shortage

 The issue of shortage of staff had emerged since last year. G had asked for a reassignment to OPD and later S left us for his children. Well, 40% down of man power and we started looking for locum. We had a few good hands who came for our rescue. They are competent and physicians of good standing. However we were unable to secure any new staff. Part of it was the salary. EP pay around the rural area at some central part of the island had risen to an unbelievable level; we were closed but yet still a fragment less. 

A few had come to ask but none of them opted for us. After the CNY, our HOD had finally asked for a 10% raise and finally the hospital agreed for it. More pals came for interviews but none of them stayed.

Distance was the main concern as most of the well paid didn’t want to live around rural areas. After some begging and persuasion, we finally got a senior physician to join us; A Sabahan who had worked nearby; the hospital had a crisis and a large part of the staff EP left( we could manage to grab one….)

Well, hopefully I gotta make my trip to London in October….

Visa run...

 The rest of the 70+ days was multitasking; decision, decision, decision and only guides were info over the net.

The most heart pumping session was the VISA application. 

The CAS was issued within days of submission of IELTS result. However the challenging part was the on-line visa submission.

I am not unfamiliar with such online applications but yet the info required to fill in was massive and some of the information needed to submit was massive; eg. travelling record of past 5 years. Exact date of in and out was required. In the past, you just flipped your passport and everything was there for references. However with the e-gate implementation, it would be difficult to trace every single entry and exit. 

A record from the local immigration department had helped with the info gathering mission. Combining with the flight ticket record on my email, we had managed to compile the full travelling record. 

Another issue which disturbed me greatly was about the medical check up needed. 

For visa application, a medical check up was needed for some applicants. As a Malaysian, an Xray will be needed, but for a Taiwanese, medical checkup was exempted. Well what about Malaysians staying in Taiwan ? No relevant info was found over the net….

The worst thing was if an Xray is required, where should the xray be done as there is no authorized clinic in Taiwan.

I had to keep my finger crossed for such issues. We would only know when the biometric was taken.

The other issue was the bank statement about sufficient funding. The fund was banked in since last year but yet the format provided does not fit the requirement of UKVI application. The statement would only state the amount in the account as of bla bla bla date. It was a standard format and it could not show that the account had held such amounts for how long. Luckily the bank could provide a transaction record for any duration. So it was a separate documentation for this proof. Would it satisfy the relevant authority ? Fingers crossed again. Luckily, it was not mandatory for Taiwanese applicants; but again, we were Malaysians living in Taiwan….

Too many uncertainties and I was unable to make it 100% proof and had to live with it. Another round of agony for me; compared to what I had for the past 12 months…it was nothing actually.

This first round of filling up the visa form  ended up in a chilly back situation. It was a post 36 hours shift for me and we started the session at around 11pm and it took us 40 + minutes to complete it and upon completion a strange feeling had haunted my nerves and a quick check had revealed a silly mistake. By that time, I had paid up the process fee and NHS fee which summed up to almost 100k NT. Luckily, withdrawal of application with full refund is available prior to biometric collection. Although many had said that an undercover letter on submission of biometric could pave the error, but we did not want to take the chances. The refund was quick and only took us less than 2 days to get the money back.

We decided to cool ourselves down and proceed with the application 2 weeks later. The rest was actually quite straight forward and mostly focused on gathering information.

The final submission of form was done and we did a don’t know how many times check and recheck before pressing the button. It was smooth but yet it was slightly more than a month before the travelling. The official statement was maximum 3 weeks for approval. Some gotten it within a week and some got delayed.

Xian had gone to Taipei with Ving for the biometric submission. I paid up for premium service so that it could be done on anytime of a Monday. They completed the submission before noon. Later that night, while travelling on the HSR, Xian got an email confirming his visa approval .

So the verdict; those requirements were not nationality dependent; it all depends on the submission of your document. 

TORMENT

 It was a time of despair for me since last July. It all started from Xian acceptance to the UAL; the rest of the journey was filled with agony. 

Xian had a short time frame to meet the language requirement. As he applied late, the  pre-sessional course was closed and the only way was to attain the requirement.

Xian was over confident with his ability and failure had struck him again and again.

Even though the administration had granted a grace period but yet he had to forfeit the acceptance. 

The path was tedious and filled with sweat and tears .. and also lessons beyond money can buy. If money can settle the problem; it would be fine but yet you can’t buy time….

It was a down time for Xian and me as well. I tried to persuade him to give up and maybe get a hit on the local graduate school. However he is firm with his decision and nothing could rock his will. 

No tuition, no agent, no change of destination. No matter what I said, that was his bottom line. It was destined since his birth; my teacher had told me that he might look normal in the future but yet he would still show some features of the spectrum. Well, minor conflict and lots of talking during this period.

Months had passed and I was consistently haunted by what would be coming. Although I had said I would be prepared but yet I was not; I didn’t know what would be heading toward me. It is not up to me to decide, it was Xian that needed to withstand the impact. 

The first question to concur was if he would be accepted into the program since he had forfeited the first offer. Frankly speaking, I had no confidence at all. I had prepared for a premature end for this attempt. Xian had however  focused on the preparation of his portfolio and English. 

Day and night passed and 1 day after CNY,  Xian had gotten what he wanted AGAIN!!!

An offer letter was served to him and he started his next tour of preparation; the ILETS.

It was another warzone to struggle since then. The ILETS was taken late and Xian hit the mark for the 7 weeks pre-sessional english course on campus. The joy was later struck off when we applied for the combined CAS for the pre-sessional english course and the main course.

CAS would be issued only if we had ILETS UKVI Academic. Unfortunately, Xian took the ILETS IDP(not because it was cheaper, but the oral part was done face to face rather than in front of a monitor remotely). 

So we fell into another round of ILETS run. 

At that point, pre-sessional english course was booked and confirmed and we need a combined CAS. If we had applied for an independent CAS,  Xian would have to come back to Taiwan and apply for another CAS and visa again after he passed the pre-sessional course. It would be only 3 weeks to go to apply for a CAS and visa plus one more to and fro ticket. 

