outer rims...

 

Boss had declared the we would be joining the “outer rim scheme” of the national health insurance bureau plan next year few days ago.

The NHI bureau had started on a claim-pay basis initially. The hospitals submit their bill and the bureau pay as submitted. The bureau has no man power to go through all the cases so it would choose 1 chart per 1000 or per 100 and review the chart. Inappropriate item would be crossed out. The amount of such item would be x 100 (or x1000) and deducted from the payable claim to hospital; that means the chart represent x100 or x1000 of the case note.

The bureau has however allowed the hospital to write appeal for the deduction.

So proper charting is essential, every drug prescribed/exam ordered should be accompanied by appropriate charting.

Under such scheme, some of the hospital had tried very hard to pile up the claim. The annual growth had been enormously high and the govt. had decided to restrict it growth. The bureau had implemented a budget system. 2 schemes were set up -> he inner rim and the outer rim. The budget is separated into 2 pieces. 70% was limited to the budget limit group(inner rim) and 30% to the unlimited group (outer rim) . In the inner rim group, the hospital claim per quarter is set (with reference to claim done during the same period in the past), and a growth of 3-5% is allowed provided the hospital attained the working target set(eg. Total drug cost/total claim <30%....). Any claim beyond the amount would not be paid and the bureau would not deduct any inappropriate item from the claim.

The outer rim portion means the hospital would follow the old rule – claim – review – deduct.2 months before the next quarter, hospitals would have to decided if they wanted to join which portion. If less then 70% of the hospital(counted on claim amount basis) join the inner rim than there would be only one scheme - > the old rule.

Most of the hospital would opt for the inner rim as it is safer and the burden on charting is less. However when a hospital expanded it beds or equipment, the hospital would opt for the outer rim and tried to out perform it past result and gaining chips for bargain in the future.

in the outer rim the deduction rate starts from 20%. That means no matter how good your charting or setting, one would face a minimum deduction of 20% initially and with luck it could be reduce to 10% after appeal.

Not a burden for me but still more time would be spent on typing case note. But I would tried to modified my program. Each time a drug is prescribed an automated generated case note would be done…..and the only job is to print it out….cross my finger……

Instructor Course --- Disaster Medicine Training Course

 

Ving had complained that I was hooked onto gaming for the past few weeks…indeed, I am currently playing 3 version of advance war – the advance war, advancewar: black hole rising and advancewar:dual strike. I am playing them on 3 different console of coz. The advance war:blackhole rising on the GBA SP, the Advancewar : dual strike on the NDSL and the advancewar on the WII(vgb:on homebrew, striking experience on the 46’ LCD of coz…)….

Indeed, I played game to divert my anxiety….I had gone for the instructor course for the basic disaster medicine. In Taipei 2 weeks ago….

The society of disaster medicine was set up about 10 + years ago around the peri-921 earthquake period. Most of the core founders were from the SKMH in Taipei. One of the senior ED physician had later held the office of Health Director in Taipei City during the tenure of President Ma as Mayor. I had joined the society 4-5 years ago when I got my certificate for advance and basic disaster medicine course. The society held several teaching course for NBC(natural, biological and chemical) disaster management and disaster medicine course every year. Completing a credit of 24 would eligible one to sit for the disaster medicine specialist test. The specialist cert was unfortunately not gazette by the law as specialties(The GI is not a gazette specialty but still it was recognized by the national health insurance bureau)

But any way, who cares…

I had intended to join the course as I wanted to run the course in our hospital. Our hospital is currently situated in a disaster prone location. We are 70+ km away from the nuclear power plant and we are under the threat of tsunami if a large quake hit the Manila trench. There was a preparation meeting held 1 months ago in one of the govt. hospital in K city. Local officers from various related agency were summoned and there meeting had broken the news that a severe quake leading to tsunami would be expected on Jan 13-15(peri Voting Day for President). The meeting had warned the officers to be prepared for such disaster. Just after the meeting one of the village which suffered from heavy loss during the 88 flood had undergone a tsunami warning exercise. One of the officers who happened to attend the meeting had warned the elder of our church. He had told me the news.

I had done some research and found that although the prediction was a crap..(nothing/no one could give such prediction…except GOD), but the threat is still there, the southern part of Taiwan would be affected by tsunami if the Manila trench suffered from a heavy quake. If sliding occurred on the whole 900+km length of Manila trench -> there would be tsunami with wave of 3m high…. Just if….but still it could occur….

Anyway I had filled in the form months before the pre-tsunami warning meeting.

There society had sent us a set of slide(700+) and we would be requested to present two 8 mins session on selected topic. Not an easy stuff as the slide was prepared by others….

I had bought The Fundamental of Disaster Medicine from the Society of Crital Care Medicine -> cost me around 3000NT(shipment via airmail..)….However I had gotten this pdf version of Koenig’ Disaster Medicine which I could install in the Kindle…

Most of the slide came from text book written by the Society but still some of the slides lead you to no where. I spend sometimes reading the above 2 textbooks during the 1+months of preparation.

Some of the slide was confusion as I did not know what the author wanted to present on the topic... for example – I just don’t know what is MCMS..

on a quick glance and I couldn’t find it in all the 3 references textbooks…. But with the help of google, I managed to trace it to a manual produced by the WHO…

The preparation was not smooth as I had to prepared a talk on tsunami and disaster planning in the church 2 days prior to the course and Ving was not feeling well …

The course was held on Saturday and it started early at 8:30am. The earliest high speed rail hit Taipei at 8:20am – SKMH was 25 min drive from the Taipei Station…so I decided to put a night in Taipei…

The kids had complained that it was so good for me to stay in the hotel as we had been camping for the last few trips… they missed the sensation of staying in a hotel… I felt a little bit sorry but still they had been pampered too much in the past….

It was tiresome Friday. Post call and govt clinic rounds in the mountain area. I came home at 1:00pm after a 20 hrs of overnight work. Catch a little sleep and drove to the HSR station in K city. I wanted to take the 5:00pm train but unfortunately it was fully book. I took the HSR instead. (RM100 difference in price...)

Although no reservation was done I got a small room with the price of RM300….it came with a luxury buffet breakfast….A hotel run by Japanese firm. I noticed most of the guests were Japanese during breakfast on the next day…

I ended my study at 1am and hit the bed. I felt peace though as I had prayed to the LORD for the passing this time….

The breakfast was Japanese orientated but still I had a good bite despite of the hanging over from poor sleep.

I took the monorail and managed to get to SKMH in time. I was surprised as there were only 12 candidates…

I was not surprised when I saw the topic allocated to me, those topics which were not in the 3 references textbooks. I was an outsider from no where; candidate to be failed with the excuse of “Don’t know what you are teaching..”

