Referral blue

Boss had approached me after my long break. He had related the case that he had encountered 2 days ago during his ward call.

Our neurologist had submitted her resignation 1 month ago and after some serious discussion and compromised; she had agreed to stay with the condition of waiving Sunday ward call. The immediate “lobang” were filled by Boss as usual.

A 7 y/o boy with abdominal pain was admitted to the pediatric service on Saturday. He was seen on the next day where the pain had worsened. Clinically the symptom favor acute appendicitis; but boss had chosen to do a CT for confirmation. The radiologist was consulted for final decision and a report ruling out of acute appendicitis was done. Boss had informed the family about the report but on Monday, when the surgeon saw the kid and CT. He had concluded that he favored acute appendicitis and with the diverted result, the family had asked for transferred to a tertiary facility immediately.

Acute appendicitis had been one of the “notable” diseases in my memory. One of my elder cousin had been mis-diagnosed at the age of 6 and ended up with a long HORIZANTAL laparotomy scar over his belly….
We were told not to jump nor run after meal as it may lead to acute appendicitis( a myth of coz) by our parents during our childhood.

I was cautious with this disease from D1 of my practice. Our new surgeon had wanted a CT scan for confirmation and he had ruled out 10-20 percents of the clinically favored acute appendicitis. He performs appendectomy only during office hour; cases who presented after office hour would be admitted and given parenteral antibiotic and surgery would be delayed to the next morning.

I learnt to differential diagnosis acute appendicitis on CT after his arrival.

I do not blame the radiologist for the report but yet our consultation system is the major culprit.

In the standard version of referral consult, a the relevant physician/surgeon should see the patient personally but yet some of the them do the consultation over phone or via communication app.

We had complaint multiple times regarding the setting and now finally our Boss had it….Hopefully some change will be done in the future..

fading specialty....

I encountered a emergency labour case few weeks ago. The patient was a G6P5 , 39 weeker. The husband had rushed her into our ED during a busy Saturday. We had double consultation going on but yet, the initial scenario stunned my nerve. My colleague (a junior cardiovascular surgeon) told me that she had no experience of handling such case. The 2^nd event was the meconium stained liquor which was noted on my vaginal examination. The os was fully opened and contraction was regular. Rupture of membrane was noted few hours before their arrival. No pitocin/ergot available was another disturbing fact which should have been corrected a long time ago. While I was worried about how could I take care of both the patients, one of nurse told me that our visiting obstetrician might still be around. She had called up and the obstetrician came to ED and took over the labour. I set up another resus area praying that the kid would be fine after delivery although the quick sonography look revealed the kid’s heart was still pumping.

The baby came up within minutes and I was cheering when the baby was passed over to me….the Apgar score was 9 and I did a suction via endotracheal tube without difficulty….

1 hour later, the mother and baby were on their way to another hospital.

I was lucky the baby did not come out flat, although there were still a few things to complaint about. The visiting obstetrician did not repair the episiotomy wound and he later refuse to issue the birth certificate. I had asked around and found that he had some medico-legal issue earlier and he had given up his practice of obstetric. He is currently attached to our health screening team and doing pap smear only. I had recalled once that I had consulted him about a missed abortion for DnC and he told me that he is a Buddhist and declined the job.

The medico-legal case had scared the hell of out of him; lots of the obstetrician had quit and practice cosmetic medication since the last 10 years.

Well, I am not the lucky one that day….the kiddo was….

Arcade。。。。

I am not a man of action…not in the gaming world. My reflex is not good and most of the time, I am a watcher rather than player in the world of action gaming. But yet I completed the street fighter round during my college days (in easy mode of coz). The only arcade game that I had completed outside my home is the Warrior of Fate; with a bag of coins…

As Xian grew over the years, he had started to join me in the world of gaming. Lately when we transformed our 4^th floor into the entertaining area, Xian had started to show interest in  action game. I introduced him to the world of Street fighter and Mortal Kombat. We got a couple of game from the xbox online store and it took only a  few days for me to realize that I had hit my ceiling. My hand is clumsy and my hand muscle is weak as well…my hand sore after 15 min of play and the successful rate of performing combo and special move reduce to 30%.