Collapse and lose faith was not an option as we had come so far. 

The offer was truly a gift as previous forfeit was definitely a minus point during the 2nd application. 

The first attempt was a disaster as the remote oral session was something new to Xian. The 2nd attempt was much better but yet the result was similar. Xian decided to appeal and finally a +0.5 was awarded 3 days later and he had made the cut.

We had 2.5 months for the final preparation.

The list was not long but traps were noted everywhere. 

1.Booking of 2 lodgings

2.Flight arrangement

3.Arrival Arrangement

4.Money transfer arrangement

5.Luggage preparation

6.CAS and VISA application

The worrying went on and I wandered will it ever end???

what is the good ?

It was a busy night and there was a long list of pending being seen was noted on my computer. A man in uniform was rushed into the ED by EMT from local mountain area.

A police man in his 50s was crying loudly for help. The patient was hysteric screaming about backache. He was like a child who cannot reasonable his parent refusal for his wishes. Patient was paraplegia and his lower limbs was flaccid and movable. Back pain with paraplegia had limited our differential diagnosis. I had called an immediate CT scan with enhancement without waiting for the renal function test.

A lax anal tone was noted after Foley catheter insertion and confirmed my suspicious of spinal cord involvement.

Worst of all, he was bradycardic and complete AV block was noted.

The CT revealed a type B aortic dissection and nothing could be done here.

Patient was intubated and ventilated with fluid support via central line and inotropic agent for the crushing BP that noted after the CT scan. A temporary pacing was done for the bradycardia. Apparently the dissection had involved artery supply to his heart and spine.

It took me a whole hour preparing him for the transferred. The ambulance arrived minutes after his wife came with his colleague. His condition had improved with his limbs moving and he was more conscious with all the life support effort we provided.

2 hours later, the nurse accompanied the transferal had come back and told me that he collapsed instantly on arrival at the tertiary facility.

It was double jeopardy for me; QF and this policeman. We managed them promptly and we had done everything we could but yet, patients did not have a good outcome.

QF had noted with seizure on D4 and we knew that he would not wake up anymore. The policeman had collapsed despite of our effort.

Right diagnosis, prompt management and ....

still not our call for the result..

I hate this job sometimes...

Hope for the best

The heat had built up again since the last raining episode and it was “summer arrived” day when I did my 10-10 shift. It was quiet until an ambulance call which brough our attention. A traumatic OHCA patient was being sent over to us and we had prepared the resuscitation area for the patient as usual.

An elderly male was pushed into the ED with the LUCAS on his chest and LMA in his mouth. I was not the designated attending physician to the case but as usual, I stepped in for help. While my junior colleague doing a FAST echo, I had moved to the head side and started the airway replacement. No rapid sequence medication was needed and I removed the LMA and found out blood secretion was filled over the oral cavity. The intubation was smooth with the aid of Glidescope. A great tool but yet over relaying on such tool would definitely spoil one skill. After the intubation, I swapped my glove and did a PE. A right femur fracture was noted. Within minutes after the airway alteration, pulse was noted. From my past experience, swapping the LMA to endotracheal tube was a crucial step as most of the time, the LMA does not do what it should have; the most significant evidence was the follow up chest xray post intubation which would reveal a severely bloated stomach. Securing the airway was the crucial step for return of spontaneous circulation from my experience in the past.

While we continued with the survey, I heard our triage nurse brought in a lady to identified the patient. I was shocked when I saw the lady; she was wife of our ex-colleague QF. It could only mean on thing….the patient is QF. I quickly take a good look at our patient again and spitted out the 4 letters word starting with F in my heart.

My heart sunk as I resumed my position at the head side of the bed preparing for the central line insertion over the neck. It took me under one minute to complete the procedure and all I could do was prayed as I am not the attending physician. Normally the attending would complete the procedure, but in this case, I just stepped in.

I knew QF for more than 2 decades. He was the senior maintenance technician of our hospital and we had helped each other during the past few decades.

His wife had told us that he had gone for a hiking trip around the mountain area today morning and was hit by a superbike during his return.

The CT revealed intracranial hemorrhage and pulmonary contusion. Our senior neurosurgeon on call was reluctant for the surgery but yet I had urged my junior colleague to ask for one. As usual, the orthopedic surgeon would go in if the neurosurgeon wishes to go for surgery even if something as simple as an icp monitor placement. The latest ATLS had prioritized the management of circulation and pushing for surgery had become the top mission. My colleague had done a great job pushing for the surgery.

QF’s condition was not stable as he was put on double vasopressor during the surgery. A drain was placed despite the ICP monitor and the brain damage was worse than what was shown on the imaging. Luckily the fracture was fixed without difficulty.

He was still 3 over 15 today morning when I visited him in the ICU. BP was still less than 100 despite double vasopressor use.

Later today evening, he was able to furrow his eyebrow when I called him; tapering of vasopressor was done as he was more stable.

I hated it when I had to attend to whom I knew as I realized the fact that the final result relied upon the great one.  

Jupiter Collision

 

After the turbulence CNY shift, I had started my preparation for the IPSC world shoot which would be held at late June. The venue lasted for 9 days and I would need to cleared out a 11 days window to attend it. I am definitely not up to the standard but yet would like to join such event; the local association had set out some rules initially and requested all of us to attended the event as a squad. A go in and out in one policy was set down.

I had paid up the guarantee participation fee as soon as it was announced. However the announcement of itinerary and tour fee was delayed until March.

I had lost my patient and started to tour around the net and found out that association of nearby region had announced that participation had been opened to any member who was interested. I contacted some of the shooters and found out that some of them had started to booked hotel and even air ticket by themselves. It appeared that they would be ignoring the association requests of going out as one team.

Accommodation within walking distance was cheap as 4 stars hotel nearby cost about RM300 per night.

I had contacted the person in charge and was told to stay calm as everything would be in daylight in the near future.

After discussion with one of the gunmate at the club, we had decided to give up and forfeit the event.