Apart from the topic I mentioned above, I got a topic of confined space rescue …. Some of the slide of which I just don’t know how; I had neglected it as I thought I would not be such mishap to get it…

just don't know how to described them....

this was original text....

the classroom was situated in B4(basement 4 -> no signal for my 3G card…) so I had a very fast lunch and hit to B1 where I could get a signal.. I managed to get the origin (it was from FEMA US&R task force medical training manual).. and I was quite confident I could impress the examiner…

The oral presentation went great as I could mention the origin to the examiner…

The result was not published on the spot, although I was given a good remark by the examiner, I was still feeling a bit of anxiety…the returning trip was smooth and I managed to get Yun’s Licca Baskin and Robins set, and I got a motion plus for the WII….

I was checking email and mail for the next 2 weeks hoping for the result… I finally got the letter yesterday, it came with a small certificate …..

The next step would be preparing the course... need to get approval from da Boss and I would run the course in the church as well....

hard one...

A church member had passed away 1+ week ago. He was a case of lung cancer with brain metastasis. He had joined our church 1+ years ago months after he was diagnosed… A simple man with no “carcinogenic” habbit, non-smoker + non-drinker; he worked as a clerk in the land office. I did not have any close contact with him initially but later on he had gone into coma after a severe pneumonic episode. He was admitted to hospice ward in the K metropolis (previous K county but later merge with K city and become K metropolis). On most of the Friday night, I used to travel to the hospital bringing his children over to see him. After a miracle recovery, he was still in coma though but he was transferred to a smaller hospital as the National health insurance prevented for him to continue for staying in the hospice ward(in the same hospital) after he was stabilized.

Weeks later, he had suffered from a diarrhea episode and his wife had accepted our suggestion to stop the milk feeding and switch to soy bean and grain base liquid diet. Another miracle occurred as he had regained conscious and able to communicate. However he was still paralysis due to the brain metastasis.

His wife had tried every possible excuse to keep him in the hospital as the insurance claim was RM 300 per days for admission. After a wild goose chase of moving from 1 hospital to another, they had decided to return for home care.

They had hired a indon maid but unfortunately the wife had misused the maid. She had asked the maid to help out with the house hold job instead of staying beside the brother and taking care of him…He had vomited while the maid was working back in the garden planting tomato he had choked and aspiration pneumonia was noted.

He was very dyspneic later on and the families were unbearable to see his suffering and  sent him for admission. He was admitted to ICU in my ex working place. Do-Not -Attempt-Resuscitate order was signed on admission by his wife.

It was a hard decision for me when the wife and mother had seen his condition worsening on D2 - he was experiencing severe shortness of breath. They had asked me for opinion regarding intubation. Unlike working in the ED, the opinion was though. The ICU did not provide any strong sedation and narcotic for the patient despite of the 40-50/min tachypneic condition. Under the counter, the mother had complaint to me that the wife had asked the maid to leave the patient for some gardening job leading to the pneumonic episode….

I had recommended for intubation as the aspiration is an acute episode hoping for recovery after antibiotic therapy. That could also buy some time for the mother to undergo her anger…. The wife forfeited the DNAR order and proceeded with intubation.

Despite some improvement on D3, the patient had gone into severe respiratory failure c high O2 use. He finally passed away on a morning....

It was a difficult choice for me to give such recommendation. I was standing on the side of the family despite of the patient… from the point of practice, it is against what I believe… but still watching your relative in a stat of shortness of breath and passing away is something very suffering….

Well, anyway with the grace of LORD, things just went fine and everyone were happy….excluding me of coz…

I had wandered what would be my decision when the time comes for me to decide…

 

 

a path I had taken...

Both Xian and Yun had gone through their examination 1+ weeks ago… A new milestone for both of them….

Yun was doing averagely in the past, most of the mistake was due to carelessness instead of not-knowing… I did not push any pressure on her as a happy life is what I hope for…. Xian was improving though he was still bottom of his class.

Xian was attracted by the Xbox Kinect during one of our visit to Taipei. He had asked me if I could buy one for him. I was too tired during the request and answer session and I told him if he could hit the target of average of 90, I would buy it… well, He got an average of 81 in his last examination. He was darn dedicated and I felt regret of giving such demand… Then Yun came and asked if she could get a similar deal as her brother -> Licca Baskin and Robin icecream stand set…I told her yes and set the target at 470(she got 460 in her last attempt).

Yuns.....	Xian choice...

Both of them was dedicated but it does not mean they studied hard in the past like I did… Playing and watching “Black Jack” TV series (by Dr Tezuka Osamu…) were still on the list of activities….

Well, Yun was so easy few days prior to her examination. She hovering around and I told her that her weak spot was Chinese language and asked her to write the vocab again and she said she was fine with that….Xian did badly on his nature and sociology on his last test and I focus on that.

I told them 2 days prior to the exam that I would not be rewarding them for their good result as I felt it is not right to do so….I had seen their effort and I decided to buy it for them but not immediately after the exam as we need a cool down period….

Xian had a strike back for his nature and sociology but surprisingly he was knocked over by the practical question of math…he got a 60+ and stumbling his effort despite a great improvement for his other subject…Yun was 1 mark away from the preset target and she was a few marks away from the award; most of her loss was due to mis-writing…

The did well… and I feel their had gotten the hang of study…

Yun got hers last week during my trip to the instructor of Disaster Medicine Course last week….

Xian would be expecting his prior to Chinese new year if I got my bonus….(I told him just if, but still, he would get it anyway…)

 

pro and cons

Part of the facilities were moved into the new building despite of any CF. The old block A and B was demolished(including the old ED call room.). This 2 section would be converted into a parking lot. We were still situated in the old Block C but the environment is more comfortable than ever minus the 175 of coz. The size of 175 had shrunk 60% and lately our lockers were taken away. Rumors said that we would be given a table in the new medical staff room but still at the stage of rumor. The call was better as the call room was few steps away from the consultation desk. The air quality was far better and I was not the only one who share the same feeling. However there are some haze masking our future. No new physician nor surgeon is being recruited. We are worried as Boss had hinted lem few weeks ago that they might not be able to give our any. I have to cross my finger and hope for some miracle…..

something that fall from the sky...

 

I had mentioned about the pity young chap who had uremia and currently undergoing haemodialysis. He was lucky enough as the fund raising was pretty successful. According to his blog, he had changed his mind about the renal transplant and opting for stem cell therapy. Someone had told him that there is hope in this stem cell therapy and it cost less with the risk was lesser. He had even met with a middle-aged male who claimed that he had undergone such therapy and cured.

It was a news to me…as I had never heard of such therapy substituting the renal transplant.

I had dug around and found that it is a very new technique currently at its researching state. Although the result on animal was promising but still it is not a standard therapy.

The young chap had plead to the fund raising committee that he wanted to opted for the stem cell therapy trial(fee was estimated a t RM100k). I had written a long response on his blog and he had however defended his point of view (http://firelynx1992.blogspot.com/2011/11/blog-post_07.html)

He himself had claimed that the successfully rate was not high but yet many was save; which I considered as crap as no research article to prove so, from the search over pubmed, most of the published articles regarding stem cell therapy for uremia focus on animal trial…).

He had further described the risk of peri and post renal transplant …… which he had intended to take it initially but later found that the stem cell therapy could be better (less risk and no further need of high cost Immunosuppressive drug) so he had opted for something safer and less burden for him in the future...

