Thanksgiving USA

I suppose the Thanksgiving holiday is second only to Christmas here in the US. Every year, on the 4th Thursday of November, Americans celebrate this holiday with their families and friends; having a traditional Thanksgiving dinner of turkey, stuffing, sweet potato, green beans, pumpkin pie and lots of mashed potatoes and GRAVY! It is a giving of thanks for all that we have, and are grateful for.

The story of Thanksgiving (as I am told) goes like this: the first Thanksgiving dinner was celebrated in 1621 by the Pilgrims of Plymouth Rock and Wampanoag Indians as a celebration of the autumn harvest. The Plymouth Pilgrims had sailed across the Atlantic and landed in the previous year; but did not know how to grow their crops in the new land. That winter, 46 of the original 102 who had sailed on the Mayflower had died. Apparently, Squanto of the Wamponoag tribe taught the Pilgrims how to survive, how to plant corn and crops that would survive in the new land. And when the autumn harvest was successful, they had a 3-day feast to give thanks.

But it was Abraham Lincoln who actually proclaimed it, and made the 4th Thursday of November Thanksgiving Day in this proclamation on the 3rd Oct 1863 in the midst of the Civil War.

"I do therefore invite my fellow citizens in every part of the United States, ... to set apart and observe the last Thursday of November next, as a day of Thanksgiving and Praise... and fervently implore the interposition of the Almighty Hand to heal the wounds of the nation and to restore it as soon as may be consistent with the Divine purposes to the full enjoyment of peace, harmony, tranquility and Union."

We spent Thanksgiving with two families; who opened their doors and welcomed us into their homes and families, to join in their celebrations. We were treated to wonderful meals; but more than that, we were treated to a memorable experience in American tradition and family life. To the Norris and Chiao family, we are truly grateful and will always cherish those memories.

This blog post is really about being thankful for all that we have; much of what we have to be grateful for, cannot be described in material terms. I am grateful for this opportunity to be here in the US for the last 2 months; extremely happy to have my wife and daughter here with me for much of that time. I am thankful for the health and well-being of my family, friends and loved ones. I am grateful for the foundation of my life, family, work and career. I am thankful for all my friends and colleagues. I am grateful and thankful for ...... [it is a long list, but one worth listing out on your own]. I shall not bore you with mine.

It is also a good time to "heal the wounds" of the nation, in the family, amongst friends and colleagues or with close and loved ones. A good time to say whatever needs to be said; and do what the Californians do; give a HUG!

So, a nice time of the year indeed; a time to give thanks, to mend wounds and to give and get hugs. Selamat Hari Raya Haji to all Malaysians.

Code TRAUMA !

It started off when it was least expected; but after all, that is what happens with road traffic crashes.

A car crash at the freeway intersection. A few calls are made to 911 [more than 10 call actually]. Some of the calls reach the San Mateo 911 call center; others get diverted to the Alameda county 911 call center. [there are a several call center covering a few counties]

The calls get reconciled; and emergency calls are directed to the fire services; and ambulance services. Interestingly, the first responders are the Fire Dept (who responds to all emergency calls with their fire engines, with paramedics on board). In some areas, the Fire Dept even has its own ambulances! Response time usually less than 8 minutes in these parts.

At the same time, the ambulance services also get alerted and respond to the call. Their response time; a bit slower (but then again, they are NOT the first responding team, and they do cover a greater area). When they get there, the fire department paramedics have been on-scene for about 5 minutes. The police are also there, controlling traffic and maintaining safety of rescuers. They have extricated the patient, who is still unconscious. Risk factors: high speed, side impact, air-bags deployed, persistent decreased GCS. Not good.

The Fire Dept paramedics and Ambulance team paramedic work together to immobilize the patient. Decision: transport by land to nearest Level I trauma center [there are only 2 in the Bay Peninsula ie San Francisco General Hospital and Stanford University Medical Center]. Other options in play were transfer via LifeFlight helicopter but this was not necessary; cos Stanford was just 15 mins down the road.

So, patient gets put on the ambulance, paramedics get on. EMT driving called in a Code 3 to Stanford ED (ie Code 1 transfer only; Code 2 non-critical; Code 3 Critical) which is received and recorded by the ED nurse. ETA 15 mins. The ED nurse speaks to the ED attending, who decides then what level of trauma activation it will be. Trauma 95 - lowest level activation, fewest staffing, least likely to be critical patient; followed by Trauma 97 and Trauma 99, which is what was called for this patient.

Trauma 99 means pagers are bleeped for more than 30 people; from Trauma Attendings, to ED Attendings; from Nursing Managers to LifeFlight Nurses to ICU and OT nurses; from phlebotomists to X-ray technicians to blood bank staff; from medical social workers to supply distribution technicians to interpreters to the anaesthetists. And they all appear at the ED, before the patient arrives. They all get ready, gloves on; in position, supplies ready, USS machine switched on, scribe ready with forms; waiting. In fact, they already pre-registered the patient even before arrival [pre-determined trauma code name and registration]. All waiting in that small Trauma bay.

One team runs the Trauma Code ie. the team leader performs the primary examination of the patient, directs the actions and makes the calls; and his/her voice is supposed to be the only voice in the Trauma Bay. They take turns; one day, the person running the trauma code is from the ED, the next day from the Trauma service (ie part of Surgery). It is usually the Attending doing it for Trauma 99s but often the senior residents do it with the Attendings hovering nearby. [I've seen nurses run the Trauma 95 code, though. They were excellent!] But the place is small [see above] It gets easily congested and easily too noisy and chaotic. So if you have no life-saving business there, out you go!