I notified the local association of my decision.

It was a shame to missed the 4 years once event but yet pending the method the association’s way of organization the team; I rather give up  than find myself stranded in an embarrassing situation after paying up a handsome amount of tour fee.

I had struggled with the decision of participating the event it would be a bad year for me; according to the tradition, this year would be the Jupiter Collision year for me. Not smooth , not smooth and not smooth for everything. Well, looks like things had streamed down the way as prophesized.

2025 CNY trip - the rest

 

After a good night sleep, three of us had gone out seeking some yummy breakfast. Upon return, Ving was much better and started to some liquid diet and she was strong enough to make it to the flight.

I had brought my nephew and niece to the Setia mall where we patronized the bookshop; the Nasi Lemak The Game had caught my sight and I grabbed it without hesitation.

We had a good game before we headed to airport.

The drive was smooth and I only filled up RM20 of petrol for the 100+km drive. I delivered the car and proceed to the check in. Prior entering the restricted area, I had taken a sip of old town iced cham and Ving had bought some fries from the Burger king outlet. The Oseltamivir worked great and Ving had started her tour of junk food…

Flight was on time and we met our parents later and we had our dinner at Aeon Mall. The food joint selling a variety of Malaysian cuisine and none of them were up till the standard. As usual, I slipped to the non-Halal area and grab a six pack of Shandy. Out of my expectation, no shortage of stock as in the past.

We slept early that night; frankly said, I haven’t recovered from fatigue aggregated from those long streak of shifts.

I brought my mother to the JPN the next day to obtained a letter proving that she had lost her thumb print. She was actually frightened by the bank staff on her last visit to bank. She was told that she might not be able to withdrawn her money if she was unable to past the bio-metric check next time.

During the journey, I was disturbed by the new parking payment system implemented by the local administration. The app supporting the system was not available to the mobile phone bought from outside the Bolehland. I had to installed the app via unauthorized apk site. Not easy to operate and I think old folks who is not good at using mobile phone would have a hard time parking their vehicle without getting a red ticket later. A good way of stopping old folks from driving to street….

As the main event, we visited my columbarium the next day and stopped by uncle hwa fire steamed chicken restaurant for lunch. A Balak factory turned into restaurant with no air-con; food was great and the price was affordable.

The rest of the day, I had wandered around the housing area, playing with my bro’s pet dog and spent my time recovering from the fatigue that accumulated from the past.

The return trip was uneventful where we put up a night sleep at the Tune hotel before we continue our trip the next day.

Food at KLIA1 was really disappointed as OldTown was replaced by another all rounded but so so restaurant, I would usually ordered a dried hor fan and half boiled egg before I left the Bolehland. Shop and dine wise, KLIA2 was still the best.

The uncomfortable ride on the A320 series was masked by sleep on the flight.

We had a 3+ hours stopover at CLK airport with grilled goose as our lunch. My comment was just like the last time I tried it 10 years ago, “last time, I would order this meal”. Tasty, juicy but not my cuppa of tea.

Final ride back to K city with the more spacious plane but the wait at the luggage belt was longer than usual due to large amount of passenger flying the same flight.

We arrived home later and I had prepared myself for the dooms-day like CNY shifts.

you can run but cannot hide

 

Weather had become extremely chill since December. Patient with URI symptom had flooded the ED initially and later, diarrhea and vomiting patient joined the long queue.

You can discharged fever patient with a jab but yet you need to make sure your patient overcome their vomiting to take up oral medication when they reached home. The ED was flooded with patient due to the excessive parenteral treatment being ordered. 

The worst part was as regional hospital around our area had met a disaster few months back leading to a massive bed reduction.

The hospital who was hit by mischief was the hospital I had worked in for more than 3 years before I came to my current job. A fire broke out 6 months ago causing a fatal scenario claiming 9 lives. The investigation had led to a major fraud with the building structure and setting.

Excessive extension of the hospital wing and the power center was done about 10 years ago. A building of 5 level on the original architecture plan was extended to 10 floors and the power center which was supposed to be 1 story height had been expanded to five.

The fire had started from the power center where the ventilation and backup power were installed. A typhoon had struck the power line and the emergency generator powered with diesel had overheated due to rapid switching on and off. Fire was noted and the smoke had later spread through the ward via the ventilation system.

The construction, supervision and finally the certification of fitness of the relevant building would need a load of peoples stamping those documents. String and connection were pulled through channel and interest exchange. The overbuild area was 3000%....

As my ex-boss was a political figure and the local county government was not on his side of the faction; the hospital was bashed violently without mercy.

The wing involved was sealed and later torn apart leading to closure of half of the bed and 60% of its ICU. Patient had floated toward nearby hospitals and part of the load had spilled to our setting.

During the period, I had been very careful; constantly washing my hand but yet I was hampered 10 days ago by the tiny viny malice organism.

The first episode was hoarseness after few days of shouting in a chaotic market like environment ;our ED was crowded and filled with patients stranded in ED waiting for slot in the ward. 

One night, I had left the desk voiceless and I had taken 30mg of prednisolone just to make sure I could able to commence with my job with hiccup. The next day, part of the voice had come back and I continued my shift for few more days before I had a severe crampy abdominal pain with nausea noted prior to starting a long string of night shifts.

Xian and Ving sent me to work later that evening after I slept whole day without any intake. I arrived early and ordered 1000cc of fluid with parenteral antiemetic before the pass over. I finished the 12 hours shift with a branula over my left hand, accompanied by low grade fever that chills through my shift. Xian and Ving picked me up and I gone into limbo for the next 6 hours before I drunk some fluid and headed for job again.

The symptom continued for the next 3 night shifts and I repeated the go back- home - sleep - drink and go to work event. Every sip of fluid would accompany crampy abdominal pain minutes later and I refrained myself from taking any large amount of intake. The best part of poor intake/fasting was sharpening of sense and apart from the bodyache, my mind was clearer than ever. However, the biggest achievement was preventing other victim in the family – Ving and Xian were good despite of my diarrhea x 15 times per day.