He had missed the point that the money donated for him is for renal transplant instead of a don’t know result stem cell therapy…

He had questioned that if I am as ill as he is would I had done better? With my knowledge and life experience I think I would…. But back to basic as a public, I might had done worst….

The shocking part was he is  invited to give talk and counsel to some youngling….Instead of focusing on his study which he missed from the absent of lower six classes. He had gone to swimming, playing snooker and wandering here and there...I think he is waiting for the post renal transplant and then restart his life and pausing whatever study he should have done at the moment...

A sick one with sick thought sharing his mind…our future is at the mercy of our LORD….

of BOLEH and lies.....

 

I had read the news regarding the EV and REEV(hybrid) by Proton lately. Proton had speculated when it is launching (2013) and even an estimated price tag…

A little bit upset again when I saw how the high level management could just simply throw out word and sentences which they knew is untrue.

The key to success for an EV to be marketed depends on the country infrastructure – setting up of charging station or battery exchange station. Charging of an EV took at least 2 hours and as far as I know, the shorter the charging time, the shorter the battery last. Unless there is a breakthrough with this battery technology, the EV is just an prototype….It would be different for an hybrid car, charging take place when the driver hit the breaks. Hybird car is not charging station dependant,a certain amount of hybrid car running around and if the Proton could produce something other than the prototype, a mass production model could be launched NOW instead of 2 years later…that mean – they are not readied….just another "others can so we BOLEH" tactics….

Too many similar examples occurred in the past – the astronaut, female arctic adventurer, Mt. Everest Climber…..and the origin : PROTON…

Yes, Malaysian got to enjoy budget car with so less safety feature….just because foreign car had to be taxed….

Prayer heard...

 

My prayer was heard and there was ok as no one had come for harassing our locum ED physician…

We had shifted to the new compartment. Nicely set and I had a good sleep during the 1^st call I did. The 175 is 1/3 of the size of the former one. Lem and I were satisfied with the current setting although some minor tuning is needed in the future.

There is this auto toilet installed which can give the anal a good flush after the passage…

Don;t treat the public like a fool.....

 The “prince” is a famous actor cum singer, the princess is a famous singer cum TV show host. The prince, together with some 40 peoples are investigated by the prosecutor office for forging record and illegal hiring foreign maid. The prince had instantly admitted his crime and was put on probation while the other accuse who plead not guilty were charged in the court of law. After the probation decision, the princess had told the press that they were in a mass than, she was pregnant and expecting the baby, their granny had fallen sick in the ICU and they had no man power to spare so that they had complied with the suggestion from the labor deploying company in order to get help…

She look so pity and innocent…but I think she treat the people like a fool…lies and deceit trying to gain the mercy from the public…

Just look at the lies…

1. Granny lying in ICU means the ICU staff would look after the patient… why need a maid to assist ?

2. There is this so called da LOCAL MAID…which charge NT30000 more than the foreign maid…the princess had a gross income of over RM 4 million last year… NT 30000 /months is just like hair from a cow skin…

Bad thinking, bad excuses and bad example for the public….

But there is still justice, the probation was rejected by the court of law and the prince was sent back for reinvestigation....

Shave yourself before you shave other....

 I had seen the news over the TV last night. A famous singer from Malaysia, Micheal Wong(光良) had written an article on the blog accusing of a impolite act of a ground service crew, he had posted a picture and told the public to avoid the counter manned by the crew mentioned or take another airline….One member from the group (a hair stylist) had placed a spraying gel in the luggage. The crew had asked them to open up the bag for removal but his act was regarded as impolite and unsuitable. Many versions of the incident were posted over the net. According to one of the newspaper report; Micheal had asked the crew why it is forbidden to bring such item…. For a frequent flyer like Micheal, it is a basic knowledge to know what you can carry on aboard and what you can’t – this incident which tried to embarrass other had exposure his lack of common knowledge…..

life of an explorer....

T is our chief of ICU(trained as a cardiologist but never took the board…), whenever we met during his going off and my coming to work, he would grin and greet me,” going to the beach again ?”. I usually wear a Bermuda shorts, T-shirt and a sandal to work( change to the working suit later of coz…).

Since my childhood, I had been fascinated by fairy tales and legend, my mother was a good story teller and later when I could read, I had a good supply of comic from my cousin. I still can feel the thrill of entering the library of the primary school. Borrow books and read through them…..it expanded my view, expanded the fantasy dream of a young boy. Reading was not enough and the fun was involving in it. During my secondary school, my father bought us a computer, an XT, 4.77mHz c 2 floppy drive and a VGA monitor( a luxury then…, most of the XT come with a monochrome).

 

We were poor then yet my parents fulfilled our dream – I had my first adventure game – Ultima III.

game by the famous Lord British....

My English was above average then most of my classmate but yet, it took me weeks to understand “thou art…”. My favorite character is Paladin which had a balance of magician and fighter. Joining the St. John and later building my path to the post of Warrant officer had enabled me to master the skill of living in the wild.

I often wander if there would be a day when I could venture into the unknown dimension and lead a life of an adventurer…

Life was cruel and I had to coup with the reality; I got lucky as my effort pay off….

I had the eagerness for the wilderness life; tried very best to get myself closer to it. The thought had influenced my life -> everything I purchased is explorer oriented – another reason of buying an 4wd SUV. I added Wenger Ranger, G-shock Mudman, Teva Itunda into my arsenal lately.

enlarge version of the victrorinox, more suitable for wild life use....	twin sensor c a compass....	fast dried and spider rider suitable for wet and muddy terrain....

All came in handy while working in the farm and just a preparation for my next stop – Taman Negara……

 

anxiety

 

I had to do night shift on Sunday once per months…the dep supt(medical care) was on call that day and we had a discussion about a case. The case was managed by our locum doctor. The patient had gone into arrest after hours of management in ED. Case was later transferred out to a medical center on a PEA wave. I did not concur with such act….the management was kinda old fashion and might not meet the standard of present day care. But still the family attitude which is that major cause of anxiety….

Lem was worried later as he was afraid that the locum would have to give himself up as the family would come here for trouble. I was more worried than him as I would be the one going back to the 30 hrs weekend call….praying hard to GOD that this would never happen….

...of unit

 

It was quite a good call…. No code blue, code red….I had a call just after I completed the upload of EMR chart. The shift lead of the ICU called me and informed that the ICU is now full and they no longer intake any patient. I was in a mist when I heard such news. Lem did not advice me on any new rules when he passed over the ED to me. I asked the leader about the new regulation. She told me that the ICU director and boss had agreed that there ICU would maintain 12 beds and no extra patient in the future.

Indeed the ICU had been over stressed for the past few years. We would accept any critical patient and there is no such thing that referral because of no bed available in ICU. The bed occupancy rate had most of the time been 105%-110%. The nurses are all stress up.

