2/3 of 2016 summer trip

The Qing Jing trip was a test run for me during this summer holiday. We had planned another trip up to the northeast coast of Taiwan at the mid of August. However I had a shift change and Ving had asked me if we could do a trip up north to Taipei. I gladly complied and we had trip up north at the end of July. The trip was an adventurous one as we had to push off in the evening after Yun and Xian classes. I had done it years ago and the drive was a strenuous one.

The days had come and it was a smooth start. We managed to hit Taipei after 5 hours of drive. We had stopped by Taichung for a quick grab of dinner. I had given up the plan of camping as I knew it would be a tiresome one as Ving and Yun had drafted a long list of place for us to visit.

I had reserved a hotel room near one of our target site. The picking of hotel is not an easy job for me nowadays, it had to fulfill a few requirement :

1.  4 beds room

2.  Car park

It is easy to get a 4 beds room but difficult to get a hotel with car park in Taipei. I was lucky as due to the policy of Mainland; mainland traveler had decreased since the new regime come into power. In the past, hotels were filled with mainlander and now, it is easier to get a room at the mid-range level. The car park was however an uncomfortable one…to get to the B2 level, I had to drive the car into an elevator. It made me very nervous about getting Fefe into a large elevator. However, I still get the job done and finally parked Fefe.

I hit dreamland after a few MPQ round. The next day, we started our tour after breakfast. The first stop was Di Hua market which was within walking distance. At noon, we had changed location to the Wu Fen market. We had taken the MRT and at 3pm. 4 of us could barely walk and we had decided to head back to hotel and continued the rest of the journey with Fefe.

Yun had decided to visit one of the top 10 book store of the world thence we had landed ourselves at the Zhong Xiao Region. Parking was a pain of the axx in that part of the city. It was like parked your car and then take a 500m walk no matter where was the location.

We had come across a Mamak store like restaurant but we gave it a skip as I had wanted to dine in hell one of the dim sum shop.

Well, the food was up to the standard but I was not satisfied as Xian has walloped most of my roasted pork (and it was the last plate available). Maybe next time….

The day ended late in the night as we had toured the only 24hrs book store in this country. Everyone was exhausted and hit dreamland when we returned to the hotel.

The next day was a long drive back home with a brief stop at Ying Ge( famous for its ceramic product).

Taipei was indeed a great city. Most of the residents are dressed stylishly; we looked like bunch of peasants touring the big city. My coat which was hanging peacefully in my closet was worn once only (during the wedding…).

I had chosen the path of a humble life but yet was unable to unlink myself from the high tech world. 

20th Anniversary of Alumni Reunion...

One of my classmates called me 2 months ago and invited me to the 20 – year anniversary reunion gathering. 10 years ago, one of our classmate had initiated the event 1/3 of the classmate was found. I had an invitation 5 years ago for the 15 year anniversary gathering but I had planned our trip back to Malaysia and had to forfeit the invitation. This year, I did not hesitate to accept the invitation as I had no plan for a long trip. I joined the line chat group and found that 70% of our classmate was on it. GSW who opened up family practice in Sri Aman had also decided to come for the reunion. I had volunteered to pick up GSW at the airport. We had a long chat during the drive. He had apparently open up a successful practice there and enjoyed the life of being a general physician. I could sense that he indeed enjoyed his life. I told him that I might visit him on my next visit back home. I had never stepped my foot on the land of Sarawak since my birth. I had planned to visit Kuching, Bako National Park and then to Sri Aman. It would be a 5d4N tour if there is no other arrangement. Renting a car in Kuching is 40 % cheaper than the west Malaysia.

I met other classmates at the reunion. After 20 years of effort, everyone had gained something. We had more than a handful of classmates with PhD added to the end of their names; a few of them had earned full professorship and currently in the power struggle of Deanship in various university.

I praised the great one for arranging my path and leading my way…..

failed central line...

The technique of inserting a central catheter had been improvised since 20 years ago. I had heard that one of it was utilizing color Doppler to locate the vein before puncture. But as a man of action working in ED, I preferred the traditional way to visualize the anatomy and proceed with the puncture. 90 % of the time, I am par to my standard. But yet, from time to time, I will tripped over by my own shoe lace..

This patient is an elderly male suffered from latent  Tuberculosis. He had presented to our OPD and ED with multiple complaint after starting his medication. However, he was hypotensive on this presentation. He was not tachycardic though. I decided to flush him with fluid via a central line before I start the dopamine drip. The catheterization process gone smooth before the guide wire insertion part; obstruction was noted when the wire was passed beyond the 15cm line. I retracted the wire and reinserted it. Still I faced the obstruction at the 15cm mark. I redrawn the wire and did a blood drawing trial and it was smooth. I proceeded with the wire insertion part (still 15cm..) and inserted the catheter. Everything was smooth and fluid was flushing with no problem…

I grinned when I saw the follow up xray. I ordered a full run of 2000cc of fluid and removal of the catheter after the flushing.