I had refrained from taking any antidiarrhea but finally gave in and taken some kaolin based mixture during the last day. As expected diarrhea was less watery but yet pain in the ass was noted….definitely a wrong choice.

Even though the diarrhea and nausea was better after 1 week of torment;  my hoarseness persisted with phlegm that was difficulty to cough out, occasional wheezing was noted and I tolerated with intermittent antihistamine only.

However strange sweety smell was noted yesterday when I cough out my sputum. Time for antibiotic and I had swallowed a 750mg levofloxacin before I hit dreamland.

Dxmn, no more cough nor sputum since then….

Life goes on and so are the suffering….

CNY 2025 - the return trip

Having a united dinner during CNY was one of the important matter for Chinese and I had been struggling to comply with this arrangement since my return to work in the Ghost Island.

These years, I had strived to arrange a trip so that the whole family would returned and had a united gathering.

The planning was disrupted as I had to wait for Ving’s examination date to be fixed. It was quite late when everything was sorted out; double A was out from the preference and I could only place my hope on the CP.

The ticketing was complicated one as Ving and Xian would be travelling back earlier and Yun and myself would be back 6 days later.

The purchasing process was a heart pumping one as the returning date should be on the same day and I hit the hard deck during the last phase while I booked ticket for Yun and myself. The failure to entering the final payment phase of purchase was noted and after 40 mins of struggling; I finally got it through. Average price was rm2500 per ticket and I was glad to be able to closed the deal safely.

It was a lousy plan; the returning flight from KUL to HKG was A321 and from HKG to KHH was A330 which was vice versa from the home going phase. We had to be trapped on the smaller A321 seat for 4+ hours. But nothing to complain as I consider myself lucky to secure a seat doing a late hour booking.

For the CNY escape to materialized, a long streak of shifts had lined up for me prior to the takeoff.

I still remember the day of Ving departure. I slept by 11pm and woke up by 3:30am. I helped Ving and Xian doing the final preparation and left the hut by 4:45am. The airport was crowded with passengers leaving for Korea and Japan. The CP counter was quite empty and we were third in the line. The check in was smooth and I had given Ving and Xian a final hug before they entered the restriction area at 5:45am.

I had headed back home and sunk into the sofa for the next 30min before I headed to job again at 7:05am.

It would be another 5 shifts before my turn of boarding the plane back home.

The next 5 days was a streak of long and boring shifts. I traveled between home and the desk and utilized most of the time in the house placing everything in order before my departure.

Meanwhile Ving had attended her cousin wedding which was broken into two part, the pre wed party with open house buffet dinner and a ballroom wedding dinner at a luxury restaurant. She had however fallen ill after the ballroom dinner. From her symptom, I presumed she had influenza however I was still D-48 hours before my flight.

Yun had joined me for a late dinner D-30 before departure while she wrapped up her project and came home. It was a memorable night where we were shattered by the most stunning earthquake since 921. The quake lasted for more than 5 minutes and it stopped before we decided to evac from our home.

Shaking continued for the next 20 hours and I finally reached home from job 8 hours before our departure. Leaving home with wave by wave of earth quake hitting was an unpleasant feeling, but as there was no turning back for me at the point, I could only surrender my faith to the Great one.

I glanced through my luggage and double checked everything before I headed to bed at 1am. I was truly disturbed by Ving’s illness. I loaded whatever it was necessary hoping that I did not miss anything.

I had bet my luck driving straight to the airport parking zone that day. There were many parking slots when I sent Ving and Xian off. In the past the credit card offered a great deal of goodies when you pay the flight ticket with the card. However goodies were shredded to kacang putih; no more Priority Pass, no more free parking even you owned an Infinite card. The goodies were reserved to superior infinite grade holder who need to pay a non-negotiable annual fee of at least 1kRM; not my cuppa of tea at the moment.

I spotted a spot near the international terminal and headed toward the counter. I rested at the gate by 6:30am. Unlike the last year heavy queuing session at CKS; everything was smooth.

I fell into dreamland before the flight take off; even though the seat size of A321 was slightly better than the double A. The fatigue aggregated from the past 3 week of straight shifts had finally crushed my spirit and I was awakened by Yun when the staff served the meal. Shaomai with fried noodle, favorite for both of us. Sadly speaking, it is a shame that no coffee nor tea was served after the meal. Cheap coffee or tea doesn’t seem to be a great offer but yet it was enjoyable taking a sip of some sugarless drink after meal.

CP landed promptly at HKG airport. Yun and I took a slow walk to the transit gate and passed through the gate smoothly.

It was another 2.5 hours before the next flight. We tour around the Disney outlet and eaten a snack meal at one of the food joint. Expensive as usual and frankly speaking, Malaysia Cantonese food are still the best….

The flight to KLIA departed on time and the meal was surprisingly nasi lemak with a small scoop of sambal; definitely beyond par but yet no fish prawn also ok la…

We landed on time and boarded the KLrapid to KLIA2 to picked up our car from PRAC rental.

The process was not smooth as I finally realized that PRAC doesn’t have an office at KLIA2 and the car needed to be sent over from KLIA1. However, if I had picked up the car from KLIA1 and returned it tomorrow at KLIA2 it would be a surcharge from different pickup and drop off location.

I had booked an Accord but a new Camry hybrid was delivered instead. It was my second drive with Toyota’s hybrid and the driving experience was great and fuel efficient.

The evening jam was packed as usual and I managed to reach home by 8:45pm.

Ving appeared weak and had been laying the whole day with minimal food and water intake.

I fed her with the Oseltamivir and crossed my finger she would be well before tomorrow afternoon...

The night ended after we had a great meal at a local mamak shop. My bro in law Tango, Xian, Yun and I had placed order 4 rounds before we stepped out from the shop. All kind of roti, mee goreng, nasi lemak and 2 glass of drinks per person....

When we reached home, Ving was much better 3 hours after taking the medication….

last trip of 2024

had done a short trip back to Malaysia last year during November. I had to settle with double A again for the same reason.