I pity them but I had to follow the order of da BOSS. I told her politely that no one had told me that I should turned down referral because there is no bed in the ICU, I would forget there conversation as I don’t want to get into any trouble. She told me that the head nurse had told them on the issue when they went off their shift last night. The agreement had been made….I told her that I doubted the decision and I would confirm it later.

During the conference, the issue was raised and Boss had strongly clarified that he had never promised anything even though such conversation had been made. It was a long discussion and the final verdict is the ICU director and Boss would try their best to maintain a 12 beds or less occupancy before they went off. In such case there would be 2 bed spare for critical patient from ED/ward. I had gone back and returned the next day morning before I went to the govt clinic. Lem had told me that our colleague K was barred from admitting a case with pneumothorax s/p chest tube to ICU by the nurses as the nurses had told him that the 2 extra bed is meant to accept case from ward instead of ED. I got really fired, night shift attending physician had been bullied and pushed around. I called up the matron and told her about our situation.

I knew the person behind is definitely the head nurse. She had been pushing us around and tried her best to work less… had been so during her day as asst head nurse….got pissed off as she had tried to spread such lie but still I had to let someone handle her….thing is not going to change if our man power is not increase….

struggling...

I got a call from my brother yesterday. He asked me about if there is any disease that would kill without a renal transplant. Technically is no – one can live for a very long time on dialysis. He told me that one of the Chinese news paper in Malaysia had posted a news regarding a STPM student in Malaysia who need a transplant to “Save his life”. He was unpleased with the title and wished to complaint to the newspaper. I totally agreed with his opinion regarding the misleading title. But I was curious about the young chap who score 12A in his SPM.

I googled and find something out about this poor young chap. He had made news in 2009 when he was diagnosed with acute appendicitis during the SPM exam, he and his parent had decided to postponed the emergency surgery undertaking the risk of peritonitis to complete the exam. He had done great with 12 A. However during the perioperative period, he was diagnosed having glomerulonephritis. His condition had deteriorated over the next 2 years and had to undergo hemodialysis since months ago.

He had to stop his study after upper six.

Some of good hearted people had tried to raise a fund of RM300k for him to have a kidney transplant done in China.

An act of love but take a further step looking into the issue… Kidney transplant in China = “Buying” a kidney in China, a very unethical act. Save one by hurting the others…it is an suitable act ?

It was a very disastrous event to have a uremia in Malaysia. Hemodialysis 3 times/week and the cost would drag a family straight down to the land of torment. There are lots of charity funded hemodialysis center in Malaysia but no one is going to pay for the immuno-suppresssive drug after the transplant.(the Malaysia govt had decided that no free drug for transplant done abroad.)

Anyway still feel bad for the pity young chap….

_

the corridor....

The 175(duty room was) never a good place to live, however there was another place which is more inhuman……from the ED to the 175, there was this corridor; the doctor had to walk through the corridor to reach the ED. The 175 had a big window which face toward the corridor. The corridor is also the resting area of the cleaner.

The hospital cleaning service is contracted to a company. The boss had hired a group of ladies mostly aborigine and foreigner bride with a very low pay. The cleaners use to meet at the outside the 175 during the morning pass over. The boss was so kind to put 2 folding chairs cum beds outside the 175 for the cleaner to take a nap or rest.

In the night, I had to walk slowly without making noise as the cleaner on duty slept outside the 175

Life is so unfair. I told myself when I took the long walk in the night. Both doing night shift and the prey was so different. I am at the mercy and grace of the LORD…

relocation....

 

The final plan of ED was settled few days ago. Lem had brought us the news that the 175 would be relocated in the ED – same level instead of basement. A real good news…..the long walk would be dangerous in the night. The coward still call up and threaten us from time to time, we don’t know when we would be ambushed…. nothing much to shout as justice had been served. The room is definitely smaller than what we have at the moment… there is window still, the view is still bad – facing wall of an building, but better than none…1 more month before the shift begin…

ambush...

There was this violence incident occurred during my weekend off last week. A local scum had attempted to strangled our gastroenterologist during his ward round. The scum was “neutralized” as other had come to help. Later he had confessed that he had done this as a favor for another patient. The same old patient who had threatened me a few weeks ago. Well, what an event, very unsecure but have to live with it….As a black belt holder, I felt more calmer facing this kind of threat but still, facing an ambush is a different kind of story…

Most of the time, the management would fight fire with fire, a local gangster would be sent to the patient and issued a warning and further action would be taken if the warning is ignored…I hope it works…

the move

We were led by boss to the new building yesterday… Its infrastructure is readied but still lot of interior renovation going on… Me and Lem had the same feeling – outsider job. Our ex-dep supt had said that the architect who is specialized in hospital design charge an additional fee of NT 500k….well, a small figure compare to the construction fee, but still no one wanted to listen…

7 days before the move begin….

new lifestyle....

 

I had been reading a lot regarding food for the past 6 months… There were a lot of stunning materials which I did not know clinically. I had found that the way I and family used to eat would lead to a path of no return. We had decided to cut down meat and the final destination was pure vegetarian food. However to lay our hand on health vegetable was truly a challenge. Nothing is safe out there – I do not trust those farmers to be frank. I would encounter a few farmers (who farm Jambu) in the ED complaining of intoxication after spraying insecticide and pesticide. In the past most of them use 1 or 2 chemicals, but nowadays many of them use more then 3 types of insecticide and pesticide. The product and profit were their primary concerned, just can’t blame them – they rely on that for the living…

We had decided to grow vegetable by ourselves. We had rented a small piece of land in the local citizen farm. A land of about 400 sqm2.

I did most of the land shaping job…. It was really a tiresome one in the beginning. Although the owner provided a free plough of the land at the beginning, we were able to plant half of the land prior to the typhoon and rainy season. After the rain pour the other part of the soil was harden – the land shaping stuff was really a physical torment for a office worker like me.

One of the challenges was digging a good drain… I learnt a lot from others who farmed there.

We have harvested our first batch of vegetable this week… It was great eating vegetable which was grown by your own hands….The next step would be proper planning so that we could harvest every day…I had once read an article from the web, one of the organic farm owner had said that he used 70% of his time planning instead of actually farming…. At the moment, I total agree with him…

The land is about 5 kms from my house. We go to the farm 4-5 times /week, 2-3 hrs per trip. I am closer and closer to my dream. My final destination is to attain a state of self provision – growing and producing the food we need….

safety in ED

 

I got a threat few weeks….An alcoholic was brought into the ED in a stupor state. I had did a check of GCS and the alcoholic had jumped up instantly and accusing me of using “force” on him. He had threaten me that he wanted to call his buddy over and teach me a “good” lesson. What a crap. Few months ago, there Department of health had issued a statement after an assault incident involving patient and ED staff stating that it would be must for ED to have restricted assess and security coverage in the future. I remembered those old days working in the Casualty department of Hospital Tengku Ampuan Rahimah…. There is always a security guard outside – the ED. Every pt would be triaged and called accordingly. There is a police’s hut nearby and there is always a police on guard… Relative safe environment protecting the violence victim in a sense. There was a case about 9-10 years ago, a wife which was assaulted by her husband sent to a local hospital nearby. The husband had later arrived in the ED and unexpectedly drawn out a knife and stabbed her over her flank. She had sustained kidney laceration and later death on table despite of emergency surgery in the ED.