This is the first time, I inserted the catheter into the subclavian vein; I had multiple insertions into the internal jugular vein and I am familiar with the “obstruction” encounter during those insertions. Well, it still serve it function anyway…

1/2 of Summer trip

I had gone for camping trip in the Qing Jing Area earlier this week.  I had planned this trip 2 months ago when I decided to cancel my Malaysia trip for this summer holiday. It was a tough decision for me to cancel the trip back to the Boleh Land but yet I had to give in. Yun and Xian had to attend summer school during July and we had only a window of 8 days to perform the trip which I consider to be inadequate. 

It would be my second time to try out my Coleman Weather Master 10p Tent. We had been to Qingjing few years ago for a brief stop and camped for only 1 night. I had booked a camp site for a 3D2N stay and planned to visit the sheep breeding farm. I had spread the news over the Line camping group and 4 other families had joined our trip.

The most difficult part was the booking. It opened on the 1^st of June for booking and I had made 800+ redial in 2 hrs before I got through; it was summer holiday and nothing to shout.

We pushed out early at 8am and reached Puli town at 11am where we stopped for lunch. The trip to the 1750m camp site took us about 40mins. Fefe had problem during the last 10 mins of the climb. Gear jamming was noted, the gear was fixed at 3^rd gear and unable to downshift to 2^nd gear. It was a protective mechanism of the gear box. I was not surprised that it happened at 1700m during the climb(it only happened at 2900m few years ago). Fefe was loaded with 5 persons (last time it was 4) and a huge load of equipment. We settled at 3:30pm and enjoyed the cool temperature of 20C (vs 35C down south).

There was a 7-11 outside the camp site and the younglings had grabbed every chance to go for a tour. The elders had some cash and were able to buy freely with the younger one looking and fascinating around the store without the supervision of their guardians. I knew the feeling and told them to grab one items of their choice and paid up. Their grin on the face pacified my soul and I had repeated my act several times during that period.

We were lucky as despite of the weather forecast which indicate possible lighting storm in the afternoon; the camp site was dry during that period.

The drive back home was smooth and as usual, I was back to my desk that evening due to shortage of staff.

It was a prep trip for me as we are going to the Wuling Farm for camping next months. It would be a strenuous drive since the Wuling Farm is 120km farther than the QingJing Farm. The 120 km include another climb from 1750 to 3000m above the sea level and descend again to 1400m. The Curvy winding mountain road leading to the destination would cost us 3-4 hrs of drive. I would be sending Fefe for a service before the trip; hopefully with the less weight and service, Fefe will be able to made it through the journey without choking.

Taiwan is a camper friendly country with many camp sites which are safe and well equipped with clean wash room and electricity supply. 

Camping is reminder to Yun and Xian that we do not necessary need to stay in top graded hotel during our travel. I told them that comfort is a relative term and we should enjoy what we had at that specific moment and praise to the great one for the grace.

Cloud in the house

Few weeks ago, Yun had asked me about our internet service; why we still subscript to a fixed line data plan as both Ving and I subscribed to an unlimited 4G data plan?  I explained to her about the need of a fixed line as we are currently running a cloud service in our house. I was using Dropbox for over a period of 2 years and when the compliment data space expired; I was forced to move 100G+ of photo and movie from Ving’s storage to a mobile hard drive. The downloading process took me over 20+ hours… a strenuous process and I decided to host my own cloud service. The searching process was simple, either synlogy or qnap? No much to compare as I had a budget to follow…. There was a promotion going on for the TS231+; although I am not satisfy with the ARM processor, I have to compromise for it.

Installing the machine was simple; but setting it up was a pain. I am not unfamiliar with the port forwarding part and the system was up running in less than 30 min. Everything was ok for the first day but my “cloud” had disappeared on D2. The machine was running but I was unable to locate and logon to it. Rebooting the machine is simple solution but yet the cloud disappeared after a day later. It took me a week to modify the setting and finally I found the culprit – my dlink ip cam recorder DNR 202L…..

The removal of the recorder solved the problem. The rest of the learning process was simple and I am happy with it.

A simple UPS was added later on and as long as the power failure is less than 1 hours, the system is good.

I had wanted to upgrade the fixed line to 300m/100m when I set up my cloud, but I was disappointed when I found out that my area was not eligible for the service. My 100m/30m data plan at that moment was running on a double VDSL line basis instead of optic cable.

When Yun brought up the question, I ran a check over the net and found that an upgrade to 1G/600M was available…..My eye shinned but yet the fee was way out of my budget; the fare was RM400/month and the 500M/250M was RM300/month. I opted for the 300M/100M which cost RM100 less and submitted the application.

The contractor came 3 days ago and the FTTH was installed. The upgrading of the speed was noticeable but I lost the convenient of having a fixed IP. I had to rely on the DDNS service provided by the router.

I later found out that a 100M/50M data plan provided by TMnet cost RM300/month; same price with 1/5 of the speed. No wander when I in law visit me, they were amazed by the surfing speed....

Well, the price of a 100M/50M in Sri Lanka is RM 75(limited to 100G, additional 1G = RM4). Water fish price by TM.

I considered myself lucky, but felt sorrow as I am so far away from home...

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….