I was lucky to get a connecting flight which arrived late at Senai.

The connecting flight was operated by MAS and we had to transferred to KLIA1 with the KL express. 

The flight was uneventful and we had arrived slightly late at the KLIA2. As I had opted for the “Xtra carry on” with the double A. I had no  baggage to wait for and we cleared the entry gate in no time.

We had the luxury to enjoy a good meal at the KLIA2 and I had opted for the ABC one bistro at the L1.

All the staff were of south asia origin; the food was darn spicy even for someone who had spoiled tongue like me. The mee mamak goreng was actually not as tasty as I had tasted previously at the food garden but the roti canai and nasi lemak was up to the standard. It was just like the old Genting highland taxi stand canteen.

After the satisfactory meal, we had proceeded to KLIA1 and boarded the flight on time. The kite airline had maintained its standard even though negative news had struck them since months ago.

The trip up north was actually a packed one for us; a drive up to KL then stopped by Seremban and put up a night in Malacca which lasting more than 450km in a day.

We pushed out early and reached OUG garden slightly late after mid day; traffic was heavy and we had encountered a few jams on the way. Later someone had told me that jam on the PLUS highway occurred without any cause(no construction work nor traffic accident nor other bla bla bla reasons) during the weekend.

On arrival at OUG garden, I had found a BKT shop near my aunts house and everyone had put up a thumbs up about the meal. A good BKT for every trip back to the homeland was one of my wishes…

We arrived at Seremban at 4pm to visit my big aunt.. My big aunt’s health had deteriorated markedly since 1+ year ago. My cousin is a retired senior manager with the GE insurance company and is currently full time looking after her. I had been visiting them for the last 2 years. My mom feared that it might be their last chance to meet and she had requested the trip. 

Our trip landed in Malacca and I had booked a luxury lodging to put up a night to make up for the lousy stay on our last trip.

I had booked a service apartment at Casa de Rio. An excellent riverside residence that was located near the Jonker street.

Spacious 2 rooms apartment which was very well maintained. We had our dinner near Salud Tapa; a spanish restaurant offering nice food. It was a special meal for us as we had never try out any spanish food in the past.

After the good meal, we had picked up some nyonya kueh on the way back while touring the Jonker walk.

The next day started with a average breakfast at a restaurant near the apartment and we had tasted the gula melaka cendol at the Jonker street before we headed to meet my cousin and their parents. The strong gula melaka aroma was not my cuppa of tea; the aroma would mask the taste of cendol itself.

The meeting with my cousin and their parents was enjoyable and we had left Malacca after lunch.

We reached home before evening as the traffic jam continued along the plus highway.

My dad did not feel well that night and he was struck by giddiness the whole next day. I prescribed medication and acupunctured him with clip and his condition had improved before I headed to the airport. His condition had deteriorated as well and not fit for a long travelling trip in the future.

The flight up north was slightly delayed and we had checked into the Tune hotel after midnight. The check-in was not smooth as usual and we hit dreamland soon after we unlocked the door.

A good Malaysian breakfast at Tune hotel before we boarded AK170 heading back to the ghost island was the most graceful part of the journey the next day .

The Xtra Carryon package was a good option for travelers not wanting to wait for luggage. However you no liquid nor handy tools is allowed if you do so.

The next trip back home during the CNY would be a great challenge for me as I had to wait for the part II of cloth making examination date; Ving was sitting for the exam. I had to try CP again as it would be difficult to secure any seat on the appropriate date if I booked the ticket after November.

Rubber issue

 

The new Fe came with PC6 when we took her in. I had a flat tire noted after 2 weeks of driving and nail pricking had been karma for the new F since then. For the past 2 years, she had 5 patching session over the 59000+km drive.

The last one happened 4 weeks ago; when I glanced through the panel while stopping at the traffic light during my drive to the hospital for work and I found out that the left rear tyre psi had dropped 15%(20% dropped will cause the light to lit on). Definitely a leak and I had pulled over at the first petrol station available and pumped the pressure up. I saw a nail on the tyre during the pumping process.

I googled and found out that a tyre shop was still opened around my hospital at the late hour.

I had an early start that day and if the shop still opened when I arrived, I would not be late for the job that night.

The mechanic cum boss was an elderly uncle. He jacked up new Fe and removed the tyre. I told him that I just needed to patch it from outside instead of inner part as the tyre is due for change. He told me that he always patches from inside and if I requested to patch from outside, he would still remove the tyre from the hub as it was easier for him to access the leak part. Some old fashion guy still believe patching from inside of the tyre is better for the tyre.

I had a good look when he removed the tyre from the hub. The wear was way beyond the thread wear indicator and I need to changed it soon

I usually changed my tyres at around 40k and this was the longest distance I had travelled on a set of tyres.

I contacted my usual mechanic and told him that I needed a change. I opted for the PC7 but it was not available and he recommended PS4 which was same standard as PC7. The PC series was noted with better noise reduction than the PS but yet PS is better at control and grip.

The replacement was done 4 days later. The price was 2.5x of the Bibendum’s tyres I used previously on my Z. The control and grip was better than the PC6 but yet it was noisier as review. You gain some and you lose some...

Well, safety come first and since 20 inch tyre doesn’t come cheap and there would be another pain again 2 years later. 20 inch tyre ? I would think twice next time I buy a car….

game of balls

 

I had always hated testis pain who presented to ED. The examination includes an ultrasound which need the physician to touch the sensitive part of the patient. The difficulty is increased as the ball will be sliding as you glide the probe over the surface. If the testis is painful the patient would start to resist and the scanning is more hazardous. Without the power doppler mode, you can only diagnosed testicular torsion if no definite flow is noted and it would be too late by if you see this….

Someone had told me this story months ago; A middle-aged patient was seen few times for abdominal pain with each consultation separated by 12 hours apart; even though CT scan was done twice(enhancement and none enhancement) during the visits, he had still ended with ball removal.