When the ambulance finally arrives, it is quite different from what we see on TV. No slamming open of doors, or blaring of sirens. No shouting "I need a nurse here STAT!". No machine-gun staccato presentation of the patient's condition and vital signs while pushing the patient in. [although the paramedics do really really talk like we see on TV - either TV is realistic or the paramedics grew up watching too much of the stuff, like I did!] In fact, the entry of the patient is very controlled. Patient pushed in; everybody does what they are supposed to. Paramedics give their report; mainly to the scribe and charge nurse [they get quite upset if they don't get the reports properly]

Team leader starts primary survey, calling out every finding so that the scribe can document everything. Nurses measure vital signs manually [yep, first vital signs are always manual!]; phlebotmists get line and blood; draw, label, send. Other doctors perform FAST, while yet others set-up immobilization, removal of clothes [everything goes, including clothes, board straps, underclothing; everyone has big scissors], personal belongings to paper bag and labelled. Very very quickly, the problem is identified and steps are taken to do what needs to be done. If OT is needed, then the patient gets to OT very quickly indeed. [One GSW was in OT within 9 minutes of arrival!] If x-rays are needed ... [actually, most x-rays are done bed-side in Trauma 99, digitally with the images immediately available on the screen if you want to see it] I think most of the time, they tend to just CT [and almost always with contrast!] quite liberally. With results within minutes!! on the HD review screen!

Things that need to get done, get done. Decisions that need to be made, get made. Responsibilities that need to be dispensed, get dispensed. Not because of anything fancy, but because everybody is there. Playing their part in a system that works. So the patient gets that life-saving care that he or she needs, at the time that he or she needs it. If there is no life-saving intervention to be done, things can really slow down and waiting for the entire process of investigations to be completed will easily take hours and hours. But that is another matter [maybe for another blog post]. But for the patient that needs time-related interventions, they have proven that they can deliver in the time that it is needed. That saves lives!

The story does not end there. Each month, there is a Trauma audit meeting, attended by the ED and Trauma service teams; where all Trauma 99 and all complicated cases or where issues have arisen will be discussed, reviewed and concluded. The team will decide whether to close the case or seek improvement. If it involves any member of the team from either side (including the Chairman of the committee), he or she will step out of the meeting at that time, so that a fair and impartial discussion can ensue and the appropriate decision arrived at. And it is all documented and reviewed in every meeting.

Now, THAT is a trauma system.

My conclusion is this. They are really good at it. They OWN the Trauma service. It is something that they want to do, the ED guys, the surgeons, the hospital administrators. They own it, and they are doing everything to make it better. They are doing everything to maintain their Level 1 Trauma Center status. And do a better job for their patients.

Our job maybe is to find others to co-own this trauma service, this "abandoned infant" who looks like becoming an unwanted orphan child; but I'm sure will, given the chance, grow up into something that we can be proud of, and boast about, in our twilight years.

The best climate in the world

The Bay Peninsula (centering around Redwood City, which is about 10 miles down the road from Stanford) has reputedly "the best climate in the world". This was apparently determined by American and German climatologists in the 20's, who found that 3 areas in the world just have absolutely perfect climate ie the Bay Peninsula, the Canary Islands and the North African Mediterranean Coast. That invariably led to the slogan of "Redwood City - Climate Best by Government Test"

The weather here is really nice; the bluest skies, clear crisp air and an average humidity. Not too hot in summer, never too cold in winter; when it rains, it drizzles. When it is sunny ...... well, it is almost always sunny. [the picture shows church at the corner of our road; look at the blue skies].


Even when it rains, like today, the clouds just cannot seem to hold back the sun, nor the blue skies.


It is indeed difficult to dispute those climatologists findings.

It is not merely the climate that draws people here. Sure, there is money to be made [and spent] here. So many people made their fortunes in these parts; and many chose to continue staying on.

One of the reasons why Stanford has been so successful is because of the climate that they have created. They take people with potential, and provide them an environment for them to excel, to do what they can, to achieve their potential; and reap the rewards. They seem more willing to take risks, and allow for failure or setbacks. This is probably the basis of their success.

Here, there is nothing like "follow the boss" or "boss is right" or "my job is to obey orders". Instead, the name of the game seems to be "let's get it done" and "what do we all want out of this" and "my team depends on me doing my job well". There is sooo much less of catering to egos and hierarchy; and soooo much more of working together to achieve common goals.

And to achieve goals, Stanford has been pushing for more and more inter-disciplinary collaboration; not merely within the fields of medicine, but between medicine and engineering, IT, economics and the other sciences. In fact, they built the entire Clark Center for this purpose.

A state of the art center, built solely for the purposes of collaboration between fields. It is even strategically located between the schools of Medicine, Engineering, IT and Sciences. Here, a collaborative project will be allocated physical space in the center for the entire duration of the proposed project; for team members to do what they need to do. And at the end of it all, they leave; and another project takes it place. So nothing is permanent here. No fixed empty offices, no fridges nor pantries, no assigned car-parks nearby. Electrical power sockets, internet nodes and everything else comes from the ceiling; to facilitate changes. Obviously, it had its own coffee place.

To me, it is a reminder that the most important thing to address in order to achieve success, is people. People with the ability and motivation to succeed, encouraged and given the environment to grow and do; people who were allowed to achieve their potential and personal goals.

To me, it was also a realization of our mistakes. Our over-emphasis of hierarchy and behaviour protocols, our chronic need to put down our fellow man; our penchant to discourage instead of encourage, to speak of problems instead of opportunities, to give up and think it is someone else's problem. Worst of all, those of us who do nothing about it, always seem to be the ones to complain loudest and most critically of what we cannot yet do.

Sure, we have our problems. We don't have the perfect climate, nor the best environment to excel. We probably don't have anywhere near the amount of resources either. But, we have hope. And great potential. We need collaboration. We need to continually work toward better things. We need to take those small steps, that all of us can do. Small steps. That's all.

And to the nay-sayers, just shut-up!

The Stanford - Kaiser Emergency Medicine Residency Program

The Stanford - Kaiser Emergency Medicine Residency Program is one of the 120 odd residency programs in Emergency Medicine available in the US. The initial proposal to set up the program began in 1988, the first interns in 1991 and the first graduating batch in 1994. [Hey, that's not too long ago!] But even at the beginning, they got Emergency Physicians with significant experience and expertise at residency training as part of their faculty.

It is a 3 year program, jointly conducted between 3 hospitals (Stanford University Medical Center, Kaiser Permanante Santa Clara Medical Center, and the Santa Clara Valley Medical Center). It was a unique collaboration between a University based academic strong center (Stanford), with a HMO organization (Kaiser) and a county general hospital; allowing their residents exposure in different environments; whilst creating a balance between academic learning and service oriented emergency medicine.

It is a highly regarded program and Emergency Medicine residency training is a high in demand program. This fact allows residency directors to pick the best students, who will then become the best Emergency Physicians.

