a change ... wound it happen....

I had been following the news regarding 916 takeover ...

I grinned when I learnt that 1/5 of Malaysia Yang Berhormat had arrived in Taiwan for an agricultural trip.... Taiwan had no official relationship with Malaysia, both had only trade office as their representative.
Taiwan is definitely not a suitable place for our YB especially those muslim. Back in my school days, we had welcome the recognition team from Malaysia and most of the prof and official was muslim. They were not that particular about HALAL food. The only thing to watchout is pork. But I think if HALAL is considered seriously then only vegetarian food is suitable for them. We had taken the group to Hotel and specially requested HALAL food( 5 star Hotel , and money was really well spent...). There is a Muslim Restaurant run by local muslim in Kaohsiung and we had a good meal there...the reasons for our back bench YB to opt of a trip here - no visa is needed for 1 month visa to Taiwan....

I am looking forward for a change - I am fed up of the racist to accuse other people as racist. This racist who carried a title of datuk (ex senator as well )  had faced a disciplinary action by his own party but no action was taken by the police for such act eventhough peoples had lodged police report . In the past, lots of people were arrested under the internal security act ... I think he should be as well... I regard myself as a Malaysian and hope to be treated as Malaysian. In most of the developed country, the minority was given privellege and aid from the govt. But the minoirty such as Indian was not look after, I am not surprise ( but was shock instead) that our MIC senior persons was pulled down in the general election. There was once I thought the Indian was still hypnotized by such figure. I met those very very rich Indian and met the very very poor ones...

I remembered when I attended the state health medical officer training in one of the secluded resort in Kuala Gula. It was a very long drive from where I lived. Nice bird watching place and the bird watching site was in the middle of the sea (wood cottage build on the sea).
Most of the MOs were Malay and I am the only chinese. During a chat after meal, a senior Malay MO had told the other Malay MO to plan for their life. She claimed that the chinese are different from the point of view of financial management. She said that an average chinese family save every penny for their children college fund since birth. The Malays do not have to worry about such issue. She asked me weather it was true in my case. I nodded. And I looked around and saw those other MOs who gave an innocent look. But changes were noted; Chinese was given scholarship by JPA(public service department) to India to do medicine nowdays which was impossible during my time.

The govt kept telling Malaysian that the Malay is still unde par and needed to be looked after for ,thence scholarship, quota system for university admission are still being practice. But nowadays, the names of rich Malay I knew were more than those rich chinese....

Peoples were being fooled....look at the automobile discussion board of Malaysia. Looks, pickup and fuel consumption were main issue Malaysian talk about. Malaysian pay more than people in the developed country to buy car without airbag... for me airbag is a mininum entry requirement for car safety. Nowadays in Taiwan, car under 100k are being served with traction control and stability control, in Malaysian, such car would cost more than 200k - why ? becoz Proton need to be protected ! nope I don't think it is true - under the present tax scheme (that lead to sky high car price)  , the govt is the organization which benifit most from it. Malaysian were being punished for buying car with more safety feature and the punishment(tax) goes to the National treasury....

I pay a visit to a nice Malaysian lady who operate a L&B facillity up north lately. We had a chat after dinner. The couple had asked me why did I go back and did my time with the MOH (ministry of health). I told them that I am a patriot - I had been a patriot since my 1st step on this land; I tried very hard to prepared for the Malaysia doctor entry exam just because I wanted to serve my mother land(although I never went through it). Unfortunately thing did not work up that way - Later I realized that I need to provide a good quality life for my family...... I still love the mother land - but I could only make a good living here. Sometimes, I looked at Xian and Yun playing in the living room and thinked back of my decision giving up the chance of being a MU master grad( only 2 MU grad in my whole family ...)......I am happy that I made a choice....

Snake bite....

I was covering for the ED in the afternoon... the emergency dispatch center informed us that the 911 is sending over a snake bit patient, ETA (estimate arriving time) was 20 minutes. The ED was not busy then... A 14 y/o girl was sent in. 2 teacher accompanied her to the ED. She appeared frightened. Her left wrist was bandaged but not splint. The teacher told me that it was Green bamboo silk snake(青竹絲) - Trimeresurus stejnegeri. There were lots of snake in our area, especially in the mountain. We get a snake bite every 1 -2 months.

