shit in the hole

This is a patient who admitted for NKHS, septic shock , pyelonephritis....He was intubated intially and noted with acute renal e failure. Hemodialysis was considered for him once - but he managed to recovered and extubated. He was planned to be transferred out ICU when he was noted with fever again. A red patch with local heat was noted over his rt flank. The cellulitis than worsen and abscess was form. No I and D was done and it ruptured. Initially pus was noted then brownish substance came out form the hole - substance same as what came out from the ASS. He had went into respiratory failure last night due to sepsis and was intubated.
Well, a GS consult was done and no indication was ops now. The surgeon told us to put on a bag and treat it as a colostomy while waiting for his sepsis to subside...

putting on colostomy bag	closer look

Needle, needle...

I had this influenza vaccine on 4 days ago. All medical personnel is entitle to a free vaccination yearly. Few year back, when the SARS hit Taiwan hard, Influenza pneumonitis had been one of the major differential diagnosis and since then. The Dept of Health has offerred such vaccination to us to make the differential diagnosis narrower.

However, I had missed my shot since the beginning of the free offer. I had many reason - no definite protection, may have severe symptom.....etc. But the major reason is I am darn affraid of needle. I hate being pricked. Eventhough Ving had grumble over this matter with me many many times - I still refuse to take the jab.

This year, I changed my mind, I had this bad flu few months ago where I had this severe headache...I decided to take the shot this year.

Well, the injection technique of my nurse was good. Slight pain when I was pricked. I had this severe muscle ache and easy fatigue since then. Yesterday, we went to this shopping mall for few hrs, and I got home and unable to walk due to severe muscle ache(not over the injection site, but whole body) ....I hope it is worth the price.

CPR...

I went to this CPR course tody...

I was SJAM instructor during my service there - CPR was one of the main course I ran. 1 months ago, the nursing supervisor asked me if I am interested and I gladly complied.

The course was designed for Form 4 students. The education ministry has set the rule that all high scholl student should possesed CPR cert to graduate. So There were 140 students and I went there with 7 of my nurses. I did the main lecture and each one of us took 18 students for practical. It lasted for 3 hrs and the pay was NT 800 and a big cup of tea....

	The drinks -800cc cup of tea.(sweaten of coz..)
	Students doing the written test..

Paraquat survival..

This is one case that misleaded me...

This middle-aged female had presented to ED 1 week ago. She c/o sorethroat and running nose and others flu-like symptom. I took a look at the mouth and noted some blister and oral ulcer, the throat and tongue was also involved. She had mild fever as well and told me that she was seen in local clinic but in vain. I did a blood test and white count of 16000+ was noted. I admitted her under the impression of flu. 3 days ago I seen her again in ED and showed me a referred letter from a medical center. The cousin who came with her told me that the medical center said that she had no sign of agriculture chemical intoxication and was ok for her to get admitted back in a smaller hospital. I was confused while glancing through the referrel letter(it was not a referral letter - more like a lab result). The medical center ED did a cholinesterese test for her(it was normal).

I asked the whole history again and was irritated by it. Appearently, her oral ulcer has worsen the next day and the attending physician( my senior, nephrologist cum toxicologist cum infectionist ...a Malaysian as well) was suspicious about the history and asked her again"properly". She claimed that she had drunk some Paraquat ! 2 days before she was admitted. Due to her " paraquat" history - she was referred to medical center for further evaluation.
But I don't think the medical center ED buy her story - no urine paraquat test was done. I didn't buy story as well...I has seen lots of paraquat intoxication(mostly in Malaysia) - well, a very very very toxic chemical - there is only 1 survival I seen so far. A Malay Chap who had an arguement with his father about his girl friend. He took a bottle of paraquat and put it in the busket of his Honda cub and rode away. His father chased him from behind and rammed his bike to stopped him. Unfortunately, the bottle spilled and few drops went into his left eye, few drops into his mouths. He was admitted for 3 weeks and lost 1 eye sight with discharge with severe pulmonary fibrosis...This is the only survival.
I had met a few paraquat intoxication here - unlike the Malaysia paraquat which smelled like X%$@...  the paraquat here does not have a strong smell...
Back to the patient - she was then discharged from the medical center after the cholinesterese test was normal, and negative of urine paraquat test.  The oral ulcer has worsen..

D4 oral ulcer	chemical burn all over t

Me and my senior favor a corrosive injury rather than paraquat...

The cause of suicide  - Some misunderstanding with her family... This is one hell of the patient : she has this fulminant hepatitis few months ago complicated with acute respiratory failure intubated and ventilated , acute renal failure,  - she just got back from the gate of Hell/ (or maybe Heaven..) but chose to give it up due to some minor cause....

conjunctivitis

There is this conjunctivitis epidermic going around north and central Taiwan region. There is a few case here and there lately around my vincity. According to the Taiwan CDC - the causative agent is Coxsakie Virus.. but so what - the treatment is the same...prevention might be more important..

I had this red eye few weeks ago when we were cleaning our house - some dust has gone into my eyes and I had this allergic conjunctivits. I had to too some antihistamine to ease the itchness. And sicne then, my eyes itches easily from time to time.

I deeply pray I don't get infected....I am not worry about myself, but my 2 kids and Ving...

abscess..

The lung abscess ah mah came back for admission - due to fever and vomiting... I had done a CT for her, it looked better. I had re-started her on Tienem and no fever was noted. In fact, she had also had UTI - I think the fever is more due to the UTI. I had shifted down to Unasyn today after 3 days of Tienem..
My another lung abscess patient is better and the family had agreed on tracheostomy - I  would complete the 4 weeks Tienem course and transfer him to Respiratory care ward later.

The ah mah lung CT..

3 weeks ago prior to treatment	after treatment

 

Lung abscess...

It was 1 years ago ... I ended up with Lung abscess during my internal medicine board exam...I did ok....I was finally back to the lane of physician and ended up with 2 Lung abscess lately...

There is this Pan-Citizen Health Insurance Scheme here in Taiwan...People need only to pay a monthly fee and enjoy it...However for admission - there still need to pay 10% or RM17000 maximum of the In-patient medical fee. However if the patient is admitted more than 30 days, they will need to pay 20% and 60 days - 30%...I have this lung abscess patiente, who was lucky that she was not intubated. But she had been admitted for 50+ days and I had to discharge her under family request...today the family called me up and asked me if she need admission again as she was having mild fever. I told her that she should but as she had only been discharge for 7 days her medical fee payment will be set at 30%..   only if she admit after 14 days than her medical fee payment % will be 10% again....I hope she could hold until that day...

I had another lucky and not so lucky patient - another lung abscess who was intubated - as he had been intubated for 21 days, his medical fee payment is 0%...he is now better but we were unable to wean him off the ventilator was noted. He will need a tracheostomy instead - yet another difficult situation...

Both of them were on Imipenem - imaging the cost of antibiotic...no drainage was done for them after discussion with family about the risk...

I am not frustrated - it could be worst in Malaysia...