The first year is a varied mix of off-service postings with some emergency medicine; whereas the 2nd and 3rd years are much more focused to the Emergency Department. Residents spend about 50% of their time at Stanford and a varying proportion divided between the other two hospitals. They work 12 hour shifts, 4 times a week. [Sorry, correction, they work 12 hour shifts between 52 to 58 hours per week; cannot exceed 60 hours]

Every residency program has a residency program director. They have a group and they all discuss with each other, and share resources (eg. question banks). Each month, a general area of discussion is agreed upon; so all lectures, teaching sessions, grand rounds discussion will revolve around that specific area of discussion for that month. Eg last month's topic was toxicology. So all teaching sessions was centered around toxicology inclu grand rounds, journals, group discussions etc. And at the end of every month, there'll be a monthly online test, on that topic of the month. In this way, training resources are shared between all residency programs all over the country.

Assessment is taken very seriously. Firstly, residency directors monitor residents projects, results and achievements online (MedHub system). In addition, every faculty member is asked to review residents abilities and progress. This online system allows the residency director to be more closely in touch with each and every resident.

At the end of each year, there'll be a yearly internal examination. Passing each exam will mean that you have successfully completed the residency program. But in order to be "board-certified", they will have to complete their board exams; the written exams often taken within a few months and the oral boards up to 1 year after the end of their residency program. Being board-certified essentially means that they can now work independently, and call themselves board-certified emergency physicians. These board exams are tough; including 5 single patient situations and two 3-patient situation; total 4 -5 hours !

They are very open about continually improving their residency programs. They share resources between programs, share exams and try to coordinate as much as possible. Residents themselves are asked to participate in making their program better, by providing feedback about the program, ways of improving it, issues with off-service postings etc etc. One year after they graduate, they are polled to find out if the residency program provided them with the skills and knowledge that was useful to them in the current careers. And their bosses were also polled to see if they were good enough. I wonder what my boss would have said, if he was polled about me, one year after ? Probably something like "too ambitious, doesn't know when to say "Yes Boss!", never knows his limits". Heh heh heh!

Where am I going with all this ?

I think that one of the main roles of Emergency Physicians in Malaysia today must be to create the next generation. We must have many more EPs; good ones that will carry on the flag, share the burden and pass on the torch. We all have to role to play in this; not just the University guys.

The Stanford - Kaiser program, a collaboration between a university hospital, private HMO hospital and a county general hospital, allows a blend of academics and clinical experience which benefits residents. It benefits the faculty too, allowing EPs in non-university hospitals to participate in academia, be given clinical appointments in the university, and reducing the teaching burden on full-time faculty in the University. Above all, it allows many many more residents to enter and go through the program, that would not have been possible before.

That is exactly what we need. A collaboration between KKM hospitals, where we do have many EPs with significant experience, interest and capability to train MMed residents, and the University Hospitals, who will take the lead with the academic side. We can use the online resources including the IT solutions that help monitor all our MMed residents. We can then train many more EPs, that we badly need.

How many more ? As is my previous post, we need 60 - 80 new EPs per year. That is what we need. It is no mere task; but one that we can do, together.

What say you, guys?

And if you are interested in some websites, these are the links

• Accreditation Council for Graduate Medical Education (ACGME) which sets up the requirements for residency programs
• Residents pages from the professional bodies Society for Academic Emergency Medicine (SAEM) and American College of Emergency Physicians (ACEP)
• CORD Council of Emergency Medicine Residency Directors
• EMRA Emergency Medicine Residents Association
• Two of the Online Residency Management solutions MedHub and New Innovations
  

And for more accurate information on the residency program, just get it from the horses' mouth here.

The best of Korean ooohs and aaaahs

Some of the greats

"You Can't Say" from All about Eve


"I believe" from My Sassy Girl


Enjoy!

More ... more ..... MORE !!!

Emergency Medicine worldwide is like a cancer; we are growing and growing [and sometimes don't know when to stop]. But this is justifiably fueled by the knowledge that well-trained people working in the emergency department and in pre-hospital care makes a positive impact on patient's outcome. We provide better care, simple as that.

Conversely, it is also true. Untrained healthcare providers working in the ED and in ambulances can cause great damage to our patients. Not being able to identify signs of deterioration, missing diagnosis, failing to act safely will compromise patient care.

It is therefore imperative to get as many Emergency Physicians on the floor, as soon as possible. Are we doing enough at the moment, to make this a reality ?

Let's look at some numbers. The US has about 120 Emergency Medicine residency programs all over the country, producing annually about 1200 - 1300 Emergency Physicians. Don't forget that they already have more than 32,000 EPs already in more than 4,000 EDs all over the country! So they are way, way ahead of us. How do we catch up ?

The US has about 250 million people. Malaysia has about 25 million. They have 4000 EDs, we have about 200. So simple calculation will tell us that if they are still producing 1200 EPs every year, we should be training about 10% of that; wow, that's 120 EP per year every year. We are only just producing 30 a year. That's not enough.

At the current rate of training Emergency Physicians in Malaysia, we will never reach the sufficient numbers that we need. Soon, some of the older EPs [me, included] will want to retire, or do something else. If we maintain the current rate of production of EPs, we will reach a steady state soon, not having enough EPs around. That's a problem.

We need more EPs because it is better for patient care. We need more EPs because we can then expand the field of Emergency Medicine. We need more EPs because it will be difficult to argue with and look down upon so many specialists in such a vibrant growing field of medicine. After hours, EPs may be the only specialists in our hospitals. We need more EPs because we all want to do something else as well as clinical work after a few years. We need more people to share our burdens and share our love of Emergency Medicine. Maybe, we need more EPs because we are a cancer ! [haha!]

You see, we are NOT like some other specialties, who have always wanted to limit the numbers of specialists produced each year, so that their demand in private practice is not affected. We don't care about that. We just want patient care to improve.

So my friends, I think our main aim, the main aim of all current emergency physicians in Malaysia, is to ensure that we produce many many more; good Emergency Physicians that we can rely on, and can hand over the reins of Emergency Medicine in the country. Our role may not be to shape EM in Malaysia, but maybe to produce the generation that will do so.