There were 2 kind of green snake in our region. 1 non-venomous and the other is venomous. The non-venomous carried a strong smell and it was name as smelly green mother ( 臭青母) aka King Rat Snake ( Elaphe carinata). The venomous one is this T. Stejnegeri and it produced hemorrhagic venom. The bite is less striking than the cobra (neuro-toxin) which may lead to respiratory failure. However the swelling of bitten region is frightening.

The girl entered our ED at + 40 min. She was nausea and vomited in ED. It is common for patient to had GI upset following bite. But when I saw the vomitus, I was worried, She had vomited blood clot. 6 bite hole was noted over her left wrist around the ulna artery site. The wound was oozing when I took off the bandage. I asked my team to move fast and called my nephrologist cum toxicologist H down. He was preinformed about this case before her arrival. He was worried as well as the course was too fast. An allergy test was done to see if any allergy present. Usually if allergy is noted, the case would be transferred to a medical center and venom were given there. ( some venom was given actually but if any complication occured the family wont raise any arguement...). Luckily there was no allergy noted. But I had decided to give the anti-venom anyway even if allergy had occured. The hardest part was the girl was staying with her granny and her parents was in Taipei. I ordered 2 vial of anti-venom stat and admitted her to ICU. H checked the drug storage and found that we had 7 bottle of hemorrhagic anti-venom left. He told me to passover not to intake anymore similiar snake bite case as he expect a full dose of 8 vial of anti-venom would be needed. I concurred with his suggestion. A third vial was infused later in the ICU as hematuria was noted. Her parent was called and informed about her situation. I left the ED 2 hrs later and her forearm swelling had started to swell. I told the on call doctor to give a 3-4 more vials as needed. I arrived in the ICU the next day and found that she was transferred out to the nearest univeristy hospital under the request of her uncle. Later that day, the nurse would accompanied her over told me that the swelling had worsen later and the uncle had insisted a transfer. The transfer was done against advice. As the ED of university hospital had told us that no bed (not even a strecther) was available. Our nurse had to stay there for another extra 1 hour as no bed for her in the ED(she had to lay on our trolley) instead. However the nurse told me that a ortho consult was done stat and she was sent to OT stat as compartment syndrome was noted. I was worried when I heard such news - no fasciotomy should be done until haemostatic abnormalities have been corrected as recommened by the The Clinical Management of Snake Bites in the South East Asian Region(edited by WHO). Well, I called up the university hospital ICU today , and asked about her condition. Fasiotomy - yes , Oozing was noted for the first 2 days and now better total antivenom used 3 + 10 vial Yes - she is currently stable... Thank god, she is stable at the moment....13 vial of antivenom used , more than 8 as recommended. But the challange is not over yet as the venom would be re-released from soft tissue few days later and further bleeding maybe noted later. Frankly said, no patient had died in our hospital because of T.stejnegeri bite. Most of them recovered without complication, unlike bite by cobra where tissue necrosis would be noted.

I had a dicussion with H later and he told me that the snake might be a mutant variant and the venom is super toxic...

I was covering for the ED in the afternoon... the emergency dispatch center informed us that the 911 is sending over a snake bit patient, ETA (estimate arriving time) was 20 minutes.
The ED was not busy then... A 14 y/o girl was sent in. 2 teacher accompanied her to the ED. She appeared frightened. Her left wrist was bandaged but not splint. The teacher told me that it was Green bamboo silk snake(青竹絲) - Trimeresurus stejnegeri. There were lots of snake in our area, especially in the mountain. We get a snake bite every 1 -2 months. There were 2 kind of green snake in our region. 1 non-venomous and the other is venomous. The non-venomous carried a strong smell and it was name as smelly green mother ( 臭青母) aka King Rat Snake ( Elaphe carinata). The venomous one is this T. Stejnegeri and it produced hemorrhagic venom. The bite is less striking than the cobra (neuro-toxin) which may lead to respiratory failure. However the swelling of bitten region is frightening.
The girl was entered our ED at + 40 min. She had nausea and vomited in ED. It is common for patient to had GI upset following bite. But when I saw the vomitus, I was worried, She had vomited blood clot. 6 bite hole was noted over her left wrist around the ulna artery site. The wound was oozing when I took off the bandage. I asked my team to move fast and called my nephrologist cum toxicologist H down. He was preinformed about this case before her arrival. He was worried as well as the course was too fast. An allergy test was done to see if any allergy present. Usually if allergy is noted, the case would be transferred to a medical center and venom were given there. ( some venom was given actually but if any complication occured the family wont raise any arguement...). Luckily there was no allergy noted. But I had decided to give the anti-venom anyway even if allergy had occured. The hardest part was the girl was staying with her granny and her parents was in Taipei.
I ordered 2 vial of anti-venom stat and admitted her to ICU.  H checked the drug storage and found that we had 7 bottle of hemorrhagic anti-venom left. He told me to passover not to intake anymore similiar snake bite case as he expect a full dose of 8 vial of anti-venom would be needed. I concurred with his suggestion. A third vial was infused later in the ICU as hematuria was noted. Her parent was contacted and informed about her situation.
I left the ED 2 hrs later and her forearm swelling had started to worsen. I told the on call doctor to give  3-4 more vials pending her condition.

