Anaphylactic SHOCK !!!

Anaphylaxis; the term comes from the Greek words ανα ana (against) and φύλαξις phylaxis (protection), indicating that something has gone wrong with the protective mechanism of the body. Instead of protecting the body, in anaphylaxis, overactivity of one component of the immune system may actually cause death.

You would remember that IgE-bound mast cells containing histamine are found in the respiratory and gastrointestinal system; mainly as a protection against foreign particles and organisms. When exposed to these foreign particles, the release of histamine causes local increased blood flow, better inflammatory response and on the whole, the foreign particle is rapidly brought under control.

But in anaphylaxis, the abnormal overactivity, or a Type I hypersensitivity reaction causes excessive amounts of histamine to be released; totally inappropriate and out-of-proportion to the initial trigger, which can be very small (eg. single bee sting, small quantities of specific foods, or even some drugs in small test quantities). This histamine, in large amounts, causes all the effects of anaphylactic shock ie profound hypotension due to the widespread vasodilatation, severe ventilatory compromise due to the severe bronchospasm and mucosal oedema, and severe shock from the combination of the above.

Early treatment is vital, and is targeted at reversing the adverse effects of histamine. Interestingly, Adrenaline is the physiological antagonist of histamine ie they do not compete for the same receptors, but their effects are diagrammatically opposite. Histamine, vasodilatation, bronchocontricton. Adrenaline, vasoconstriction, bronchodilatation. Seems quite simple, give la Adrenaline.

But woaaahhhh hold on there bro. Adrenaline, in the wrong hands, can kill the patient. Adrenaline, given too much and too fast, increases the risk of stroke, myocardial infarction and especially life-threatening cardiac arrhythmias. So, it is not something to be taken lightly, nor administered without some serious consideration. For years, these has been an on-going argument within the medical fraternity about how adrenaline was to be given, whether subcutaneously, intra-muscularly or intra-venously. I think recent research have still failed to come up with strong evidence either way, so existing recommendations must stand.

The preferred way of administering Adrenaline in patients with life-threatening anaphylactic shock is to give intramuscular adrenaline (dose undiluted) according to the table shown below. In an adult, use 0.5 mg or 0.5 mls undiluted adrenaline, via a 20 - 22 G needle long enough to reach the muscle layer of the thigh. This can be repeated after 5 mins if the response is inadequate. This is done after the initial steps are taken, as shown below.


IV adrenaline should only be used by experienced doctors, or when profound shock occurs. Here 1 mg Adrenaline is diluted to 10 mls and given at 0.5 mls titrated doses with full cardiac monitoring. If the patient is in cardiac arrest, use the full 1 mg dose of Adrenaline, as in the guidelines.

It is also important to include the adjuvants ie the anti-histamines (which do not act against histamine already released) and the steroids (which reduce the entire inflammatory response both acutely and in the later phases).

Interestingly, all this is a return to what we had known for ages, that pre-packed adrenaline in syringes (Epi-Pen) administered intra-muscular early in anaphylaxis works well and is relatively safe. Funny that we had to argue so much over what our patients had been trying to tell us, all these years.

Slipping through my fingers

Children grow up at a pace we cannot imagine; this is especially true when fathers look at their daughters growing up. For the first few years, you are the center of their life, the fun and the spoiling .... and they are the center of yours but all too soon they grow up; first a bit and start ordering you around, then they start thinking you are a bit silly, good only for fun times or for things. Later, you are out of touch, to be ignored, placated or just someone to get exasperated over.

Soon, some joker comes along, and she is gone .....



This amazing piece from ABBA tells this; from the mothers point of view. The lyrics below.