A day with Stanford Life Flight

Stanford Life Flight is a 24-hour helicopter emergency patient transfer program run by Stanford. It is staffed 24 hours by a 2 specialized flight nurse team flying with one pilot using the EC 145 chopper, that can seat 5 persons and 1 patient. It mainly takes inter-hospital transfers primarily from outside hospitals to Stanford ICUs; and also responds to emergency 911 situations where there are requests for helicopter transfers from paramedics on site. I spent a day with them; they were really really good.

Just missing the dark glasses, or else I could have passed off as Tom Cruise after his F-14 TomCat days !!!

The helicopter was high tech, man with all the twinkles and toots. In fact, it costs more than the average small commercial plane !

It was back-loaded and was capable of on-board, in-the-air monitoring and interventions.

We flew over Stanford campus, reputably the most beautiful campus in the US. The heli was remarkably steady, that allowed nice photos to be taken. [contrast with the ambulance photos taken later in the day]

View of downtown Palo Alto from above Stanford Campus. We flew over hills and valleys and forests.

And over rich men's homes [note the swimming pools in every home. I tell you, in this weather, those pools can only be used at most 3 - 4 months a year. Unless they are heated. Wow, that would really really be a sign of being filthy rich]. We flew over the fog and clouds ...

... and to the Pacific Coast

... where the waves looked very much like Tsunami waves from high up !!

But it really wasn't about the helicopter itself, or the great views. It was about the people on-board, who were highly trained and really good at what they do. The Stanford Life Flight Nurses were really impressive in the air,

... and on the ground [this picture was taken inside the Monterey County Ambulance Service on the way to hospital for a pickup]. But the guy who really stole the day, for me,

... was Andy, the Paed Resp Therapist, who is just about the best I've ever seen.

A great sunset to end a fulfilling day.

What were the defining moments in Emergency Medicine in the US ?

Emergency Medicine in the US is really different.

Firstly, their training system is different. They do a basic 3-year undergraduate degree (some call it Pre-Medicine; Stanford discourages this, I'm told) followed by a 4-year medical school program. At the end of their medical school, they start applying immediately for residency programs. Emergency Medicine has more than 120 programs all over the country, most of them 3 year residency programs, producing about 1200 Emergency Physicians yearly. It is only at the end of their residency programs, that they can actually work independently, and be called Attending Physicians. Not before that. In other programs, eg. Internal Medicine or General Surgery, you actually have to do even more years of added training before being certified as nephrologists, cardiologists or neurosurgeons.

Many Emergency Physicians proceed to do an added year or two in Fellowships, esp if they are interested in academia; there are quite many of these fellowships offered, mostly program specific. At the moment, there are only three ACGME accredited fellowships available for Emergency Medicine ie Paediatric Emergency Medicine, Toxicology and the newly approved Critical Care.

Then they work differently as well. Huge effort to save time in Trauma cases, STEMI, Stroke, Codes etc; but then huge amount of time taken to "work-up" patients completely in the ED before disposition. An elderly person coming in with dizziness can expect to have a CT Angio or MRI before any decision is made; and if it is negative, very often these patients are sent home. So patients presenting with worrying symptoms, often get seen by large numbers of staff, then spend hours and hours for all kinds of investigations, and finally actually go home. That is very different.

How did this happen ? Why did this happen ? What were the defining moments in Emergency Medicine, as it developed in the US, that made it the way it is ? My thoughts, below.

"Pay for service system" - that's the US healthcare system in a nutshell. Just think of it like Malaysia, with all private hospitals. Clinics charge even more than hospitals. Government hospitals only for Veterans (VA Hospitals). There are government owned hospitals, but they function very much like private ones too. In this environment, Emergency Medicine had to prove its ability to earn a revenue for the hospital; and to reduce costs. It did this very well, because good EDs attract more patients, and the more complicated they were, the more lucrative too. EDs also did very well to save money. It is expensive to admit to the hospital; it is very much more cost effective to investigate from the ED, get a clear diagnosis, and admit for fewer days. After all, any admission more than 3 - 4 days in a normal ward would probably not be financially good. Observation, Clinical Decision Units, Admission wards allowed EDs to admit to short stay wards, investigate, treat and charge the patient. Generally, it was good for the patient [they got good care], it was good for the hospitals [they made good money], it was good for the EDs [they got to do what they wanted to].

"Insurance Industry" - this is how everything was paid for. Medical Insurance, often paid for as part of worker benefits, or social benefits for the poor and elderly. Not good for the poor, unemployed, immigrants, children and illegal aliens. [herein the problem, recently these groups have swollen to more than 15% of the total population]. So, the insurance industry wanted to reduce their costs, and needed fewer admissions to hospitals, ICUs. Fewer complications from delays that would extend length of stay, worsen outcomes and probably result in long-term disability, which they would have to pay for. So lots and lots of funding went into pre-hospital care, safety and prevention of injuries, and the very effective emergency departments. Yeah, they realized very very very early on, that if you wanted to make a difference, place your money at the ED.

EMTALA - This is the law that governs the transfer of emergency care; it is essentially an anti-dumping law. Many years earlier, patients that couldn't pay and would not be profitable for the hospital were essentially dumped to other hospitals (usually government funded). Sound familiar ? This law prevents it, by leveraging hefty fines for such practices. This law says that the hospital [yes, the hospital; not the ED] is responsible for an appropriate medical screening examination, stabilization of an acute critical patient and the proper transfer of the patient. It made administrators place lots of emphasis on the ED, because any lapses in "appropriate medical screening examination", "stabilization" or "appropriate transfer" of patients would invite grave consequences. EMTALA made EDs, front and centre of major hospitals.

I think these were the defining moments for Emergency Medicine in the US. In Malaysia, we are not there yet. No EMTALA, no universal insurance coverage, and we get paid poorly for all the patients that we are not able to see. But, things are a-changing. In our near future, we will go through some of these "defining moments" as well, that will shape how Emergency Medicine is practiced in our country in the future.

The important thing is this: we must have a voice at these times, to make ourselves heard. To play a part in directing our field in the right direction, we must play a pivotal part. We must have a seat at the table. We must do right for our field, for our future colleagues, for Emergency Medicine in Malaysia.

It would be a disaster if Emergency Medicine is defined for us, by someone else. That, is not beyond reasonable possibility. Think about it. Actually, worry about it.