 I arrived in the ICU the next day and found that she was transferred out to the nearest univeristy hospital under the request of her uncle. Later that day, the nurse who accompanied her during the transfer told me that the swelling had worsen later and the uncle had insisted a transfer. The transfer was done against advice. As the ED of university hospital had told us that no bed (not even a strecther) was available. Our nurse had to stay there for another extra 1 hour as no bed for her in the ED(she had to lay on our trolley instead.) However the nurse told me that a ortho consult was done stat and she was sent to OT stat as compartment syndrome was noted. I was worried when I heard such news - no fasciotomy should be done until haemostatic abnormalities have been corrected as recommened by the The Clinical Management of Snake Bites in the South East Asian Region(edited by WHO).
Well, I called up the university hospital ICU today , and asked about her condition.
    Fasiotomy - yes , Oozing was noted for the first 2 days and now better
    total antivenom used 3 + 10 vial
    Yes - she is currently stable...

Thank god, she is stable at the moment....13 vial of antivenom used , more than 8 as recommended. But the challange is not over yet as the venom would be re-released from soft tissue few days later and further bleeding maybe noted later. Frankly said, no patient had died in our hospital because of T.stejnegeri bite. Most of them recovered without complication, unlike bite by cobra where tissue necrosis would be noted.

I hate snake ......

Orthopedic - 1

Before I left the O&G department, I had gone to the clerk in charge of the HO posting. I wanted to do orthopedic as I lack experience in such field. I was told the medical was very short and orthopedic was packed at the time. I told the clerk I preferred orthopedic and I found that when you asked properly and politely you would get what you want...so I joined the orthopedic department after I finished my medical. The orthopedic department was headed by a chinese, Mr Ong. There were lots of Mr instead of Dr in the department. Well, unlike the US system, the UK surgeon was known as Mr or Ms instead of Dr. Back in the old days, surgeon was not regarded as doctor - some of them were barber actually. So they did not carry the title of Dr. But later the title of Mr had become symbol of surgical specialist. Mr Ong was a pakar perunding kanan(Senior consultant) but he was retiring - I had worked under him for 2 wks.

Life in the orthopedic department was much more easy then the Surgical department. The HO calls for surgical deparmtent were decided by the amount of HO in the ward. If 3 HOs was posted in one ward - the HO do a call every 3 days. If 2 HOs then the call would be every odd day. If only 1 HO left - that means the HO do call every day( that means he/she stayed in the ward and cannot go home - and would be called anytime when something need to be attended to).
The HO in ortho do call every 3 days. 2 type of calls was noted - the A&E ward and the ortho ward. The ortho ward HO covered the OT, but unless it was a life threatening condition ( gangrenous limbs which needed urgent amputation) - no ops would be done in the night becoz the Head of Anesthesia department said his medical officer might make mistake when "Giving Gas" in the night.....
The A&E ward was actually the surgical ED. There ED was called the Accident and Emergency department (A&E department) in HTAR. The A&E department saw the medical case and minor trauma. For major trauma, the case would be admitted to the A&E ward straight and managed by relevant surgical or orthopedic MO/HO. There was a call room in the A&E ward: 2 beds : 1 for surgical HO and the other for the ortho HO.
The call was less hazard in the ortho - I was happy then and started my preparation for the MRCP part 1....