The unless proven otherwise rule was not applied in the case where the pain was not proper diagnosed and patient was discharged. The patient was treated as urinary stone where radiation pain to testis was an acceptable symptom. The key in the case was no stone was noted by the scan and a negative UFEME was noted.

I had been more cautious lately and I met a few cases of ball pain lately where I performed ultrasound without hesitation.

It was an embarrassed moment for everyone, the physician, the chaperon and the patient. Especially the chaperon who mostly is the nurse or nursing aide available and most of them were female.

Frankly said, I hate doing it as flow noted in the ball does not exclude torsion as we had no power doppler mode on our ultrasound and there is a 50% chance a urological consult was unavailable. Our urology consult was supported by two inhouse staff and half of the time the consult was covered by visiting staff who was reluctant to come...

I crossed my finger on every discharge…

we are one.....

ML was sitting on the bench opposite the triage area holding her belly while I walked into the ED. I thought she would be my first patient but her name did not show up on my screen after I seen three patients. I asked around and found out that she was turned by K today morning and G last night as she was just discharged from ward few days ago.

ML was a female with a sorrow past. A schizo since her young age and victim of a fire incident leaving scar over her appearance. She was jobless since the accident and living on subsidy.

Her visit to our setting had increased markedly since last years as she developed liver cirrhosis and massive ascites which required frequent tapping. She had visited us on an irregular basis. Her psy stat plus her noncompliance to medication behavior had led her ascites to increase great speed.

She was turned down from time to time as she tapping request sometimes was too frequent.

Prior to her arrival yesterday, she was admitted to our ward and tapping was done 3 times during her 11 days stay. A good 20000cc was removed and you could she her walking past by our desk with a tea drink jumbo cup on her hand.

After K and G turned her down, I was in no position to help her even though I estimated 10000cc in her peritoneal cavity judging from her belly size.

She had wandered around the hospital since then and I had asked one of nursing staff to hint her that to come back tomorrow morning and someone would proceed the tapping for her if she do so.

She however ignored those advice and kept bothering us from time to time.

I stood the ground as it was not an emergency situation which demand urgent management. The integrity of the EP team is important if no medical emergency is involved. She had then shifted to the OPD and later referred to our department gain but yet the staff did not attend to her.

She was still hanging around the hospital when I went off by 10pm.

When I arrived to work the next day by 9:30am, she was still wandering at the convenient store in front of our hospital; her belly was taken care of apparently.

Well, I logon to my account and found that G had settled her problem after midnight. Even though her problem was solved but yet she was still wandering around…. nothing to shout and comment as my decision to keep the integrity of our team was correct. No hard feeling of delaying the tapping.

too old ...

 

For a local hospital with 100+ beds, we were considered by the govt as small hospital. We are graded as community hospital - the lowest grade according to the standard of hospital evaluation scheme.

According to the diverting plan, we were not supposed to admit patient with severe respiratory infection caused virus. The plan was drawn after the SARS era to more efficiently managed such malignant wave of attack. Resources were directed to designated hospital so that patient would be care under the best team with adequate equipment.

The Covid rampage had however proven the insufficiency of the planning. There was always patient that was unable to transfer out.

Respiratory infection caused by virus had always carried a risk of worsening into acute respiratory distress syndrome or myocarditis and ECMO might be needed.

1+ years ago, a nurse who worked in a medical center grade hospital in K city had collapsed while she was going for trip to the east coast. She had collapsed in her car and later sent over to our setting where she was comatose and shock was noted. She had cardiogenic shock and ECMO was initiated in the ED. As her condition was poor and ECMO usage on the ambulance was not feasible. She had succumbed to the disease days later.

It was a difficult time for the whole team as the patient was placed on a venoarterial mode and a dedicated team was needed to the care for the patient. The day to day routine of the ICU was affected. The patient was young and families were hoping for miracle. It was a bad practice but as the patient was a medical staff; we did our best to pacify the family.

Since then, we had cautiously choose our patient but however some patient was difficult to turn down.

A father of our nursing aide had come to our ED presented with fever and cough and later proven as pneumonia caused by influenza virus. The patient was admitted as influenza pneumonia; it was considered as severe influenza disease and should be referred. However family wanted to stay back and we had admitted the patient.

The patient had deteriorated on D3 and one day after he was transferred to ICU, he was intubated due to ARDS. A referral was warranted as ECMO was needed due to poor oxygenation despite aggressive respiratory intervention. It was a Sunday and only one ECMO was available at the southern part of the island. Yeap, the last ECMO was in our setting.

The visiting cardiothoracic surgeon was available and he was summoned and patient was hooked on to the machine in no time.

We were lucky as only venovenous mode was needed as the patient did not had any cardiac failure condition.

The patient’s renal function had deteriorated few days later after being hooked onto the ECMO.

Our nephrologist was consulted and hemodialysis was planned and insertion of double lumen catheter was warranted.

Tan who covered the ICU had however gone back for a long trip in Penang and the ICU was partially covered by a junior neurologist and boss.

It was a difficulty decision to be made for the double lumen catheter insertion and Boss had come to us for opinion. The ECMO VV was inserted via the right side and a CVP was inserted over the left femoral vein leaving only the left internal jugular vein to be available.

A double lumen catheter from the left upper part was not a usual practice and the catheter would need to squeeze with the ECMO catheter along the superior vena cava when being passed through. Definitely not a good idea.

After some exchange of idea, we had decided to switch the CVP into the double lumen catheter with guide wire method and then a CVP would be inserted via the left internal jugular. Not a good practice as the possibility of contamination and infection would be high for doing so.

Boss had agreed and asked us to proceed with the procedure as no other option was available. I had to perform the procedure as my colleague had failed a pigtail recently and I understood his mental condition.

I was lucky as I had the senior surgical aide on shift that day. The changing was a smooth one and no massive oozing from the insertion point was noted.