Schoolbag in hand, she leaves home in the early morning
Waving goodbye with an absent-minded smile
I watch her go with a surge of that well-known sadness
And I have to sit down for a while
The feeling that I'm losing her forever
And without really entering her world
I'm glad whenever I can share her laughter
That funny little girl

Slipping through my fingers all the time
I try to capture every minute
The feeling in it
Slipping through my fingers all the time
Do I really see what's in her mind
Each time I think I'm close to knowing
She keeps on growing
Slipping through my fingers all the time

Sleep in our eyes, her and me at the breakfast table
Barely awake, I let precious time go by
Then when she's gone there's that odd melancholy feeling
And a sense of guilt I can't deny
What happened to the wonderful adventures
The places I had planned for us to go
(Slipping through my fingers all the time)
Well, some of that we did but most we didn't
And why I just don't know

Slipping through my fingers all the time
I try to capture every minute
The feeling in it
Slipping through my fingers all the time
Do I really see what's in her mind
Each time I think I'm close to knowing
She keeps on growing
Slipping through my fingers all the time

Sometimes I wish that I could freeze the picture
And save it from the funny tricks of time
Slipping through my fingers

Slipping through my fingers all the time

Schoolbag in hand she leaves home in the early morning
Waving goodbye with an absent-minded smile


I'm holding on tight for now .....

War Games

"War Games" was a movie in 1983 with Matthew Broderick and Ally Sheedy [she was cute!] about a huge computer program WOPR that played games in simulated nuclear war, trying to find out how to win. Boy, it was a great movie, and released at the beginning of the personal computer revolution, it really moved this 15 year old.

Those were days so long ago, belonging to a different time. But the thought of War Games came to mind recently, when I was looking at our H1N1 pandemic, and how we handled it. In Malaysia, and worldwide. In a sense, I think God was really very kind with this pandemic, and maybe He was trying to tell us something.

You see, the H1N1 virus spreads very rapidly, like any human flu virus, very much as feared; but it doesn't kill. It is no more deadly than any of the flu strains that we get every year. So, if anything, it is the ideal way to test our system, to drill, to see if we can really manage the surge capacity of a flu pandemic. It is the ideal War Game.

So, we should look at our "achievements" to date, almost 100,000 cases worldwide; more than 400 in Malaysia already. To see how we have done. We have 91 confirmed positives in quarantine, mostly as cohorts [single isolation rooms are now used to isolate patients under investigation (ie not confirmed positives) who are sick and require admission]. Patients under investigation (contacts with confirmed H1N1 cases or persons who have traveled countries with confirmed local spread and meet the screening criteria) are now throat-swabbed, given anti-virals and home-quarantined; waiting for their results in 24-48 hours. If positive, they are admitted to hospital, given 3 days of drugs and discharged after. Doing this was the only way of preventing congestion at the hospitals, which are already breaking at their seams, as it is. And even by using this abbreviated protocol, we are still unable to maintain it. Soon, we will be in mitigation ie nobody gets admitted, everybody to self quarantine at home; probably anti-virals only for at higher risk group.

But imagine what if it was different. Imagine what if the virus was a deadly one; killing 10 - 20% of the people infected. It would automatically mean that the strategy would have had to be different. Patients who were screened and likely to be infected, could not have been discharged, like now. Contacts would have to be chased down, instead of phone calls and press releases telling them to go to hospital. Our work of screening would have been increased manifold. The health services would not have been able to cope. No way. Not in Malaysia, not worldwide.

But all the effort, all the work was really not wasted. It was an excellent way of testing the system; seeing what we could do, and where we needed additional resources. It was an excellent way of letting us know what's important, effective and worked; versus misplaced myths that wasted resources.

Important, effective and things that worked - telephone hotlines providing information and decisions manned by clinicians, not administrators; screening rapid tests because the time period between test and result is the most difficult period in deciding where to place the patient; public announcements and current developments updates by one single source; flexibility and responsiveness to changing situations, and the ability to communicate these changes to the public; and the believe in the effectiveness of our personal protective equipments.

Misplaced myths that probably wasted resources - airport screening at point of entry [probably better to do it at point of exit], contact tracing of airplane contacts, and probably the "over-use" of PPE [double layer everything, N95 etc] especially by every healthcare provider with an unreasonable fear of infection.

