Day of a ex- MOH staff...

 I had a change of shift yesterday…well, change of shift is definitely not a good sign. Usually the shift would be a bad one. But sometimes you just cant help it… Lem had gone for a course of Disaster management. So Instead of the 2pm-11am 22 hrs shift, I took over a 8am-8am shift. The ED staff combo was excellent one – head nurse plus assistant head nurse and a senior nurse, perfectly capable team. 3 MVA victims present at the opening and since then I did not go into the office. One of the MVA victims had a Galleazzi’s fracture and he did not want any further surgical treatment. Since our new orthopedic surgeon would be start working on 1^st of June. I had to do something. Just cant bare to put a splint and sent him out. I decided to do some – CMR (closed manual reduction). It was more than 5 yrs that I had done any. I sedate the patient with dormicum and pethidine and manual reduced the fracture and dislocation. A almost perfect one. While I was amazing with my skill – the patient had changed his mind and decided to admit and have plate implant later in the evening. A waste of effort. By noon, a female patient from nursing home came, underlying cervical cancer with massive vaginal bleeding. Holy spirit – when I read the referred letter from the nursing home, I had a transient vertigo.

There were no spotting on the diapers and I decided to a per-vaginal examination. I showed a bitter grin when the head nurse passed me the speculum – rusty crust over the blade. Can’t blame everything – it had been more than 8 yrs since our O+G specialist left. The last time the speculum was used was 1+ yrs ago ( yeap- you were right : me of coz…). The vaginal was filled with irregular tumor growth but no active bleeding was noted. I admitted the patient under my service later.

Well, for I sudden , I realized that the 4 yrs service with the MOH was not a waste. The other ED staff did show a unbelievable expression when I did those procedure….But that was not what I am chasing for – I finally achieved what I dream for when I first enter med school.

manual vs auto

I remembered back in my schooling days, most of the car had been manual... I took a ride once in my father's friend's car, it was a Volvo c automatic gearbox, you can felt the jerk and drag with every shift of gear. Later the trend had changed when I graduated. Automatic gear had become the main stream. In Taiwan - the condition is worst - there are countable cars under 2000cc with manual gear box. That is why the Proton Gen 2 can still survive here in Taiwan - some young chap who wanted to 'play' with the gear and have no money to buy a Subara hard skin shark ( synonym of Impreza) would make it the first choice.

I still remembered the feel of looking my dad driving a manual car - his last manual car was a Daihatsu Charade(993cc).

 small and fuel saving care - RM 13000+ during the old days...

 

I remembered the process of downshifting to 3rd gear while overtaking and shifted back to 4th gear later. Frankly said, I am not familiar with the manual car and tried to avoid driving any of them in the earlier days. After the I got my Z's - I had changed my view, I was thinking of getting a car with manual gearbox in the future. The Z's easytronic is great to drive as it had no clutch( still got the feeling of 'gear playing' and no need to worry about the clutch). The clutch is one of the nightmere - especially during 1st gear, if the clutch is releaesed too fast , you get this horrible jerk...

I finally saw some fanatic over the net lately. He is a high school physic teacher C who wanted to buy a Zafira 1.9 CDTI MT. We had only 2 version selling currently in Taiwan - the Z 1.8 easytronic and 1.9CDTI 6AT. He is currently driving an Hard Skin Shark STI (manual)... and he wanted a shift.

the Impreza STI rival was mitsubishi EVO series however the price of STI was way cheaper than the EVO and it had become one of street racing favorite.

 

 We had a sole Zafira B OPC(2.0 turbo , 6MT) currently roving in the northern part of Taiwan.

The blue color is unique to the OPCs series... and all the OPC car has a manual gearbox

This OPC was introduced as both a verification car and demo car but later sold to this lucky owner at an unknown price. As for the C,  I had never seen anyone wanted a manual car so badly, he is willing to pay the price but unfortunately the GM dearler turned him down........After this incident, I had begun to think about my future car ( day dreaming of coz... My Z is only 1 +yrs old...) it should not be an auto. Inspite of waiting a kickdown by stepping hard on the oil pedal, a 2 stroke of downshifting from 5th gear would make my Z roar like a lion and sprint..... hell of an experience, I remembered the sales who acompanied us for a testdrive. He had encouraged me to drive with M mode but I was too afraid to try it out at the time. Now 90% of my driving is Manual mode ( the 10 % - talking over the phone, eating ....). However buying an european car with RM200000 is considered too luxurios for me....