MVA - drive carefully and slow

I was doing my order renew with my the order program when I got a call from ED. The ED had "requested me" to go down and help a. I think it must be something not that big but not serious. Lem was managing the ED - nothing could knock him down. Lem was seeing another patient with scalp bleeding when I stepped into ED - he told me to attend to the DOA patient in the active resus area. I turned and dipped into the scene. MVA victim - superbike rider : lost control and collided toward the divider. Everything was there - ETT, CVP . large bore. CPR was done for 10 min when I took over. I did a quick secondary survery. Left flail chest and possible abdominal internal bleeding. I did a quick look abd sono while waiting for the chest tube preparation. While - minimal ascites was noted. I inserted the chest tube and pneumohemothorax was noted. Still return of spontaneos circulation(ROSC). It was 20 mins since CPR started. Blood transufed was done but no response was noted. I certified at 35 mins. Well, there was another poly trauma with open book type pelvic fracture managed by Lem while I was managing the DOA. Well - 4th major trauma since the beginning my 24 hrs shift. I had a bad feeling when doing the resus. I was prohibited to ride a bike during my high school days as my parents considered it as very dangerous. Indeed in Malaysia - motocycle is a very dangerous toys for your kids. I owned a bike during my college day. Frankly said - I hate those bike who like to show off their skill. Left- right - left like a viper in the traffic flow. The superbikes were prohibited in the past but later approved by the govt as there were so many of them riding illegally on the road. The road tax was high but still there are peoples who are willing to spend big money(big enough to buy a sedan) on a bike. The biker families came later and the wife denied what had happened to her husband, she sat on the bench in front of the ED. I remembered they was a phrase in one of the famous cantonese mob film - " one who walks (means being a mob), would definitely need to pay back in the future..." Well, not only drive slow but drive carefully.... I did not stay long in the ED as I still had to finished my ICU rounds. I stopped by ED before I went off, the ED was clear and the ED staff with Han(nephrologist, Mal) was there having a chat. I joined the chat. Han said,"all of us should drive slowly today." Everyone looked at Lem after Han commented. Lem was known as a fast driver in the hospital and he grinned. But I told myself - I should drive slower as well . I had been driving in a rough way lately.....next time maybe I would buy a Volvo instead....

horn failure

My Z's horn was finally fixed.... for now....

well, it had been disturbing me for months.... I had expected problems with my car before I bought it... The 7RV forum had stated clearly that owner may experienced the below problems :
1. Noise over absorber - a washer need to be added
2. Horn problems - horn failure noted on and off when lights is turn on
3. Interior lamp persistently on - unable to switch off  --> bad driving habbit misleading the car that an accident had occured : reset the battery and ok...
4. Cracking of fog lamp : ?due to temperature

The interior lamp problem was noted twice within the first 2 months. After that it was ok and nothing was replaced and I believed that it was my bad driving habbit. The horn problem was noted later - it occured once a while and I thought I didnt press on the right place( the forumer had concluded that the horn is hard to press...) but later (> 6months) I noticed that the horn failed from time to time when the light was switch on. I complaint to the service center everytime during my routine service but the was no fault noted and the horn behave itself in the service center. finally , when the sales rep came to me for my annual car insurance payment ( that means it had been 1 yr oledi !!!!) and I lost my patient. I sent my car back and the service center replaced this and that but the problem was still there. According the forum, such problem had been noted in Astra and Zafira and most of the horn problem was solved after the CIM was replaceed. I had requested as replacement CIM(Communication Interface module ) earlier but they told me wiring and cable need to be replaced first and if the horn still fails then they would replaced the CIM.

I recorded the horn failure scene with my handphone and shown it to the service counter section chief and he told me that was of no use as the technician need to personally pressed the horn and the horn failed on the spot then a change of CIM would be done. I instantly fired back at him ...

My car was driven back by the car sale rep and the horn for a short while but behaved normally then - of coz no fault was found. A rewiring was done and the horn failed on me again 2 hrs after I got my car back. I finally called up the manager and told him if nothing further could be done I would call up the Taipei HQ and filed an official complaint. He told me to leave the car with the center and they would run a thorough check. I asked him if still no fault to be found then what - he told me he would replace the CIM and horn. I photocopy what I got over the net before I handed over my Z.