Disaster Drill ala Stanford

Today, Stanford Hospital and Clinics with Lucille Packard Children Hospital did their bi-annual hospital activation Disaster Drill. The scenario was an earthquake which damaged the hospital somewhat, and the ED a bit. So the command center was set-up outdoors with a tent and generated electrical supply. And the actual ED was not involved at all in the drill. Neither was the ambulance service.

This "Command Center" was located at the front part of the ED parking lot; inside was the Medical Incident Commander, Hospital Incident Command and all the directors of the Hospital Disaster Plan. Yup, open tent in the car park; somehow, I would not have thought that our Pengarah's would do this.


They have a prepared, pre-registered drill packs for each patient [registered as named Drill, Insect or Drill, Queen or something else]. All ready made in individual packs. Actually, they do this even in normal times, for trauma codes, STEMI codes etc.

Note the very interesting modification to the Triage card, which all have a unique ID number and a tear-away for contaminated patients. There are separate tags with the unique ID for evidence, patient's personal belongings and medical treatment card.

Triage was done at the ambulance bay in front of the ED. Staffed by one to two doctors, one charge nurse, one resource nurse and one ED triage nurse.


Treatment at the IMMEDIATE bay was done at the corridor outside the ED [which stays fully functional during the drill] and is supposed to function as a spill-over area for triaged immediate patients in real situations.

It was quite difficult to move around; and probably hampered movement quite a bit. They have LOTS of oxygen tanks and vital signs monitors, so apparently that's not a expected problem with managing critically ill patients in the corridor.


One interesting thing was this Bed Control which essentially sat at the intersection of most patient movement. They were in charge of finding beds in the hospital and keeping track of all patients. The staff assigned here are from Admitting [or Bilik Daftar Masuk]. Can you see the phone plug points already on the wall ?

As is all drills, there were last-minute briefings, and lots of confusion.

And the Boss himself, briefed the frontline guys and gals.

Many things are quite familiar to us; young doctors who never bothered to get prepared, complained loudly. Surgeons and Anaesthetists either came late and scowled or never showed their faces at all. A few consultants dropped by to try to "get out of it" citing various excuses. Nobody knew when the drill was over. The phones and radios did not work [hmmm ..... ours actually worked quite well]. And the best people talked little but did the important things.

Many things were different. The hospital admin was there, full force. The transfusion team were active; coordinating all emergency transfusions. Their drill evaluator was not checking for performance or mistakes made; instead he was identifying areas where staffing was inadequate. And media was welcomed as part of disaster response, instead of our traditional "shoo-shoo" or sullen "no comment" "ask-the-pengarah" method.

On the whole, for a disaster drill with 20 patients, and probably 100 activated personnel, it went quite well.

Haloween on the move

Haloween, 31st Oct, is about pumpkins, dressing up in costumes usually themed with something scary, and "trick-and-treating" for candy. It is a big deal over here, and many families spend a great deal of money, time and effort to play the part and enjoy the day. What we couldn't figure out, and it seems nobody else knew it either, was how it was all connected. What made Haloween what it is. But nobody really cared. It was about fun, and catering to the kids, including the kid in everyone. We spent Haloween on the move, thanks to the kindness of LY.


It was absolutely beautiful, the windy, beach-hugging road, blue skies [interspersed with some areas with occasional fog] and beach after beach after beach.


Forget swimming, though. Apparently, you'll start going into hypothermia within a minute!


We visited the Pacific coast of the Bay Area which offered great views, very nice small towns [the types that you just want to retire to] like Pacifica and Half Moon Bay.


Rui Han had a great time at a pumpkin farm where she sat on the toot-toot and jumped up and down the bouncy tent [she then proceeded to jump up and down the bed the next few days!]


We enjoyed American friendliness and hospitality.


We visited the Santa Cruz Beach Boardwalk, which is the oldest surviving fun-fare in the West Coast. Here, we had a nice sea-food meal on the wharf with a fantastic view and felt totally out of place because everybody was wearing a costume.
You know, it was a great day and a great drive. Roads that really screamed out for Harley Davidsons or a romantic Vespa ride.


And to top it off, we ended the day with a drive-by at the holy of holies for the geeks: Apple's campus at N De Anza Boulevard, Cupertino. Address: Apple, One Infinite Loop.


No Emergency Medicine at all. Whewwww !!!

28 days in the US

I've been here 28 days. It has been an eye-opener, a battery charging, waaa-and-ooomphhh experience. Whether it changes the way I practice medicine for the better, remains to be seen; but I certainly hope so. Whether what I learn and experience here can benefit more than just me, depends partly on you.

In my previous blog post, I asked "What do you want to know ? What can I help find out ? What questions do you want answered from here ?" I asked for your questions, that I will try to find out. So please ask away. There are 28 days left.

Living in the US is different. Different side of the road, light switches that are "upside-down", measurements in pounds, miles, farenheits, quarts, gallons; cars that stop for pedestrians and bicycles, chicken that is cheaper in parts than the whole chicken, beer that is cheaper than mineral water, weather that is colder in summer than winter, bicycles than can only brake by cycling backwards !

Living in the US is different. Most people are very friendly; they all seem to be able to "speak" very well, having lively conversations easily whilst people like me remain tongue-tied in the corner. They speak their mind, we mince our words; they encourage open discussion and differing views; we get upset when not everyone agrees with us. They treat others as they would want to be treated themselves. We say that, but seldom do it.

US TV is surprisingly different. Lots of channels; but honestly, no sex, no gory violence, no foul language. Advertising seems to take over everything; off peaks hours are filled with TV shopping, all shows are interrupted frequently with ads (from every drug imaginable, to lawyers advertising to sue anyone). Not at all what we imagined from the US that we see on TV.

Living in the US is different. Neighbourhoods change drastically, sometimes just by walking down a single road. There is a vast spectrum of people here; from the rich and comfortable; to the middle class and struggling, to the surprisingly large number of homeless people and people begging on the streets. There are people here who don't speak English [Spanish is an accepted 2nd language; so everything must be bi-lingual]. I have heard English spoken with so many accents that I have given up trying to figure out where the person is from. Most people here, are just not from here.