I saw this Exora lately - nice car, but it seems really underpower. It is selling at almost the price of WISH (minus the surchage Proton Protecting Tax of coz, WISH 2.0 is selling about 70K RM here) and yet WISH is 2.0 and Exora is 1.6. And this Campro CPS although highly praise by some is just some old technology... Well, Proton need to work harder , frankly speaking, I think the 1.6 MT version of Exora could still be a good car ....    But back to safety issue - how safe is Exora ???? NCAP 4 stars ? I think we should wait and find out when it is really tested and verified by the Euro NCAP. The Exora could not hit the Europe market as his competitor would be the Zafira 1.6...

tripped wire

I got this call from the MIS staff around midnight (few weeks ago)... The MIS staff (the hospital did not give him the title of engineer....) is a young chap who lived around Fangliao... Local boy who graduated in this computer science. His job is mainly networking and hardware maintanence...
He asked me if I had upgraded my program today because the nurse had complaint to him that the they could not prescript any drug..... I did someupgrade but it had nothing to do with the prescirption system.
I said I would log into the hospital and sees what happen. I tried failed to log onto the hospital server...the server must had been down I mumbled when I called up the MIS staff. He acknowledged the problem and went to the hospital. 20 mins later he called  me up and told me the problem had been solved. Apperantly the cleaner had tripped over the wire of our UPS and the server was down...
Well, we really need to shape up our MIS dept and the cleaner as well... 

New threat....

The outbreak of H1N1 had disturbed our hospital although no case had been reported here in Taiwan. Many of us still remember the terrible period of SARS. I returned to work here during that critical period. I was most junior doctor when I joined the practice and I was assigned to ED and seen those fever patient.

 H1N1 under the electronic microscope...

 The OPD turned down any feverish patient and asked them to seen in the ED. I covered the daytime ED and I was the one who felt the heat most. The febrile patient was brought to the negative pressure room( it was not a standard one, no pre-room...) and I had to wear some gear (again not a standard one, I had an isolation gown which supposed to be disposable and due to lack of supply I need to re-use it. I worn a disposable rain coat (gown) outside my isolation gown for more protection. N95 mask is a must though plus a proctection face shield which I bought from a local hardware shop.) I had to tolerate it as I had nothing to complaint. We got 2 cases of SARS. They were transferred out as probably case and later confirmed as SARS. One of them had died (an old lady who was intubated for pneumonia - ) and the other recovered well(not intubated).  The SARS was a nightmere to Taiwanese medical personnels and we did not understand the virus initialy. There were still many of thems who survived and lived with with poor lung function. Some had died and these peoples had given us precious experience to warn us about such disease. We had learnt how to protect ourself and now is the time to make use of it....
We had a house discussion last week and we had gone through our plan again. Sadly, many of the unit/staff had forgetten the SOP and we would had to retrain them again.

I am not worried at the moment as Taiwan still free of any cases. But I had did some preparation - I had enough tamiflu for 4 of us in the house(NT 90 per capsule and darn expensive...).

 

I had some supply of N95 and surgical mask.... And I am starting to wear surgical mask on the job ( I hate it...it compromise the breathing and I think it is impolite ...the patient don't even know how's his attending physician look likes...)

Grade 1....

Xian is making great progress lately...

We were thinking of delaying his grade 1 study as we worried about his learning condition.
He had his first impact 1+ months ago when he had his second tour in the Baby Boss land. He had wanted to drive this Mitsubishi toy car(not EVO X) so badly on his 1st visit. He had a ride on the passenger seat and wanted to try on the driver seat. But he was too young - at least grade 1 to sit for the license exam. This time, his sister sat for the exam and he wanted to. The instructor was so kind to let him had a piece of the exam sheet ( no license if he passed as he is still under age). He was under stress and started to peek around for answers. After the tour, he had kept telling us that he wanted to sit for it when I reached grade 1.

He had been hard working since then. A lots of improvement was noted, He remembered what he had for lunch and tea time when I asked him after school. He started to learn chinese pronouciation symbol. Well, finally we had given up thought about delaying the entry.  Indeed, he is up till the standard and reassured us about his condition.

Well - Xian is going to GRADE 1 this year......I don't expect he do well like Yun but at least he earn himself a chance...

patient should be treated like family...

I had stopped blogging for the past 1 months... my domestic problem is less nowadays, in fact life was better than ever, but I had been lazy and focused  on my POMR project instead...
Finally I got the POMR working.... no smiliar product in the market after a search over google. I had discussed with my brother and he is gonna look into it and see if it is gonna be a product...

Well, a head knocking incident happened on one of my patient 2 weeks ago. He was a case of Down Syndrome and epilepsy. Bed-ridden for the past 10 years and resided in a nursing home. He was admitted for diarrhea and placed under my service. I saw him on Thurdays and noted some rash over his scrotum on Friday. I prescribed some oinment and went off. It was a long weekend break and I returned on Monday night.
I usualy asked the nurse about the condition before I approached the patient. I asked the nurse, " was the scrotum better ? " while walking toward the patient. Well, I got a confusing answer, " it did not get better, the swelling was still there..". What swelling, I mumbled, I didn't recall any swelling when I went off....
When the nurse open up the napkins, I was shock for a second. Swelling was noted over the prepruce instead of the scrotum. I started my "interrogation" while examined the penis. It was paraphimosis, well, a wound was noted. The answer from the nurse and nursing aid were more striking - "
0.A urine condom was used as the nurses didn't want the scrotum to 'soak' in urine
1. it was noted on the night shift of Friday, some reckless nursing aide tied the condom too tight.
2.all the nurses and nursing aides knew about it
3.no doctor was informed about the condition - because the attending physician(thats me...) knew about it and ointment was presribed for it [ fxxkxxg lies and irresponsible presumption]

Hack, I glanced through my ordering sheet - I wrote down scrotum , specifically.  Well, the spelling of scrotum , prepruce, penis was so different- and I did write it properly... No record about the wound/ swelling was noted on the nursing note....