I lost my Z for 4 days and they told me no fault was found but they would change the CIM and horn for me. I got my Z back and found that the horn could be pressed easily ..... and no more horn failure when I turn on my light....

but some forumer told me not to be happy as there was someone who had CIM replaced and still problem recurred later...

Compare to other european car which offered similiar safety features - Opel car price is the cheapest .  But as other european car, due to different of weathing and driving condition, minor problems was noted from time to time - that is what a european car owner need to tolerate. I had colleague who wanted a Volvo XC 90 and called the deal off last minutes due to poor comment from friends.

I hope my CIM would last....

doctors.....

I had this call from one of the head nurse 2 days ago. It was 9+am and I was reading the newspaper in the house( I work 12-12). The head nurse asked me if I knew my patient JL's  son is a opthamologist(80 or maybe 90% of Taiwan doctors are specialist...). I gave her a negative answer. She then told me that his son had called and asked us if blood transfusion was being done... I told her that no - his Hgb was 8.9 mg% and it was gold enough for a bed-ridden old-aged male. The head nurse told me that she had given the same answer and the son had complied with a unsatisfied tone. The son further claimed that he had bought EPO and injected JL from time to time. I asked the head nurse if she had told the son that he was admitted because he had fever and urinary tract infection. The head nurse said yes and she told me that the son had her  that they had been controlling urinary tract infection with cranberry juice and requesed for a discharge stat if no blood transfusion is to be done . But the patient had fever .......

Well, I had met good and all-rounded doctors in Taiwan. But many of them are only good at their sub-specialty. I recalled that when I was doing my housemanship in my hometown. I had a called from a psychiatrist  asking a patient condition. She had asked a few "sharp" question and at the end told me to care the patient properly - she reminded me that she had done medical posting before....  well, this true for a malaysian medical officer - they rotated through those major posting... well, the taiwan trainning defer : doctor dipped themself into subspecialty too early.  There is this hospital F which is not far away from our hospital which practice a different kind of rules

   1.UGI bleeding would be transferred if the Gastroenterologist is not on call that night
   2.Pnuemonia would not be admitted if the Chest physician is not on call that night
   3.Patient with pneumothorax would be transferred as they had no chest surgeon
   4. Peadiatric referral to ED would be suggested to see OPD of OPD is available

   Reason of 1 and 2 : the GI man does not want to care pneumonia patient and the Chest physician does not want to care UGI bleeding.
  My comment : they seems to forget gastroenterologist and chest physician hold a general medical specialist diplomate...

Reason  for 3 : the ED physicians( an "s" mean all of the ED doctors...) do not want to insert a chest tube ( should the board of EP retract their diplomate ???!!!!) ...

Reason for 4: The ED physician would need a paeds consult before any child is admitted and most of the time - the pediatrician would transfer the case out....

Well, anyone do something about it ... I am still waiting,.......

ghostly scene....

It is now month of the spirit... Well, some would think that on call in such a night would be horrible - imaging taking the lift alone: you never know what is waiting outside the door when the door opens.....Sometimes I got the creep wandering from ward to ward...but I never meet anything "dirty" during my walk...

1 wks ago, I was in one of the spiritual scene ... it was an average night and I was debugging my VB program. Patients came every 15-30 mins and I could not have a good rest in the call room. I was walking to the toilet in ED and saw one of the nurse (SY) taking a nap.. It was prohibited for nurses to take a nap in the night as they are working on 3 shifts basis. As most of the ED nurses was married with kids, allowing a short nap during night shift has become a practice provided that the ED is not busy. I asked her if she had a busy day and she answered no and went back to sleep.

Few days ago, when I took a over the shift, another few nurses told me that SY had seen something that night. After I walked into toilet, she was awaken by 2 persons in black. They walked into the ED carrying "COFFIN" and placed the big box in front of the ED counter. One of the man in black asked SY to take a BP for him. When they left, they mumbled a few numbers. Well, SY later placed a few bets with the number but it came out in another sequence. So she did not hit anything...

well, I was lucky I did not witness that...frankly said, chinese are particular about seeing those things - one would get sick or face bad luck after seeing those spirit.

10 more days to go..... in the past, the months of the spirit is small month for most of the hospital - people refuse to get admitted or doing surgery. But this year -it is different: I dont see the reluctancy in the past...well, good for our boss and hopefully a good bonus next year...