Maybe that is just California. But there is probably some resistance. There are many ads on TV advocating against more immigration; with all kinds of excuses from more crime and gangs, to immigrants causing more greenhouse emissions ! But one thing lovely about being here. Nobody, just bloody nobody, have asked if I'm Chinese or my colleague is Malay. Or it I'm Christian or Buddhist or Muslim. It doesn't matter. I am just simply, from Malaysia, and Malaysian.

This, we must learn, from the US. Being different, being diverse, being your own person in your country is cherished. And treasured. This we must learn from the US. This, the world must know, is still what the US stands for.

Questions, questions that I cannot answer ... yet

I have been quiet recently ... and have rightfully received quite a lot of stick from some of you. Yeah I do need a kick in the bottom sometimes [rarely, okay?]. In the last week, we have been in SF for an EM conference organized by UCSF. Americans are very serious about their conferences; they take lots of trouble to ensure that it makes a difference to the practice of medicine. Lots of tough questions from the audience, full packed sessions from 8 am to 6 pm, and nobody paying any attention to whether the food was good or not. Best of all, not a single industry vendor in sight. Not only totally independent of vendor support, but all speakers are obliged to declare any conflicts of interests. Very nice indeed.

My time here has been beset with questions; why is emergency medicine practiced this way in the US, why is its medicine so good and yet, so inaccessible to so many in the US, why so many resources are used when everyone agrees fewer may just be as good, and why the healthcare industry is by far, the largest single industry [the largest pharma, the largest insurance agencies, the largest single sector spending, the largest R&D costs] in the US ? Why is it that the healthcare system in the US is the best in the world, but it "needs to be fixed" ??

As an outside person, it seems odd to me that the central tenet of healthcare in the US is that everybody MUST be able to choose their doctors, their hospitals, their drugs and treatment, anytime they want. Add in to that, a fee-for-service, pay-for-investigations and drugs, almost all hospitals being managed as corporate entities [which means, money counts!], a seeming lack of primary health care, healthcare 'costs' were really profits for many many people. Everybody benefited, from providers, the administrators, industry fellows, insurance guys. Even lawyers were getting into healthcare, and making good money from it! Until it all ballooned out of hand, and the best medical care in the world became out of reach to millions of Americans.

Make no mistake, they really do have the best medicine in the world. The best drugs, the best investigations, arguably the best doctors, the best invasive procedures, the best of medical knowledge at your fingertips! At the ED, you could get almost everything; the medical student was discussing with the 1st year resident about starting a drug that I've never heard of!!!

How that best medicine in the world was used is questionable though. In history, medicine has always been doctor-centric ! The doctor decides, based on current knowledge, clinical experience and acumen, what was best for the patient. With good intent, solid principles, never swayed by other not-noble intents.

Recently, that decision-making is 'taken' out of the doctor's hands; by hospital protocols, by industry pressure, by fear of legal actions, by research needs, by 'evidence' suggesting otherwise, by other maybe not-too-noble causes. Worse, current research [and thus, evidence] if often funded by big drug companies who always want to concentrate of newer more expensive drugs. [eg. how many people have studied paracetamol recently?]

Medicine is on a slippery slope; we are buffeted all round by protocols, evidences, guidelines, audits, quality standards, outcome studies. We are often nudged toward doing more, using newer and more expensive, trying to prevent the inevitable, or trying to achieve some target that makes little sense. Medicine has been taken quite a detour from before.

How laa for medicine in the US ? And how laa for emergency medicine in Malaysia ?

So questions, questions that I really cannot answer ... yet. I do know this; in the US, there is too much money and too many people in healthcare. People who shouldn't be there, but like fish attracted to the seasonal plankton that attracts the invertebrates, that attract the shoals of fish, that attract the seals, dolphins, sharks, whales and men to the cold of the Artic; people in it for the money should leave it alone. In Malaysia, it is the opposite end of the spectrum; there is too little money and too few people in healthcare. The total opposite end of the spectrum. That's not right either. How we change this, is up to you.

I am here now, and I'll be here for just a while longer. My question to you guys is this; what do you want, what shall I bring back, what needs to be done and how do we do it. What can I do, in the few remaining weeks that I have here, that will make a difference, back home, in the longer term ?

That question, I want an answer to.

Knee Deep in Emergency Medicine

I love Emergency Medicine. Really really really. There is a certain swagger about Emergency guys (both genders included) which comes from being able to do what is needed when it is needed. It is about being confident working within a system that works, and knowing that you make a difference. This confident swagger doesn't come from arrogance (unlike surgeons .... heh heh) but from humility of knowing that God always has the last say; and sometimes we help in the saying.

Being here in the Stanford's ED over the past few days reminded me again of that swagger [that I must have lost a bit over the past few years, somehow] but it is good to see it back, immersed knee deep in it, as I am now. It's great to be back. Almost want to sing "....once I was lost, now I am found...."

Some really interesting cases. There was an incidental finding of an ascending aortic dissection which extended through the entire arch of aorta, the 3 branches brachiocephalic trunk, L common carotid and L subclavian artery. It was huge, and asymptomatic; and in OT within 3 hours.

There was a misdiagnosed STEMI which turned out to be an Atrial Flutter with 2:1 block that revealed itself when Adenosine was given [beautiful flutter waves!], a Wellen's syndrome, Status Epilepticus and so many investigations for fairly common-place ED presentations. But you know what, some interesting findings were detected.

I also learnt that when a young baby is screaming away, apart from the normal stuff, look carefully for corneal abrasions and hair tourniquet [babies that play with mummy's hair sometimes auto-tourniquet their small fingers].

I learnt that in elderly people, the most common cause of tachycardia is dehydration; and if they have fever, look carefully for urinary tract infection and pneumonias AND skin infections (eg decubitus ulcers). So everyone gets turned around to search for this.

Many things were great; some things were a bit difficult to understand [which usually means we don't quite understand the need to complicate matters, the way they do it] and the American healthcare system is hugely expensive and very bad for the uninsured.

To me, the one thing that we need to do is this. Yes, we need more people, and much more money. But what we need most, are Emergency Physicians, on the floor, going through almost every patient. That is the most important step. No buts about it.

Whatever it is, I am knee-deep in Emergency Medicine and LOVING it.

