Syabas.... Malaysia....

Sugar cane juice....

I had this case 2 weeks ago....

I was having a chat with Han(Nephrologist, Malaysian) about the Anwar Ibrahim case in the ICU. The ED informed us that they were sending a patient up. In our hospital, sending a patient is an urgent matter : no matter how busy the ICU are, the patient is sent up STAT. Due to lack of nurses in the ward and ED, it had become a non-written proctocol.  Pro and cons with such practice but the ICU nurses had gotten used to it...

the patient is a middle-aged female who look ill. The admission indication is Shock. Indeed, the SBP was 60+ in ED. I took a glanced at the CXR and the right side of the lung is WHITE !. That means it is either fluid or consolidation. The lady was found laying on the roadside and heavy alcohol scent was noted. The patient was admitted to Han's service and both of us was thinking either a traumatic hemothorax or massive pleural effusion. A bed-side sono was done and pleural effusion was confirmed. Han did a tap with a needle and the fluid look greenish... Well, empyema . Pig tail might not be suitable to drain it so we decided to place a chest tube.

I had a bad experience in the past, there was this empyema and the pus was pouring out like a spring when I inserted the chest tube. So this time I told the nurse what I expect and she concurred as she had met such situation before(she was a senior nurse...). We were lucky not to create a mass.... within minutes the bottle was full...but strangely unlike those pus that I had encountered it was odorless...

Both of us felt strange about the findings...the smear had revealed a G+ bacilli....She was started on Clindamycin and Ceftazidime. Later she was shifted to Imipenem.

1 wks later - the culture came back:
   The pleural effussion - Streptococcus Viridins
   Blood culture x II - Bacillus sp.

Well - she survived the shock and currently stable - there was still 20-30 cc of pus daily drain from the tube....

She was cirrhotic (alcohol related) and definitely immune compromised (afebrile on admission with WBC of 40000+)... I wandered if the she had mixed infection and the bacteria had degraded the smelly component and making the pus odorless ?

oh, was that sugar cane juice... I almost drool...but just like Lem said, " I am going back for dinner don't show me those appetite spoiling picture..."(of coz I showed it to him - he was the one who admitted the patient from ED...)	full and yet still pouring out....

Abductor....

It was hell night... I was called every 1 hrs ...

I had just seen a female with acute gastritis and just about to leave the ED to my call room; the nurse told me that 2 MVA victims were on their way. I sat back to my seat and resumed to my VB project.

The ambulance arrived 5 mins later. 2 very young couple came in. The EMTs told us that they were MVA victim. Car vs divider. I preceded with the examination. Both have seat belt injuries. No airbag on the car so no burn over the face.

I was right about the girl but wrong on the guy. The girl was only 16+ and the boy eventhough look young was 20. After the treatment I asked the girl for her parent telephone and told her that she is underaged and I needed to informed her guardians. She gave the no to me without any hessitation. My past experience was they mostly would beg not to inform the parents. I called the parent up and the phone was answered by the father - I told him about the incidence and the condition of her daughter. I got a ?angry hung up before I asked him if he would like to pick her up. The parents lived in Taipei and I don't think that they would come but I still hope that they would sent some relative nearby to do so. I called back and the mother answered the phone. She was polite and told me that she would call me back to decide about letting the daughter leave with the guy(boyfriend a.k.a abductor as far as I am concerned). The mother contacted the daughter(I knew as she answered the call inside the ED) and later called me and informed me that they were unable to picked the girl up and told me that to let her leave with the guy...

I was too tired and told my nurses that they could leave as they wishes. I went back to sleep and did not see them again...

I had seen too many of such cases. I am worried to be frank. I had a girl and a boy and I don't know if they would ended like anyone of them. Maybe I am too conservative or too old....How could parents let their 16+ yrs girl leave home 400+km travelling with a guy ? Where is the responsibility of parents  - providing food and lodging only ?

I always believe there are lots of good elements in the chinese culture , especially the teaching of Confucius. Where ever someone told me if my children are undergoing any special tuition for english; I told them that I am not worried about their English - I had traveled so far back to the chinese land and wanted my children to command such language (especially the classic chinese(Wen Yuan Wen)). They could learn so much from it. But now, I am worried if they could really adopt the concept and core value of such teaching.

A better tomorrow...

I finally told the administration I wanted a reduced in my night shift....

After the asthma attack, I had found that night night had become a stress for me...I went off at noon and hit my bed/sofa/ tilam  by 1:30 or 2pm. In the past, I would wake up by 4 or latest 5pm and feeling better. Now, waking at 5pm means feeling bad - dizziness, nausea and heavy steps.

I had been having mild asthmatic attack from time to time - but recent 1wks , I had a big one again. Although I could suppressed with symbicort and prn ventolin inhaler but the feeling is bad.

I finally walked into the deputy superintendent office and told him that I wanted to cut my shift from 8 to 6...that means I would have 2 weeks with only 1 shift. Life could be much better hopefully. But out of my expectation - the deputy superintedent was not surprised - he had been expecting my request ! Well, he told me that he would work the plan with Lem ( he had been director of emergency department for 1+ yrs now) and Big boss - most probably, Boss and Lem would share 1 shift each... Well, I am glad , at least I would have a better resting time and more daytime work so that I could spend more time in ICU...

Pay might not be less as I could take up more day shift. I should get almost the same pay eventhough the nigth shifts are cut

My progress note program is currently running well. The Order entering part is under developed and currently at the final steps of adjusting user interface.... I am considering of taking some exam such as MSITP... but my aim is in the Nov. - the Medical Informatic Adminstrator exam organized by Taiwan Association of Medical Informatic, I had a 15 marks advantage over the other examinee - there is a part : medical terminology which score 15 out of the 100.

