to improve. The room was not cleaned properly before we enter. There was this blood stain over the curtain extended straight up to the wall and ceiling. I had to tell the head nurse before she sent the cleaner to take off the curtain and take a good clean over the wall. However the new curtain was never installed before the discharge. The fridge was not clean, ice perk over the cold storage making it not cold. The dust bin was not cleaned at a regular interval… I think something should be done – after all service is one the key factor to attract people. I considered the medical industries had no different than the hotel service. Comfort and hospitality(after all we are really a hospital…) is key to success….

As a attending physician in the hospital, I think it is a basic ethic to get admitted to the home hospital if care is available. Our fellow cardiologist had chosen to get admitted to our own hospital during his last admission – he could have stayed elsewhere nearer his house, he even had to share a room with another patient as no single room was available…

the new one which come too late....

Grand starex	T5 transporter

After 8 months of dragging on…I finally saw the new ambulance ….a Hyundai Grand Starex… Diesel version. It had been bothering us for the past few months as the old one had been causing a lot of problem. The old one was a Volkswagen transporter. It was spacious and very suitable to utilize as ambulance. Parts are all around as the vehicle were so popular in this country serving as 12 seaters van. Indeed it had good suspension and chassis, that were the advantages of European car. However since it was design for use in the cooler Europe, the hot summer here make it an unreliable car after few years of use. The owner would start to experience small problem here and there – small parts to be replaced and the cost is high if you use original parts, however as it was so popular you can get second hand part “butcher” from some scarp off one. However sometimes it just break down without any warning and making it very unreliable especially using it as an ambulance. You just can’t leave the car along the road side with the patient on it…. Well, eat salt and resist the thirst. I had an encounter with our ambulance years ago, I was cruising at 130km/h at the “air-strip” speedway(claimed to be F-16 landing/take off capable , in doubt of coz….) our ambulance “slide” over my starboard side (yes, from the out side of the road as I was driving at the outer lane).

The management had chosen the Grand Starex as it had proven to be a good investment in the past. They had purchased a Grand starex diesel as a transportation van for hemodialysis patient 1+ years ago. Not much problem and the only complaint was it’s suspension that was a little bit soft. The management doesn’t mind a bit as they are not in the vehicle most of the time…. It was the price which makes the different and make the choice easier , almost 40% cheaper than the VW counterpart. I had ridden the Grand starex for a few times and found that it is a good van – spacious and comfort to be in… Well, it came too late – our late EMT was so looking forward to it…..

square minus one...

Well, I was at my 55 hrs of shift( I had a 10 hrs break in between). Our Dep Supt(admin) had come toward me and said,” the person had “Failure””. I immediately acknowledged what he means… the ED physician is not coming … well, I showed a disbelief look and told me, “No way, I got a call again from my ex-colleague telling me that he is leaving definitely today morning.”. The reply was not stunning,” well, he is leaving of coz, but to another hospital in the town , not to us..” Well, I would be damn, after all those strategic discussing about salary and shift arrangement. All had become bubble….It was still explainable as he stayed in KHH and why should he want a longer drive and he is a golfer who likes to take a break from time to time for golfing… coming here would be an end , as he would taking over as head… He had used us as a chip for bargain a better place…

 well, really a big problem in the future, we are not only back to square zero, but to square minus one… Not sure what would be happening as boss is still keeping quiet…

Definitely cannot leave at the moment…another 12 more months I presumed…..