There is only one solution but I was reluctant to proceed with it. The struggle is as painful as deciding to get a 60 inch TV or a projector. You know what was the best choice but yet there was  something that refrained me from proceeding.

Finally I gave in and started my search for an arcade stick. As usual, the bottom line of my budget was being raised from time to time as I googled more. My challenge was to get 2 arcade sticks which can be used on xbox360 and PS4.

It was mission impossible initially until I came across the “BROOKS”…. USB adapter which enable inter-usable of arcade sticks between different consoles.

I got a Q4 initially and it work fine on the xbox360. Both of us enjoy it but yet we are still one arcade stick short; the other arcade stick should be a PS4 compatible preferably with touchpad….my hunt continues…

There is a local game shop up north which offer custom made arcade stick, price should be RM200 cheaper but the problem was the long waiting list- > up to 4 months of waiting…

So there were only 2 left on the market for me to choose from, HORI and MAD CATZ. HORI is definitely at the bottom of the list a there is no authorized dealer in this country. MAD CATZ TE2+ was last on the strike list but yet it was out of stock 1 month ago. TE2 was next but I was reluctant to take it as it does not feature the touch pad….

Last week, TE2+ was back on the market and I had ordered one...

2 days ago, Yun saw the parcel and after she knew the price, she had asked me a question, “ what was the key leading to the decision of spending the price of a PS4 on 2 joysticks ?”. The answer was crystal clear for me –“to complete the childhood dream that I had left out…”

I had never had the luxury to play in the arcade center nor own a TV game back in those days; all I could do was to watch. I considered myself a lucky person but again…I envy Xian….

The missing Malaysian...

I had been following the news of a missing Malaysian student(LWS) since 1+ months ago. He was found recently near the east coast and later brought to our ED for an medical review (in our ED) on his way back to the university where he studied.

My colleague L had seen him and he was later interviewed by the media (which he remark was altered and mis-interpreted)

I googled and found some interesting facts…

Facts:

1.  LWS is a international student major in computer engineering studying in FW university. He is currently in his year 2.

2.  He was granted a 1^st year tuition fee exemption during his entrance.(international student pay 2x of the tuition fee than oversea Chinese student.)

3.  He is a mature student age 35 who had saved up for 10 years to do his undergraduate course.

4.  He had difficulty in his grades during his first year and had failed 2/3 of his subject this semester. The school is counseling him for a transfer so that he could continue his study here in Taiwan

5.  He had packed up and drawn 30k out of his account (80k) and leaved the campus with his bike.

6.  He had checked into a local hotel further up north with 4 other foreign students few days later.

7.  A call from northern tip of Taiwan was made to the police claiming that he was safe few weeks after his disappearance.

8.  He was found wandering in front of a police station near GuanShan few days ago.

9.  Upon found, he was noted with speech difficulty and claimed that he had lost his memory. (partially and selectively loss of memory was noted- which I think was crxp…)

10.             He refused to communicate verbally. He could only communicate with the police via writing (in English).

11. He is a junior from my high school back in Malaysia.

It was a very sad and dramatic event for the fellow Malaysian. He had tried hard to save up and further his study so that he could have a better and different life. 

Unfortunately it didn’t go smooth as he wishes….

I was a lucky person as I had a smooth studying process and most of the credit should go to my parents who financed my studies despite of their financial condition. I knew the feeling of being a poor student. Keeping up with study is another challenge as I had to face the elite back in my college days.

I think LWS had known about his faith of being expelled or transferred from his study and decided to go for a trip rounding the island before the event occur. This island is a good place to travel...Even the ex-communist premier from the mainland is willing to crawl to Alishan if he is allowed to pay a visit here.