Day 9: A day with the 9-1-1 service

Spent the day with the 9-1-1 emergency ambulance service. Joined a full 12 hours shift with the ALS ambulance responding to 911 calls with the largest ambulance service provider in the US. Covering an entire county stretching about 1 hour drive end to end; mainly urban population. Learnt quite a bit and finally understood their system a whole lot more. They are well-trained, effective, expensive and very legally bound; and they are good.


Very interesting "system" that had developed in many counties in the US; mostly due to the oddities of history and traditon; and how it developed over the years into the current system that they have. Essentially most 911 called will be initially managed by the paramedics of the Fire Rescue service (who are essentially paid by the Govt). At the same time, the EMS ambulances will be activated (these are large private emergency ambulance companies, contracted by counties to perform this service), mainly for the task of transferring to hospitals and care on the way. So essentially, for almost every call, fire engines will be on site, ambulances on site, and all too often, the police are on site as well. And today, for many of the calls, it was very old ladies who were not too ill [by our standards, at least]. And there we were, about 10 people from Fire, EMS and Police, all in heavy boots, trampling in the old lady's house and dirtying her carpets. Not sure if all the cases today warranted hospital review, but everyone got the works. But, they are GOOD ! And they do make the patient better by the time they arrive at the hospital. Much easier work for the ED.


Today, we managed 7 runs in 12 hours [heh heh heh they managed, I watched, and tried not to get in the way] The first two were asthmas early in the morning [which I thought warranted at least some consideration for H1N1 infection; but nobody seemed to be worried about it]; this was followed later by a drunk fellow, two elderly women [both in their late-80's and 90's], one elderly man with [probably TIA] and an elderly lady with swollen feet.


It made me realize [again] that paramedics do a great job, if given the resources to do it, and the general direction to work together with the hospital and the patient. And it does help to have great ambulances that can just about allow one to do everything.

So here's to you, all paramedics in the world.

And to that special team of ambulance fellows that has a special place in my heart, go go go EMAS !!! The photos are for you.

Days 7 & 8: It has started ...

Back in Palo Alto (Spanish for "the tall tree"). This area used to belong to the Mexicans [heh heh heh now one of their major responsibilities is to prevent Mexicans from coming over] who sold it for a measly sum of money. Apparently they used to come up the Bay Area on the only road then called El Carmino Real (Spanish for "the long road") which goes all the way up to San Francisco. They do make long roads here; in Boston near where we stayed, the I-90 starts. It ends way on the other coast in Seattle, Washington.

Anyways, yesterday was D-1 at the Stanford University Medical Center Emergency Department. As expected, it was cramped, and congested, and busy. Not too bad with patients though; but definitely with equipment and supplies. Imagine this, 3 CT scans in Emergency Radiology, probably 7 - 8 Ultrasounds all over, more than 30 - 40 computers on wireless trolleys, boxes of supplies everywhere pre-packed and labelled ready for use for almost every imaginable presentation. It was impressive ! And they had people doing specific tasks; which they did well and effectively. Nurses did nursing tasks, technicians did their tasks. They had people to pack supplies and ensure that when it is needed, it was available. They had people to take blood (phlebotomists), people to do suturing, people to call patients to arrange their followup. It left doctors and nurses and physician assistants doing what they were supposed to, and did best.

Why is it that we have our doctors and nurses doing stuff that there were not trained to do, just because we do not employ any other type of workforce in the department ? We multi=tasked like crazy; I was trying to count the number of people doing stuff that I would do in my normal job; and gave up. Crazy la.

Today, we are sitting with the ambulance service. Huh ? Why not sit with ambulances at home ? Hahaha. Their ambulances here are TRUCKS ! Everything is huge in them and about them. How do they get around the smaller roads, you ask ? They don't have smaller roads !!!

If anything, Days 7 & 8 showed me that this is a different world. We cannot import in toto; and I'm sure sometimes we cannot import at all. But there are lots to learn. Today I learnt that physical structure is the least important element in good care. Good people, effective systems and enough money is more important. At the moment, we are 0 out of 3. It truly has started ....

Days 5 & 6: Almost American

Yep, we are really getting into the groove .... this morning we were walking in the rain through the Boston financial district to the conference center, with Starbucks in our hands. In the evening, we were in the subway, looking cool as we made our way to MIT and Harvard. It has been burgers, fries, pies and chowdah on the menu. But, honestly I really really really miss my rice and noodles and vegetables. Hhhhhhh. Almost American, but not quite.

America, 6 days old to me, has been a surprise. It has been impressive for their no-nonsense approach and very systematic work processes; it has been very pleasant for their willingness to help and friendliness; it has been comforting for their diversity in cultures, and the American language spoken in so many accents from so many countries. It has been refreshing by their unique ability to be so different in so many ways, even though they are in such a similar environment. It has also been sad because there are really many many many homeless people on the streets. In Malaysia, the homeless then to be fairly youngish drug addicts (am I right ?) but here, the homeless are all old. And living on the streets in especially bad in cold wet weather.

The conference has been an example of efficiency; every lecture was started in time; and even more importantly, ended in time. It was interactive; the open discussion were great; and meticulous effort went into providing information that was pertinent and useful for the practice of emergency medicine. The technology support was great, the multimedia was flawless and the information provided was relevant and frequently updated. Really worth the USD 475 each that we paid [we were lucky cos we were considered representatives of developing countries; or else would have had to pay USD 915 each]. And as we stood outside the conference center to leave, we flagged down a bus. The driver promptly stopped, open the door and told us very politely that we were at the right stop, but had flagged down the wrong bus, cos that particular one was on special charter only. Gosh, made us wonder why this would never have happened back home.

If anything, I probably only have 2 wishes. One, maybe fewer choices is good. The types of coffee, and things that you can add to it; the foods on the menu and the condiments that come with it; almost everything came with multiple choices. And it is DIFFICULT to make choices. Even the conference was about choices; how to decide which session to attend, of the 10 that are simultaneously going on ? You know, it is like going to the nasi campur place, that has 40 dishes on display, and you can only pick 3. How to decide la ?

My second wish is really to walk faster. Boy, they walk fast. We have been overtaken by just about everybody on the walkway; old and young, male and female. We saunter along doing an Adagio and they whish past on Allegro; we go up slightly to Andante and get whished again by a few others going Presto. I do think we walk too slowly. And I remember my professor KJ in University who said in his first speech in the first semester, that emergency people must walk faster. The innate energy that comes with walking faster is important for people who work in emergencies. And you know, he was right.