The central line catheterization was however more difficult as I had to squeeze myself through a load of wire and tubing to get to the top side of the bed. No margin of error and I had done a scan prior to catheterization. The jugular vein was engorged and the neck was short. A short neck was a good sign as there is not much consideration for the point of insertion. No space was available to perform an ultrasound guided insertion as I was surrounded with tube and machine. A quick look and marking were all I could do.

I sighed upon completion of the procedure; I am a little too old for this kind of thrilling moment. I just couldn’t complaint about the judgement of my colleague about the catheter insertion; one tends to opt for the easiest path. The catheter was placed shallow than usual as I intended to avoid squeezing with the ECMO catheter. However at 14cm, there was still no flow noted and I had to retract it to 12cm and finally I got a slow but acceptable flow.

It had been 1 week since the thrilling event and even though he was still hooked onto the ECMO but yet his lung had much improvement judging from the xray.

I was still the youngest among the senior physicians. Most of the senior physicians were almost 70 and yet they are still keen on their job. In the past, Ving had asked me about retirement from time to time but recently we had acknowledged the facts, income is always the key to a comfortable life and retirement might not be an option for us in the near future…

fever and bleeding...

 The Covid era was the darkest period of my entire practice. Donning PPE was a norm and the fear of contracting Covid had been haunting me until I was infected. However rules were still to be followed and the mask wearing rule in medical facilities was only lifted about 1 year ago. I was one of the don’t wear mask physicians in my department prior to the Covid era but things had changed and I don’t feel comfortable facing my patient without donning a mask nowadays…

It was a busy afternoon and the EMT had rushed in a elderly female  with conscious disturbance and collapsed during the transit. 

She was intubated with a LMA and no Lucas automated CPR machine was used since setting up the Lucas was not practical in the ambulance. The EMT did manual CPR during the transportation. After accepting the case, I did the routine with my team; changing the LMA to endotracheal tube and bla bla bla… The patient was a small frame skinny elderly female and she was febrile.

I proceeded to the family and did a brief history taking. She was fine until noon according to her daughter. She was staying alone and her daughter would bring her meals during noon and evening. When I reentered the resus room, I was stunned by the blood noted from the endotracheal tube. It was fresh blood noted from the ETT. Fever plus bleeding led me to think about the scene of some medical disaster movie; it was hemorrhagic fever until proven otherwise. 

I started to chase most of the staff from the resus area. There were only 2 staff left in the room. Patient airway was secured in a closed system while being intubated and ventilated. However we would need to perform suction to clear the tube and everyone exposed would be quarantined should the worst case scenario happened

I called up my infection controller asking her if any recommendation or advice that she could offer; and she told me that I do whatever I think is suitable and asked for lab tests that are relevant. 

I was pretty sure that her contact and exposure history was negative and the only hemorrhagic fever around our area that was possible was Dengue. I ordered a Dengue rapid test and proceeded with the resus until the usual 30mins limit. The fever and acidosis had hinted a septic state but yet the focus was unknown.

All our efforts were wasted, I called the time and told the family about my decision and asked them to wait for the lab result before I released the patient.

Everything was negative; there was no coagulopathy nor thrombocytopenia.  I released the patient and told the family that a PCR would be done for the serum to final confirmation of the Dengue status. 

The cause of blood in the ETT? Well, the culprit was most probably the LUCAS. The automated CPR machine provides consistent and good quality of CPR. God knows how many ribs had been broken by it. The patient was skinny; my final guess was an idiopathy injury due to the CPR machine and most probably she had pneumonia.

During the resus, I couldn't bare to think about having the whole team being quarantined. We are currently shortage of medical and nursing staff and it would be impossible to run the unit if such incident happens.

It was a good lesson for us that loosening of rules does not mean lowering our standard of precaution. Next time I would wear proper PPE before entering an resus scene….

Google Doc

 

Han stopped by the ED few weeks ago and tapped on my shoulder and said” you are deity of medicine, you save one of my patient…” (deity of medicine in Chinese doesn’t mean god but just another way of saying that your had good medical skill)

I was confused and asked him about which patient…

He given me a medical chart number and I looked up the chart on the spot.

The patient came to ED 2 months ago complaining about generalized discomfort. I noticed that he had tremor and it was not typical of intentional tremor. I did a workup including a brain CT. The image was something that I had never seen before. There was unusual calcification over white matter and I had googled over the net and found a match --- FAHR syndrome.

It was not a spot diagnosis for someone like me that was not neurology trained. However it was an acceptable match, a good correlation between imaging and history. I had discharged the patient and written down the diagnosis in the medical chart.

Patient had later come back to our ED and admitted for renal problem with conscious disturbance and later admitted to Han service.

He saw my note and ordered a calcium profile and corrected the problem and patient had regained conscious…

Well, I told him that I gotten the diagnosis from Google, he however told me he could get the diagnosis even if he had googled. I grinned and told Han that  Google save the patient not me….

Googling was all about keyword and patience. You hit the correct keyword and explored as many pages of result as possible. The Chatgpt and sometimes Google function in a similar way where it found the most relevant info for you. The manual way of course took more time but yet it is more effective but no efficient.  

I did not claim the credit but yet I am glad the patient become better.

the final leg.....Peking trip

 

We arrive at the airport by 1:30pm. We had taken a slow walk around the departing area. Shops with great restaurant that cost you a hand and a leg. That was one of the reasons we grabbed the meat pie of the way. While eating the pie, the anxiety surge all over me, I was still haunted by the connecting flight. 

The security was tight however the police patrolling the airport on a mini cart was carrying shotgun !!! ; the determination of keeping peace at no course beyond my doubt. 

We had checked in our luggage after we finished our meal and headed to the restriction area.

The first area was a baggage check with a long queue. After that we proceeded to the document area to stamped our passport. One locals in front of us was taken away by the senior officer and never return…I sweated as it happened in front of our eyes. It was not rumor after all…

It took us one and the half hour to hit the boarding area. We boarded the plane without difficulty and I started to stared at my watch.

According to the flight radar; the flight had delayed once to twice every week. Any delay of take off of more than 45 mins will jeopardize our chance of catching the connecting flight. We boarded the flight as scheduled but the plane was stranded on the runway for more than 30mins.