 LWS had taken good look around the island and later needed an excuse to cover his act. Well, he chose the "path of forget" and hopefully he could return to the Boleh land and continue his previous life without an undergraduate diploma. It was cruel and brutal for him after so many years of dreaming.

I had related this story to my kids; I told them that if you have a chance and luxury to study straight after your high school : don’t hesitate and grab the chance. I would support them all the way. Working and doing part time study is not fun at all; they had seen the time and stress I undergone few years ago. But yet I told them to study is a life long process, so enjoy it and don’t hate it …..

Satun 2015: the trip

The second trip to Satun was unlike the first one; I had become a veteran and thought I knew a lot regarding a medical relief trip. I was caught by surprised when the local mission told me that we would be doing medical check-up in school and villagers apart from my main job of seeing patients. I was not prepared for that and I hate doing medical check-up. No ground to object and I have to comply with the job. With the instrument I brought it should be enough but yet, I need a vision chart….Luckily, I had dug up a couple of the vision chart from their store and downloaded a color blindness checking app from the net.

There were always some problems in each stop for me to tackle; with grace, I was able to overcome those problems.

The lodging was better as the local mission office had rented a house and converted it into a rest house for missioners. As usual, weather was bad; we were hit by downpour from time to time. Food was nice as I enjoyed the local spicy Thai food. I had a chance of visiting an evening market and landed my hand on some local roadside snack. Those food look similar to some counter Malay food, but yet they tasted differently.

I was in a dilemma during the end of the trip as I tried to figure out what is the plan of the great one. It was beyond my wisdom to compile his will but yet, I tried my best to please him. However, I knew it is not the right thing to do; I just need to follow the flow.

I had decided lately that I would sit still and not to participate in any mission this year. I needed a break; to enjoy some fun time with my family or maybe hide myself in the attic doing CQB and playing kungfu game….

hospital evaluation

We had just been through our hospital evaluation few days ago …

Unlike the past, I was not burden with any responsibility this time. The hospital evaluation was scheduled around at the end of the year, however we were informed that it would be held in April in March. Most of the unit had gone into havoc mode as they are only half prepared for the evaluation. However, our ED which received a 2^nd level emergency care certification has to be prepared all the time for any spot check; thence we were good to go anytime. The rest of the staff had been doing overtime for almost 2 weeks during that period. 

The evaluation went smooth anyway….

from VS2008 to VS2015....access to mysql....

About 1 year ago, the vendor of the EMR system of our hospital had come to our hospital for demonstration. They had presented their upgrade plan for our progress note and medical order system(which is currently using the old system I had written with the VB2008). The offer was not an impressive one as no demo program was shown. The management had however requested the vendor to present us with something that look like the system which I had implemented almost 8 years ago. They had asked me if I could provide them with the source code, and I gladly complied. Frank said, I was not a good programmer then, sometimes, it would took me a good couple of hours to understand what I had written in the past. I had however stopped any further development of the program since then. I would make minor modification and correction as per request by my colleague from time to time. At the end of last year, The new triage system was implemented and I needed to upgrade the ED triage program. I decided to upgrade the old VS2008 to VS 2012 as the OS my computer was running  xp. The upgrade did not go smooth and I was force to take a leap to VS2015. After 1 + months of struggle I had finally migrated my program from VS2008 to VS2015 with some info gathered from the net.

At that point, I was quite confident and proceeded with the upgrading of database. I managed to install a mysql server on the qnap NAS in my house. Later the MIS department leader had provided me with an old computer running server2012. I configured a mysql server on it as well and shifted the whole database over to the new home. The effect was stunning as the access time was very fast comparing with the Microsoft Access DB I used in the past.

The MIS leader had however informed me that the hospital had decided not to purchase the new progress note system from our vendor as they were unable to come up with any demo program.

Well, it was a milestone for me as my program now looks like something mature enough to be called a product.

I had finished the nursing record part and will be going to launch next month….

Well, my next step is web based….