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….

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 …..