I had to cross my finger hoping the best as we had reached the upper limit of the delay.

I was too tired and slept through the flight. The plane did arrived on time however as my club mate had told me it would take a good 20 mins before it reach the gate.

The CP flight system was well designed as it had shown the gate of our connecting flight on my seat display well before the flight landed.

Bad news was the gate for our connecting flight was so far apart as I glanced it over the seat display. We had to go down to the base level and take a shuttle train to another satellite building. I doubt it we could make it as we only had 40min left. When the cabin door opened and as I had expected, there were a female ground staff waiting for us with a signboard. There were 2 groups of passengers taking the same connecting flight. The ground staff had specifically told us that no assess to any toilet on the way. We could only go for nature call once we board the connecting flight.

It was a fast walk for the next 25mins where we could only take a rest on the shuttle train. We managed to join the line up of boarding passenger when we reached the gate. I cheered in my heart while refraining my bladder sphincter during the queue for boarding

The senior member from another group had grumbled to the ground staff during the run that why can’t the flight wait for us as it was the same flight company we were taking. I answered the question for the ground staff, “the KHH airport had curfew from 0000-0630H and our last flight had to take off before 10:30pm so that we would not be directed elsewhere, moron” (the last word did not slip out from my mouth and I had used a polite tone).

We managed to board the flight and arrived at the airport by 2340H. We reached home after midnight and I was back to the desk for work the next day.

It was one of the daring trips that I had planned and we had completed the journey with hiccup as usual.

It was a short trip to Xiamen initially and later expanded to a 6D5N trip to the heart of my ancestor homeland. Spectacular experience for everyone for us. Especially for Xian; He had taken a leap of faith out from his greatest fear….

D5 and D6 and it aint over yet...

 

D5 was another walking day as we had roved around the 1^st rim and visited the art museum, St Joseph Church and the temple of heaven.

The art museum was something modern and it was well managed with great exhibition. 

The St Joseph Church was an establishment of faith where ruling party disagreed with. Old fashion catholic church which hold the ground for the great one. 

The temple of heaven was place for the emperor to pray for his citizens. A big garden that took us a long walk before we exit the area. We run out of water on the way and we were lucky to met a lady who sold drinks at the MRT entrance.

It was a long march day again for us.

We had seen mosque, church and museum around the city. We had walked through the alley of the commoner and the royals. Well, and amazing experience for me as I had read a load of Chinese novel related to the Qing Dynasty. We concluded our last meal with cattle spine firepot.

It was just an capital of a great country. Police patrolling the street without firearm, CCTV all over the street. One of the safest city in Asia, no doubt. I did not hand out any currency note during the whole journey; I was using touch and go; only foreigner and people from very rural area use note.

Bitter gourd with lemon was one of the drink that I had drunk a few times. The locals had taken the tea drink to another level.

The police were not helpful, I had tried to ask for direction a few times and most of the police officers told me that they don’t know and ask me to look it up over the net.

There was no night life around the first rim. It was silence after eleven; no supper joint nor night shop around the first rim. Frankly said, it was kinda bored but yet we were too tired after the day tour.

The last day was not planned and we had decided to take a look at the heaven peace square. We took the MRT which arrived at the area by eight and found out that it was crowded and no way we could get into the square by ten.

We had however taken a hike around entrance. The was a large shopping area before the square.

The tourists were citizens from all over the country. We met police around the area asking for ID card. The police use a loud hailer shouting as loud as he could; however when he saw our passport, he halted for a second and asked us to leave with a calmer tone. Yes, you cannot go around without your passport…ID was needed to enter every place of interest.

We eaten Mongolian xiumai[burning sale](I like xiumai and until that day, I had only eaten hongkong style….) and bought some meat pie before we headed back to our apartment. 

The meat pie was our lunch at the airport as our flight was scheduled around 4pm.

The trip concluded by noon when we hopped onto the mini van and headed to the airport.

And the thrilling part await us few thousand km away.....

D4 - the art of slicing

 The 3rd day was sleep till you awake day. As usual, I woke up early and started my planning about the next 2 days.

It was a shame that I was able to secure any ticket for the military museum. There were many place to visit but yet I opted for an easy one.

Peking is divided into rims; the first rim was the area surrounding the old palace and Sky Safety Square. Extending outward until you reached the outward of the bird nest stadium.

All I care about was food actually. To see and to eat till we drop.

We took the MRT headed to one of the PekingU station which once posted the Harry Porter Nine and Three Quarter Station. The decoration was gone but yet it basis structure was there. We then traveled to the cow street where most of the Muslims gathered around. We were lucky that the place was not crowded and we eaten the signature mutton puff and desert. The tour ended at a famous Muslim restaurant where we had another Peking Duck treat.

We travel back to the first rim and later patronized the bookstore and mall around our lodging site.

Xian was amazed by big shelf around the entrance. A huge collection of the leader publication. I think the only place that we could see such view is located in the states where the bolehland had no diplomat ties. The book was interesting and I had stopped by the medical area where I read their medical text book. Well, the content itself explained their standard….

However, I had bought some books for my nephew and niece during the tour. Very nice translated book in simplified Chinese which I could not get in ghost island.

We headed to the ghost street for a great firepot meal. Cheap and artistic was the word I could described. In my whole life, when I dipped a mutton slice into the shabu shabu firepot, I always get a shrinkage piece no matter how fast I pulled it out, should it be raw or medium. However, the special way of slicing the mutton had led to an enlarge piece of slice no matter how long I dipped it in the firepot. That is art...

The ghost street was actually a place where ancient people do underground business just like what you did in the dark web. However, it had transformed since the revolution. The ghost street was flooded with small lobster shop nowadays but yet the shabu shabu was still the best in my humble opinion.

While I chewed the desert bought from the cow street in the kitchen. I started to worried about our last leg of journey. Should I change our flight to noon so that we could have 3 hours of transit instead of 1.5 hours?

I decided not to gamble our luck and put my faith with the great one….