I had heard threat and I think it would be appropriate to do so but it would greatly increase the cost. However Lem had told me that our hospital is different from others. Our ED had contributed 75% of the admission unlike the other hospital which comprised of only 30%. Just hope the management would look into our safety. I had told my colleague not only once that if firearm is to be legalized here, I would apply a license for firearm and carry a Glock during my shift….

new 175.....

The new building is at the final stage of construction….it was scheduled to be readied by the mid of the months but the last typhoon had delayed the work for about 1 week so nothing happens…

There are currently 2 buildings at the moment, A which consist of 3 storey and B which consist of 8F+basement. The A building would had to “go” to comply with the law (building coverage ratio….) in order to obtain Certificate of fitness for the new building. The ED is currently situated at the entrance of block A and we would be moving to ground floor of Block B. The GF of Block B is the current OPD. The OPD would be temporary move to the supply department across the road.

The plan for the new ED was initially drawn up by the medical staff of ED. But 3 weeks ago, boss had called up the matron stating that he was going to overrule the old plan. He wanted to “popped” up 5 more ED bed and the doctor rest room(175) would be shifting to the basement of ED. Lem had protested to the dept supt of admin but had yet received any reply. Life would be worst than…..basement is not a place good for resting, dark, wet …. I had told Lem that I would be utilizing the head nurse office for the rest in the night as I don’t want to walk all the way down to the basement…. What had happened when the designer could not meet the end users demands ? Bad relationship and poor working morale….Just couldn’t figure out how the management think….well, had to coup with it....

untrustable and arrogant....

There was further update regarding the mis-transplantation of HIV organ. Apparently the university hospital had drawn blood from the patient and sent the blood sample back to the university hospital for HIV and other hepatitis marker test.

So when the lab test result came out, the lab technician would inform the transplant coordinator about the status. According to the protocol, any extraordinary result(such as severe hyperkalemia) should be reported to the relevant personnel (including the attending doctor). In such case, the head of transplant project should be informed via SMS. However such protocol was not follow. Well that was why the mishap had occurred.

The head of transplant project for the university hospital is a trauma surgeon – I had attended a few conferences facilitated by him. He was a dedicated person and a philanthropist. He truly had a passion in life. He had given an excellent talk on ethic issue of ECMO and artificial cardiac machine… He is currently the only person who stepped down (not resign from his post of professor of surgery and surgeon of coz) from the post of head of project.

The act of sending the blood sample back to the university hospital laboratory is an act of arrogant and waste of public assets. Why could they just trust the local hospital lab ? The public had to pay twice for a same lab result…. One of the member of the Control Yuan(department of Supervision) has volunteered herself for investigation. She holds a doctorate in nursing and hopefully she could properly probe into such situation and in-proper act would be corrected in the future…

untrustable and arrogant....

There was further update regarding the mis-transplantation of HIV organ. Apparently the university hospital had drawn blood from the patient and sent the blood sample back to the university hospital for HIV and other hepatitis marker test.

So when the lab test result came out, the lab technician would inform the transplant coordinator about the status. According to the protocol, any extraordinary result(such as severe hyperkalemia) should be reported to the relevant personnel (including the attending doctor). In such case, the head of transplant project should be informed via SMS. However such protocol was not follow. Well that was why the mishap had occurred.

The head of transplant project for the university hospital is a trauma surgeon – I had attended a few conferences facilitated by him. He was a dedicated person and a philanthropist. He truly had a passion in life. He had given an excellent talk on ethic issue of ECMO and artificial cardiac machine… He is currently the only person who stepped down (not resign from his post of professor of surgery and surgeon of coz) from the post of head of project.

The act of sending the blood sample back to the university hospital laboratory is an act of arrogant and waste of public assets. Why could they just trust the local hospital lab ? The public had to pay twice for a same lab result…. One of the member of the Control Yuan(department of Supervision) has volunteered herself for investigation. She holds a doctorate in nursing and hopefully she could properly probe into such situation and in-proper act would be corrected in the future…

trust and aro

There was further update regarding the mis-transplantation of HIV organ. Apparently the university hospital had drawn blood from the patient and sent the blood sample back to the university hospital for HIV and other hepatitis marker test.

So when the lab test result came out, the lab technician would inform the transplant coordinator about the status. According to the protocol, any extraordinary result(such as severe hyperkalemia) should be reported to the relevant personnel (including the attending doctor). In such case, the head of transplant project should be informed via SMS. However such protocol was not follow. Well that was why the mishap had occurred.

The head of transplant project for the university hospital is a trauma surgeon – I had attended a few conferences facilitated by him. He was a dedicated person and a philanthropist. He truly had a passion in life. He had given an excellent talk on ethic issue of ECMO and artificial cardiac machine… He is currently the only person who stepped down (not resign from his post of professor of surgery and surgeon of coz) from the post of head of project.

The act of sending the blood sample back to the university hospital laboratory is an act of arrogant and waste of public assets. Why could they just trust the local hospital lab ? The public had to pay twice for a same lab result…. One of the member of the Control Yuan(department of Supervision) has volunteered herself for investigation. She holds a doctorate in nursing and hopefully she could properly probe into such situation and in-proper act would be corrected in the future…

ass covering with their head....

I was stunned when I heard that the transplantation of HIV infected donor organ to 5 recipients by 2 of the local prestige university hospitals…

The surgeons (more than a handful ) had discovered the facts that their donor was HIV positive 48 hrs after the transplantation…

The 1^st action response to the incident after it hit the news desk was to push the responsibility to the organ transplant coordinator…

The team had blamed that the coordinator and the respective lab technician who had a miss communication when the lab technician reported the “infection” status of the patient via phone to the team. (the lab technician said reactive and the coordinator took it as negative)

 It was very sarcastic as the health authority and the hospital evaluation group had stress over the patient focus care issue over the past few years. The top rated surgeon had forgotten their duty as an “attending” surgeon in this case. They allowed their job to be done by resident and other staff. I don't think they had glanced through the medical chart and talk to the family's of both donor and recipient properlly prior to the surgery. All they wants is to perform surgery and gather as many case for their research material and published as many article as they could.

The team had been touring all over the island doing transplantation...where was the basic core of good medical care ? should the doctor done a thorough history taking (the patient’s mother knew that he was a gay) someone would be alert enough to seriously ruled out the possible HIV status…

Flash back the incident -> a 37 y/o male alleged fallen from 2 storey height. He had sustained a severe head injury and treated in a hospital in Hsin Zhu. He was pronounced brain death later and the family had informed the university hospital that they agreed for a organ donation. Both the hospital was 60 km apart. A 1.5 hrs drive…. How long would it take for an urgent check of HIV and other “infection” status ? 2 hours max in an urgent situation. The data would be readied by the time the team arrived. The surgeon had proceeded boldly instead of waiting -> a decision endangering the whole team…. Didn’t the surgeon read the medical chart before they proceeded with the surgery ? Should they had read the chart properly they would definitely found out that the lab data was missing….