Well, a change in my life and I hope it would be better...

Ving had gone to a fortune teller lately and according to him - I am at the peak of my carrier : I am happy to hear such phrase but I am worried as after the peak/plateau there would be down slope and hopefully not a long long way down....

never ending learning...

My past few calls were bad - interrupted sleep q1hly either by the wards or by ED patients. I seldom spent time watching TV lately - mostly busy with my program while waiting for data. The currently phase would be finalized by next week. I would have to meet with the nursing superintendent and head of pharmacy again next week. The progress note and passover note part were completed 3 weeks ago. Although some minor modification is neither - both of the them were running smooth. The order entering and prescription printing part are my current focus. The core was completed last week but after a brief discussion with the head of pharmacy, I was forced to re-write part of the script. The head of pharmacy requested and insisted that the 1st day UD dose would need to be stated on the prescription. Eg: IV Tagamet 1 amp Q8H is not enought it shoule be IV Tagemet 1 amp Q8H 1st day UD = 2 dose(if the order is prescrbed after 8 am).

2 tasks more before I could proceed with the test run in ICU. 1. The list of oral drug were not enter into the database. 2. The re-printing of prescription part need to be revised - serial no. needed for each print out prescription to facillitate the reprinting process. Why test run in the ICU ? well, I am one of the ICU attending physician - more easier for me to implement things. The ICU is a closed unit and manuplating is more simple. The most controversial part is the temporary telephone order. The nurse would need to key in the prescription on request via phone. The ICU nurses are more senior and able to carry out this job without problem. The ICU test run would last for 2 weeks and after the run and review. It would be implemented throughout the hospital. Then I shall move on to another project.

I enter a phase which I ever imaging  - writing computer program .Once, I thought becoming a physician is the last thing that I learnt to be.  But now, I knew more surprise I would get if I keep on the hard wark of learning.....

to helmet or not to helmet....

It was tiring morning..... I was post call and I got a phone from the combined ED down south..

"We had a case of head injury with SDH and we wished to transfer him to your ED", the doctor talked to me over the phone with Cantonese slang. (Hong Kong with ROC citizenship...). I agreed to his request as the ICU was quick empty ... I asked him what was the GCS and wheather the patient was intubated and this was the reply :" The GCS is 6 but he is breathing smoothly, so I don't think he need intubation at the moment...".

What a professional answer I got.... this was what the local people down south derserved. A special fund was set up to upgrade the service the ED service - the doctor was paid RM100/hr and these kind of doctor was hired....

The patient arrived 1 hrs later and there was a nasal airway in his nostril. I took a glance at the CT. The hemorrhage was minimal but there was severe midline shift. I told the family, ops was needed and I needed to intubate him stat.

The guy had short neck and small mouth - short than mine...I tried the oral approach and failed. I did a second look and still failed to visualized the vocal cord. I decided to go for the nasal path. I was lucky as the patient was still breathing heavily. I passed the tube successfully during my first trial. Well, he was up to the OT within 40 min . That is the advantage of a small hospital ... fast and efficient of clearing patient from ED.

I obtained the history and found out that the patient had fallen from his bicycle. He had gone to the famous Kenting beach town with his wife and children. They were doing a joy ride in the morning. Unfortunately the person who rent the bicycle did not provide helmet. He had fallen and knocked over his head... The history had reminded me about a news I saw 2 days earlier - a police who took part in a bicycle ride with his chief. The unfortuante policeman was cycling down a slope a loss control. He was riding with full gear but the speed was too fast and he sufferred from intracranial hemorrhage and cost him his life...

Well - better stick to my helmet(my head ...) and Strida(not the efficient but slow is safe...)   - I am doing my ride consistently and I dont want to end up like anyone of them....

Visual Basic Programming

It had been 3 wks since my last blog... well, I was stucked with a project... Few months ago, I was appointed as second chair to the patient safety committee. The was this issue about the passover of doctors requested by the evaluation board. I was learning visual basic then and I took over the responsibility to write a simple program for this passover procedure. The concept was simple - each attending doctor enter the passover note of relevent patient on the computer and the doctor on call log on to the computer and read the passover then print it out and signed it. The concept was adapted from one of the university hospital. Well, just enter, write into file and read it out and print.... Well, the program took me few months to complete and it was very raw ... the was this obsticle keeping our staff to using it - the biodata of pt - > entering the biodata is not a simple task for people who are not good at chinese input....so eventhough it was ready but it was never in use. Until the last attack visit by the local National Insurance Agency officer - the inspector complaint about different handwriting and not so up to date progress note. So I was thinking of writing a Progress Note Program .... this time, I would need to get access to the hospital database. So after a few discussion with the project manager (our hospital computer system is contracted to a software firm), we had worked out a solution. I was reluctant to do in the past because the hospital would be billed for every task done by the firm. 

 After 6 weeks of effort - the program is currently online.... The Nursing Specialist would benefit from it and hopefully some of the doctors would like it......The passover program was integrated to this program and currently on its 2nd days of test run...... I mastered several skill during the process - mapping drive, cutting a long sentence into different line and accessing database. I am learning as an apperentice programmer and trying to evolve...The health department had started to pushed the concept of "paperless" hospital but it is currently governed by the electronic medical record act - 11 hospital had entered the project but I doubt we should follow.... there is one requirement which is strict - each record enter would need to be transferred to the mainframe of health department - electronically signed and stamped with a date and time then sent back to the local hospital computer before it is saved. That means once the progress note/ order sheet/ nursing note / imaging or whatever could not be altered later..... well, which I dont think is executable at the moment.... My next project is currently the order entry system ... I had a deathline of 2 weeks and I intend to make it...

There are lots of books regarding basic of VB2005 but only few of its talked about advance technique, most of the time, I would need to browse the net to found a solution...