Day 4: ACEP Scientific Meeting D1

Wow! What a meeting. I've never seen so many Emergency Physicians in one place before. There were thousands. Very refreshing to know that there are so many; so energetic and so young and interested. It bodes well for the field, in the US, internationally and in Malaysia.

Started off with the CPC (clinico-pathological conference) competition; something like our hospital CPC; except that the resident from one hospital will present a real case; with all findings but not provide the diagnosis nor the investigation that clinched the diagnosis. And the faculty (EP) from another university hospital, will try to deduce the diagnosis and findings by going through the differential diagnosis extensively. Waaa excellent discussions and excellent deducing. And when the faculty EP gets it right, it is greeted with roars of approval from their "supporters". It was excellent. Of course, sometimes it was wrong. But even then, it was very well argued.

Amongst the cases discussed today was the case of altered mental status, haemodynamic instability, hypothermia, hypokalemia, bradycardia and myoclonus which turned out to be a myxoedema coma. The learning point, I think, was that myxoedema coma is often missed and often presents with features of its precipitating disease as well; which in this case was the precipitating hypoglycaemia and pituitary insufficiency. Excellent argument la. Waaaayyy beyond what I can do. Hhhhhhhh. Other cases included a post-trauma with 'seizures', shock and breathlessness which finally turned out to be anaphylaxis to some food toxin. Or it the faculty was right, it should have been the Takotsubo cardiomyopathy. The third was well argued and amazingly well thought out where a lady undergoing the 48 hour protocol for 2nd trimester abortion, suddenly developed paralysis and could not breathe with hyperkalemia. Was finally attributed correctly to an incorrect dose administration of digoxin!

Later in the day, I sat through the most excellent lecture of ECGs I've ever seen. It was fantastic. I'd blogged on the topic of why we take ECGs for patients presenting with syncope before, (here and here) but the lecturer was in a class of his own. Imagine that, the lecture hall was full (probably at least 400 people inside; every sitting and standing at the back, sides and corridors).

They are good. Really good.

Days 2 & 3: Jet-lagged in the Land of the Free

Wow! Jet lag doesn't get you the first day you land; maybe it is due to all that adrenaline and excitement. But yesterday afternoon, we were snoring away. Just couldn't stay awake even though we had made plans for the Stanford vs UCLA game (heh, heh, heh absorbing the American life man !) Was wondering why, but then calculated that it was about 4 am Malaysian time. Woke up when it was dark; and would you believe it, watched the Under 14 girls and boys play football (soccer) on the beautiful artificial turf at the community soccer pitch, under lights. They were good and dedicated, considering it was less than 15 C and the wind was blowing (Brrrrrrr!!)

Today, got up early for the 5 hour flight to Boston; coast to coast travel. Wow, the US is BIG. Flight on United Airlines was full, and was very much like AirAsia. And now, we are at the Onyx hotel; tomorrow planning to walk the 1.7 miles to the Boston Convention Center for the first day of the ACEP scientific meeting. Now the work starts.

You know, America is the land of the free. You feel as it you have choices in everything, and can express your opinion anytime anywhere. They definitely do talk very well, communicate very smoothly and are very friendly conversation wise. Somehow, we Malaysians haven't really developed that skill; the ability to converse, to move via casual conversation from unacquainted to being friends. We haven't learnt that everyone should be respected, regardless of the views, background or the way he or she says it. In that sense, we are not yet free.

Day 1: Hello, Steve, you there ??

Today was about letting roots set into ground. We went to the bank, we settled our lease. We looked around the Stanford campus; which apparently is the 2nd largest university campus in the world [behind, would you believe it, Moscow !!!] Drove around our new rental neighbourhood; turn two corners and came up to the house of a certain fellow called Steve, who made a program better than that of Bill's and would almost, almost almost by the smallest of whiskers, have made the world a very different place. You know, he almost almost almost invited us in too.


We then took our very old borrowed bicycles and cycled up and down California Ave; home of Schering Plough, the Stanford Human Genome Project, and that small outfit that didn't know how to make money, called Facebook.


And after we had absorbed all that "geek-i-ness", we did the tourist thing and took photos. This is what we looked like. The better looking one is me !

Talk about being out of sorts ....

Day Zero: The Longest Day

1st Oct started in Penang, with last minute packing and midnight teh-tarik (yep .... I'm the typical Malaysian and there's some place for teh tarik in me, regardless of time or lack of it). I had about an hour of sleep, before getting up at 4:30 am to prepare to leave. First flight PEN - KUL 0645 hours. Got to KLIA very groggy, and trying to keep eyes open. Short wait there and it was the next flight KUL - TPE. Which is where I am now.

Have been here for 6 hours already waiting for my transit flight to San Francisco; and have another 3 hours to go still. After this, another 11 hour flight TPE - SFO arriving past 7 pm still on the 1st Oct. By the time the 1st of Oct ends for me in San Francisco, it would have lasted an unbelievable 36 hours !!

The MAS portion of the flight so far (PEN - KUL - TPE) has been on the business class. Now, I don't normally travel business class; in fact, this is probably my 3rd time. Never really paid for it myself. Not within my affordability range. MAS business class is really nice; they do take the trouble to do it well. And some areas where not done too well.

Since I had so much time, I thought of a few ways to have the "business class" experience; even though you and me are stuck in economy class. Firstly, one of the cute things they do in business class is hand out warm and cold towels about 3 - 4 times per trip; I guess so that you don't appear disheveled and smelly when you emerge from the plane. Another thing is that they serve you your meals in turn ie everything comes according to sequence. Dunno why our sequence today was off cos deserts came first. But anyways, it is nice, instead of the normal everything in one tray. And thirdly, lots of smiling people. And definitely much more space.

So, to recreate the business class experience in economy, my silly suggestions are as follows. [see how the mind wonders when it has too much time; and too little sleep]

• Bring wet tissues; cheap version of towels; equally effective.
• Smile at everyone; and introduce yourself to your neighbours when in economy class; almost guarantees extra smiles in economy class
• Sit at the back of the plane; safer and often less congested, so you may actually get more seats to yourself.
• Eat your meal in turn; pretend laaa

Try it