The worst part was – no one claimed responsible – the hospital tried to blame the coordinator over the incident. They management had even regard the coordinator as employee from the DOH instead of the hospital (so it was the DOH employee who did the mistake and it had nothing to do with our hospital…)[the DOH granted a sum of NT 20 million to all the hospitals which operate the transplant surgery, the university hospital had use part of the money to hire the relevant coordinator…] the hosptial superintedent(currently president of internal medicine society) had come out to apologized few days later....no attending surgeon had come up to admit their negligence (I hope they could sleep properly in the night and walk in piece during a stormy day...)

Crap SHXT story which can fool the public but not some insider like us…I hope the investigation is done properly and someone dearly pay the price (so I could be pacified as I am going to one of tax payer paying up the anti-retrovirus drug for the recipients..)

Fefe...

Having Fefe for almost 3 months… Everyone is happy about her….There is no more problem after the initial “adjusting” here and there. We took a drive to east coast – Hua Lian. A 220km drive which took us 4+ hrs.

No one wasted their lunch during our drive through the southern reversing road, thanks to the modified suspension of 4wd version. The suspension for the 2wd was softer instead. Unlike the Z with excellent maneuver ability, Fefe is a SUV with great view unsuitable for high speed maneuver.

 There were a lot of modification option around -> chip tuning, HID lamp etc…but this time, I would save the money, the original version had offered a lot of fun …..with the extra width0cm wider than the Z) it offered a better riding experience for the back seater. During a drive, I told Ving, I missed our Kembara -> we were so close then sitting in the Kembara. Maybe we would get the Terios to replace Ving’s Sirion later … but it would be a long long time….

PGYs.......

 The fresh medical graduate of the Taiwan would be experiencing a new training scheme starting from this year…

The story goes all the way back to the SARS period (2002-2003)…. A few hospitals was “contaminated” and quarantine were ordered by the department of health. There were a few doctors (govt. servant) who refuse to enter the hospital for work -> their excuses, I am not specialist in medicine and I lack of ??? skill to care for such patients. Their unethical act had led to a call for reforming the post graduate medical training. Some so called experts and professors had thought that if young doctor was given proper ethical education and basic/general skills training during their first year – then they would not have any excuse to “abscond” from their duty when needed. They were partially right....

The initial training program was set in a rush and the training was set for only 3 months -> 1 month in surgery, 1 month in medical and 1 months in community medicine. During the 3 months period, a series lectures concerning ethical issue and practicing environment were given. The secondary objective was aim at setting up a training which last for 1 years comprising basic training in major scope of medical (surgery, medicine, OBGYN, paediatrics) - > so called Post Graduate Year 1 training. The primary objective was abolishing the internship training by shortening the medical school from 7 years to 6 years and introducing a 2 years Post Graduate Year training for medical graduate.

I was unfortunately to be accepted into the initial phase of the PGY1 training. However although the training was 3 months, the DOH had promised that the certificate awarded would be valid and good for the rest of my life no matter how the training would change in the future. I considered the 3 months as a waste of time as I had gone through the solid training of Malaysia MOH few years ago.

The general medical wards and general surgical wards set up for the training were a crap as there is no true internist and surgeon around. Most of the staff specialists were sub specialty holder who know everything about their field and would referred their patient to another sub specialist about other problems. Most of the medical center had created post of attending physician/surgeon in these training ward, however -> most of the post was filled up by junior physician/surgeon who just finished their subspecialty training….

The training was so limited…..but the lectures were good…

After 8 years of effort, the PGY1 had extended from 3 months to 6 months and now 1 year. A good start, but situation did not change.

There was still lack of physician focusing in general internal medicine or general surgeon. Some had suggested setting a sub-specialist known as general internal medicine but it was never materialized.

It would be a very difficult situation for Malaysian to stay back to work here after medical school. Unlike the housemanship nor 1^st year resident training, the PGY candidate would be dispatched by the DOH. The salary was fixed at RM2300, no matter where you are posted.

However for a foreigner to obtain a working permit which lead to resident certificate, one would need to get a job with salary of RM5200. If the labor department refused to revise the current law and regulations, Malaysian graduate from medical school in Taiwan would be forced to return to Malaysia for practice.

 

Not sure if I would go for a sub specialty training at the moment as I am enjoying life of growing my own food - 2 night shift + 2 half day shift/week enable me to enjoy such life....but becoming an attending physician a sub specialty would led me back to day shift work and I would not have the luxury to spend time in the farm....

 

A painful visit....

I had seen a church member in one of the famous medical center yesterday. He was diagnosed with adenocarcinoma of lung 1+ years ago and currently staying in a hospice ward.

His initial symptom was weakness of right hand ->unable to write properly. The first doctor who saw him could not differentiate a peripheral neuropathy from a central one and referred him for cervical and thoracic spine CT. A 3cm nodule and some infiltration was seen over the CT and he was suspected to have pulmonary tuberculosis which leading to isolation of his family and workup for his family. However the were no suitable explanation for his weakness and a brain CT was done where multiple brain metastasis was noted. He was then referred to a chest physician where he was diagnosed as lung adenocarnimoa with distant metastasis.

He had come to our church after someone introducing him to us. He had undergone a course of chemotherapy and radiotherapy for his brain metastasis. His wife had chatted with me and I had fed her with some proper introduction. The chest physician had misled her that they would get Iressa would be provided by insurance after they had undergone chemotherapy. I had told her that Iressa had limited effect on brain metastasis and if the medical insurance would not cover the expanses as the lung nodule was relative small. He had suffered from multiple seizure attack due to the brain lesion and they had chosen to be treated in the famous medical center which was 35 km away(40-50 mins drive as there is no freeway…). Every time he suffered from an attack he would be sent to my ex-hospital and after some stabilization in ED, they would spent RM500 on ambulance transferred sending him back to the medical center.

He suffered from less attack some times and his condition become worsen as weakness was more prominent. He was admitted again 3 weeks ago and later referred to the hospice ward.

I had spent sometimes in the ward during the visit…and was so sad that the so call hospice care was almost the same as an ordinary ward apart from the huge narcotic dose.

His port A was clogged as phenytoin was given through it. The IV insertion site was noted with erythema and a new line was needed today. He was edematous after a long term use of steroid and poor nutrition. It would be better for him to insert a central line however I wander any resident (junior or senior) have the guts to do it on a patient which could barely show his neck…..As for the attending staff -> no way, aggressive management had seen to be contradicted to the principle of hospice care and after practicing such principle for sometimes, one skill would be reverted to an apprentice level after a short while….

 

Patient was having swallowing difficulty and aspiration pneumonia was likely as he had a lot of phlegm and low grade fever, however he was still fed orally and his wife was reluctant to insert a NGT for him worrying that NGT would irritate him more. No one ever tell her that feeding orally in such situation might ended up in aspiration pneumonia.