I told the nurse to informed the head nurse stat and I want names on the next day. I was in a ass full of shit condition. I turned to google and finally came up with this emedicine webpage who provided 3 solution for my ass full of shit condition - manual reduction, needle puncture and surgery.
I went back to the patient and tried manual reduction and I was lucky I reduced it.... there was a ulcer over the prepruce - due to prolonged constriction. I was lucky the glan was not in a gangrene state , or else I would need to explain to the family about debridement or an amputation(worst case senario)

Well, I was in a ass clean of shit but still asshole stuck with shit condition then. The next day, I asked the head nurse and I got a asphyxia / strangulating answer - " the prepruce was reduced , aint it ?" that was the answer I got. The last straw which crushed my pillar of restrain.

Well, I went to the nursing office and tell the matron and nursing director that I would start writing "bull shit" order which would make the ward nurse busy like a fly without a head if any further similar malpractice occured.

I got another bang 2 days later . I caught them redhanded - another gangrenous leading urine condom was tied on one of my patient. I did not shout and yell - I just tell them to releas it and walk off. 

I am not the only attending physician who was victimized by such reckless care, our fellow chest physician(Malaysian...5 of us in this hospital) V suffered the most - newly developed pressure during in patient care. That was axxlixkxxg kind of embarassment ; the family usual response would be, " hey, we had taken care this patient (in the bed) for th past few year [ and we are not professionaly trained] , yet no pressure sore was noted and only 1 week in your setting, the buttock looks like monkey ass...." . As a attending physicin, one would have to show a smiling face and tried very very hard to pacify the family to avoid any medicolegal suit.

My patient was retained for another 10 days - and the wound was not completed healed when I discharged him...

I remembered one of teaching by this consultant grade infectionist X in Kaohsiung  - "treat your patient just if they are your family/relative" : he means when you prescribed antibiotic please prescribed as needed/according to the guideline. No cefazolin and gentamycin combo if the diagnosis is Pneumonia, No lofatin if you suspect noscomial infection.

I remembered those words (I did not work under him, he did not have a good reputation .... treat his subordinate badly...) and vows to practice it....but now, I am stucked with some reckless people which I cannot control...

I still need the answer(names) of coz - I would squeezed it out on the next patient safety committee meeting...

day after day

I had been feeling depress for the past few weeks... failling the ACLS instructor course haunted me for sometimes... well, need to walk out from it I just kept telling myself...

The hospital is back to the same old situation. ..the consultating firm had "calm" down for a while. We had entered the new quarter and I doubt that we would make it. A clear drop of orthopedic cases after our orthopedic surgeon "partially left". He become a real "visiting staff", he had 2 OPD per week and would come for surgery if any case was admitted. And I had a FICS, FACS colleague again. Mr White is back ---- as visiting staff of course and still, his scalpel is still sealed. I still remembered those old days, when I need to take a xray to him and asked him if any fracture was noted. I am really honoured to stand there waiting for his consultation - he is damn good. He still famous - his had 50 patient during his first clinic session. He is a nice guy in fact, SAAB man ( I am not sure if he was inspired by my boss.... they just stick to SAAB, just like one of my uncle - an alfa romeo man...) , artist cum perfectionist (that was why he quit surgery)...

The ED staff were still waiting for our slashing turn.... but looks like it is not going to happen in the near future. Our deputy superintendent of admin had told us he would try his best to stop it....But new load coming in - a govt clinic in the mountain area wanted us to provided specialist support, and this time, it was a far far away....

I finally completed the POMR entry system...... implemented it this months and I am still working on my "Point n Click" charting interface....I haven't heard any true inpatient POMR implementing in any hospital here in Taiwan yet....I am on the right track I believed....

No interesting case was noted in the past.... the hospital life was dull, but with the MIS project on my hand, I am not sure how I am going to surrender the project to anyone... We had a MIS manager in the past and now it is current vacant (manager on long term sick leave indefinitely). We had a MIS engineer and hardware management took up all his time....

Boss had spoken in the admin meeting that the hospital would be underogoing major renovation( a.k.a demolished and rebuild) in the near future. I am looking forward to it but still I had a feeling I would be leaving later..