The wife kept awaking him from his sleep however patient was so drowsy owing to the heavy dose of morphine and sedative. Her wife was so worried about his constipation despite of heavy laxative use – no one had told her that after such a heavy dose of narcotic use, ileus is likely to happen….

His wife looks so helpless, trying to do something that she things would get him better which in some instance causing the patient to suffer more….A sub standard care as I think the hospice care team would have explain properly to the family about the management strategic and the final process…..

Everyone is hoping for a miracle that he would get out from his bed and returning home well…. I felt so sad during the prayer…During the 1^st meeting, I had told his wife that the best way for him to return to the hug of LORD is a sudden onset of intracranial hemorrhage cause by the metastatic tumor. But I knew, no one would pray for that…..

I had seen miracle – there was this female lung cancer patient, she was rushed into our ED for dyspnea and fever. She was also a stage IV lung cancer patient. I had done a short discussion with her family prior to the intubation. Her family was so dedicated for intensive management as her daughter was getting married in 3 weeks. I intubated her and after aggressive management, she had managed to get out from the ICU and later attended her daughter wedding. She continue to live for another year…I received a thank you card from her husband after she passed away…..I considered it as a miracle as we managed to let her gone through so many great event during that year….

I felt great pain – to know more about the process but just don’t know how to help them as I was not the attending physician of the patient…..

2nd great weekend....

 

This would be the 2^nd great weekend for me…. I had taken a great trip to the east coast last week.... This week, I am going to spent the weekend in the pool(swimming pool of coz, not the poker pool...) and the farm…

Lem would be going back to Malaysia next week, and I need to do some extra hours, but still, the great weekend hold. We had a short discussion and next months would be almost the same..Almost means, I need to do 1 Sunday night shift – requested by boss of coz…. A cut of working hours ( 180->142)..a salary cut of coz, but I can live with it…

Lem would likely to stay till Chinese New Year and my happy weekend would most probably last until then….

fefe.....

I had FeFe (nick name of Santa Fe) for over 2 months…completed a mileage of 5000km…

It was indeed a nice car -> with the 4wd feature, I felt more comfortable when driving to work during the rainy days[threat of flood was always a nightmare for me]…..

The kids just love it -> Yun had walked out of losing ZaZa very soon with the distraction from the personal LCD on board. Xian was enjoying it as well… Back seat leg room was a big improvement although it make no different for the kids.

Ving did not suffer from any motion sickness – a good sign, however it would be a great challenge next months as we would be travelling to the east coast -> the southern reversal road. I hope everyone of them could make it through without any sanitation bag.
The driving experience is incomparable with the Z due to its height and suspension system. However the extra torque and HP are very fascinating. Imaging that jumping from 155 hp to 197 hp. The gear change was sloppy before 4000km, but it had improved to an acceptable level after that. Steering is light weighted and I felt I was not in control half of the time; no more high speed sharp turn and changing of lane.

The noise reduction are good, you would noticed a faint “tatatata” sound of the diesel engine at low speed. On high speed, it sounds just like any petrol car.

The 4wd version came with ikey and a third row air con blower which was a plus. I don’t have to worry about the kids when they have to make way for other passenger.

Fuel consumption was below average during before 4000km, I got 12-13 km/l on highway and 8-10km/l in the town drive. However it improved to 14-15 on high way and 10-11km/l in the town drive. Not bad for a car over 2 tons.

The assembly was below average as I had travelled 5 times to the service center for minor tuning and adjustment. But their service attitude is darn good -> replacement is always an option…..(some of the service center would tried to adjust and tune and replacement is not an option unless you really yelled and complaint)

 

 

Great Weekend - Coming soon....

 

Life had back to normal after I came back from China. I had been to Mainland China the last week. I went to Su Zhou to visit my brother and parents. It was hell of an experience. I had seen some thing that beyond my imagination. Well, the trip was tiresome as we had to walk and walk and walk….

Well, I had learnt that Lem was leaving prior to the trip. Boss had summoned me showing me the new roster of August. A physician had decided to grab some hard cash. He had requested for the 30 hrs “graveyard” weekend shift -> all of it. Boss had moved me to the Sunday night call -> 14 hrs in exchange for 30 hrs. Well, a great leap in my life quality with a small decrement of my salary. I nodded instantly without any thought.

After showing me the roster, boss had to me that Lem will be leaving in September. A shocking news for me. Lem did not tell me -> I presumed he wanted to keep it a secret. I had later comfirmed the news with him and he had made his ground. He had not only tired of the job but had felt pressurized working in the emergency setting. Burn out + phobia -> time for him to bailed out.

Shift would be much different later on….Would be getting more working hours but also more day shift. But what the heck, August would be a great month for me -> No weekend call…..!

Greatest months

Shortage....

The new building is on its way and estimated date of use is October. 68 extra beds is added with at least 14 doctor posts to fill in. Bad news is – no one is coming. We would be facing a severe shortage of doctor in the near future.

There were a few ED physicians who come for interview lately. Each of them asking rocking sky high salary as K salary had become a benchmark. News had spread out that he is getting 30% higher than anyone else. I guess no one would be coming at the end of the day.

There is still no replacement for the orthopedic surgeon. The resident training would end in September – nothing to be expected before that date.

I would stay put at the moment, enjoying my life….

ride,tears...

 We had been bicycling here and there for few years now…….There was this event sponsored by the ministry of sports and hosted by the Yun’s school. A 62km ride for junior high school graduate…Yeah, junior high. However to age limit was lowered to grade 4 as the amount of participant was not as expected. Yun was eligible and we had agreed for her to sign up. However Xian was a little bit depressed as he was left out. We had however decided to by-ride with Yun and took Xian with us...

The ride was a little bit rough for us as only one of the bicycle was capable doing 20+km/h easily – Ving’s F20W. Yun and Xian bike is YS 256….small wheel bike which could barely do 20 km/h…

F20W	YS256	Strida 5.0

The head master had told me that there is a bus standing by picking up those who could go any further. An insurance and I felt safer. The biking would take a lunch break after 45km. In my opinion, Xian and Ving is not ready. Yun physical and endurance is exceptionally well according to her teacher, I had no doubt she could complete the course – even with the 20’ bike. However, What I worried most was Xian.

As Xian was not officially registered, he had not T shirt and those free gifts(a water bottle and some pin). However there were many who didn’t show up and Xian got his piece of the loot.

The ride was tough one. Most of the participant rode a 26’ bike; Yun was fit enough to follow up the team. I had to ride with Xian and Ving just ride with her own tempo.

Xian was insisted to ride with high gear -> easy to pedal but slow…. I had to accompanied him with my strida and we barely make it to the 30km pit stop(we started with the first group and arrived with the last group). Xian had become tired and when we arrived at the 45km stop for lunch. He was exhausted. Ving was picked up at about 35km and joined us for lunch. Yun was doing well…

After the lunch, I had “advised” Xian to took the bus but he insisted that he could go on….Ving had decided to take a car ride with the teacher and I took over Ving F20W. I had a bad start as I was still preparing myself and chatting with Ving when the team start. I had to chase the group. This was the 1^st time I had cramp during a ride. I managed to catch up with Xian minutes later and after 20min. Xian had a cramp. He cried and stopped along the road side. I told him that we should give up and took the bus. He shook his head and insisted to go on. There was this lady, a fruit seller along the roadside came over and offer some menthol ointment. After some massage, we were back on the road again.

We were dropped off from the group. Xian was truly exhausted. The 10km ride took us 50 minute to complete. We arrived finally – the youngest participant and smallest wheel (strida).

I was proud and truly amazed with the riding experience. Insist and sharing of pain with tears. Xian make it…. 62 km on a 20’ wheel….

govt service, PSD scholarship and getting richer....

 working with the govt as a non-PSD scholarship holder?

I had met a many Public Service Department Scholarship holder during my days with the MOH. Due to govt. policy most of them were Malays except one. Majority of the Malays PSD scholarship holder were bright and cheering persons, they had seen the modern developed country which influences their practice and lifestyle. The only one was a Chinese, he was the first batch who was granted scholarship after the change of policy. He had completed his degree in India and came back to serve. A nice and dedicated person but I described him as a GP type of man…I had forgotten his name and wander did he completed his specialist training and still serve with the MOH…

The thinking process of Chinese and the “Bumis” were different; the most of the Chinese would have to work like a “dog” and save up for their children education fund. The “Bumis” would not have this kind of burden. I had met a master of orthopedic trainee who had bought a car and a house with the govt loan…. And he had 3 kids….

If their children are bright enough – govt. would pay for them. It is not true for the Chinese, the saving would provide enough fund for the studies or a business starting fund for the children.

I had worked under a clinical specialist L during my housemanship. A MU grad, top of the top during his high school. A clinical specialist were mostly MRCP/FRCS holder then, they had to work under supervision for 2 years before they were gazetted as specialist. In the beginning, they had to do MO calls and after a few months, there would be promoted to do Specialist call. The major different was the specialist subsidy of RM800 and the entertainment claim.

However, he had met some hardship during his MRCP examination. He had attempted a few times before he got his pass. He had told me that he had almost given up but his wife had supported him through the exam. He is still working with the MOH and currently posted in Johor as consultant. A very nice and easy going person, he would help us up clerking new patient in a busy afternoon.

There were also some MRCP candidate then – most of them were India medical graduate and most of them were not worry over their financial problem(either came from a wealthy family or not married).

Xian arrival had truly affected my planning. I was getting about 3.5k then and I was posted to MU for my master then. That means a cut of 500RM (a special subsidy from the MOH but not from the MOE –working MU hospital is considered working with the MOE…)

I could imaging 4 of us living in a flat in PJ….Xian and Yun grabbing the iron bate of the iron gate glancing through the “lubang” waiting for me to come back…

I opted to leave…….

The medical officer got paid far more better than a average graduate -> how many Chinese govt. servant could live with the salary with any help from the parents ?

Getting a govt. scholarship means paying back by working as a govt. servant – how many of those “bright” Chinese would ? Govt. should have show a statistic how many of those outstanding student had provided their service and for how long…..it was a bad logic in my point of view,

1.govt. servant got paid less

2.outstanding student was given scholarship and later become govt. servant.

3.Govt servant got pay less compare to private sector – less/no chance of become rich

4.Outstanding student  = less chance of getting big money.

5.Average student do business/ work in private sector = more chance of become rich…

 

No wander the NEP hadn’t succeed of getting the bumis to become wealthier….

Age of not confuse....

It is milestone for me…. Attaining the age of “not confuse” , looking back my life, I am at the peak of it… stepping a pave of I never dream off… fulfilling what my parents have hope me to be – a medicine man and also a specialist. Life is not perfect but I am satisfied at what I have……

Survive a double instrument delivery and also Reyes syndrome(my mother had always told me that I had aspirin allergy during my childhood - but I finally realized that it was not aspirin allergy, the red skin was Reyes syndrome - and I was lucky enough that I survive...) and still standing... I am truly a lucky man with the mercy of GOD...

Trying to learnt more and enjoy life...

Early change..

 

I had Z service 1+ months ago – 3.5 years and I had completed 100,000km with it…Z is such a nice car – safety and driving fan. However the parts were so expansive and the hot weather of Taiwan is not really suitable for a European car. Just like our cardiologist T told me about his Volvo – good car but small problem here and there…I considered him as “car god” – he knew lots about car and an awesome driver. Don’t judge him by what he is driving ( a 10+ years old Nissan Primera P11 – sporty though, I saw him snake drive in front of me months ago…, he had a Volvo 460 before).

Few months ago, there were rumors that the OPEL dealer of Taiwan – YGM is not going to continue their dealership. The YGM is a subsidiary of the CCar (dealing with Mitsubishi and Nissan ). The CCar had however launched their own branded SUV+MPV(LUXGEN) 1 + years ago. Since then, the showroom and service center for OPEL had been shut down one by one. Last months, the rumor had become a truth. It means there would be no OPEL dealer in Taiwan after June. Market rumor had claimed that VW dealer would be taking over the dealership but next year.

My Z would become orphan, even though the service center had told me that they would continue to service my car but I felt unsecure as parts would need to be ordered and waiting time would be much longer….

I had to bring the date for change a little bit earlier(much earlier to be truth…).

My first consideration is definitely a 5+2 seaters. The +2 will definitely come in handy when there is visitors…. And the extra space could load our bicycle and camping equipment as needed….

But I still missed the SUV – better view and safer when driving over some muddy terrain. I had driven my kembara up to the highest road in the Malay Penisula - the Telekom Tower in Cameron highland - hell of an experience...so I had put an eye on SUV again...

It is hard to get a SUV c 5+2 seaters in Taiwan – not many selection . I did not consider any European brand – another walk over the plank trap, had to settle with local assembly one/Imported Asia model. One of my favorite is Land cruiser Prado -  however the only version here is the 4.0 one =>super petrol tiger….just had to skip it. The more fuel efficient selection is Pajero ( the only version is 3.2 diesel) but it cost about 220k RM…still way beyond my budget.

There were owner who add the 3 rows seat to their Outlander and RAV4, but it is not my option as I wish the seat could be completely hidden to the bunker..

There is one car left on the market with the basic requirement of mine – Hyundai Santa Fe. However, the only version is 2WD…. a little short of my expectation.

However last month, I saw the news over the net that a 4WD version speculated to be launch in May. The dealer had officially denied the plan but later I had got a affirmative news from a showroom manager through a church friend.

I took Ving to the showroom and arrange a test drive[2WD of coz..]. Darn, the engine was so quiet, I had a moment thought that it was a N/A engine instead of a diesel one. With 197 hp - >the pickup was good…

Ving did not suffer from any motion sickness and after some discussion we had decided to take the car….

come with twin exhaust ...

a roof spoiler....

10+days before the hand over – it was truly an agony waiting….