To me, as I had pointed out before in previous posts, my greatest worry is still Indonesia. There are now more confirmed H1N1 cases from Indonesia, diagnosed in other countries, than in Indonesia itself. It doesn't take a genius to infer that the Indonesians are NOT screening for H1N1, and that they have signficant numbers infected and undiagnosed in Indonesia itself. No screening, no diagnosis, no patients la. So, one country left out, can equally impact others around it, especially its neighbours.

Are we out of the woods yet ? No way, there is still a long way to go. Sooner or later, we will have our first death; or infection of a healthcare provider. For the healthcare profession, this pandemic, like SARS, was significant in that, we always thought disease was to be treated. We now have to think that disease may infect and kill us first, even before we have a chance to treat it. This would demand many changes in the way we do things, and after all that, there may still be no clear solution.

As in the War Games movie, there may be no winners, and the only way to win, is not to play the game at all.

Anyone with a job for an over-the-hill doctor ? Heh heh heh .....

A good cat is one that catches rats

I work with lots and lots of people. Many of them are very good at what they do. When there is real work to do, these are people you can count on, to get things done. If some junior staff are out of their league, these are the fellows to save the day. When the rice turns to porridge, these are the ones who will make a nice meal of it regardless.

And in my line of work, these fellows are important. In resuscitation of patients, their ability saves lives. In the emergency ambulance services, these guys give the patient the best chance of survival. In a disaster situation, they are the ones who will make things work, when all else is chaos. These fellows are important.

But you know, there are a few odd things about these fellows; and I guess "a few odd things" applies to most of us who work in this field, myself included. We work in an odd environment, and I suppose some of that 'odd-ness' rubs off quite a bit.

Sure, our work environment is odd; things are never fully expected, situations never remain the same, and everything is think-and-do as you go. It is, for want of a better phrase, continuous "breaking news". A normal day could mean relatively nothing happening, or it could mean patients coming in the door non-stop each clamouring for your attention. It could mean saving a life, or it could mean Death would have his way.

So, how do most people who work here cope with this ? Is this why they are a bit odd ? Is this why I am a bit odd ?

One of the most common defining factors is probably the passion for it. That fire in the belly, gleam in the eye, growl in the throat thing. That's a good thing. But it also means that we often have a tendency to fight our cause, to argue our case, to be a bit anti- whoever doesn't share our view.

All that multi-tasking in our work probably also leads to rather gruff, get straight to the point, direct type of communications; to some, it may seem rather rude. Often having to manage more than 10 patients at a go, we have also been regularly been accused as being 'distracted'.

Another is probably the need to destress. This happens especially when there are no patients that need to be treated then. The lull before the storm. Destressing maybe done in many ways; some talk, some eat, some surf the internet, other sit around and chit-chat freely. Most do nothing and tend to look as if they are lazing around.

My take is this. Most of the people that I work with, really do their work well. Really really well. So, to me, they are good; and I am willing to accept some of their oddness. After all, nobody is perfect. Everybody is odd, somehow.

But nowadays, we always get bashed for the other thing. Rude, get bashed. Not communicating, get bashed. Work non stop but non smiling, get bashed. People bash us for appearing to laze around, for eating and talking. They want the smiling, holding your hands, explaining rights-lefts-and-centers, look you in the eye type of attention, which they see on TV and maybe get in smaller private hospitals. Aiyahhh. If one of our doctors see 10 patients in a day [which is the standard in other countries, sure we can hold your hand.] But our doctors see 25 - 35 patients in a normal day, upto to 50 in a bad day. How la ?

My question always is this. What do we want ? An ugly old grouchy cat, that costs nothing, but catches rats; or the pretty pure-bred that costs you a bomb to maintain, licks its fur all day long, makes you happy when it allows you to pet it for 15 seconds, and probably runs away from rats ?

If you say, you want the pretty cat that catches the rat, you really must be living in wonderland !

It's not BAD, it's just CRAP !

Let's really really look at the H1N1 flu objectively. This, we can do quite well; after all, it has been more than 3 months since it all started; with almost 60,000 lab confirmed cases [and God only knows how many more have slipped through] with 263 deaths worldwide.

Objectively, this does not seem to be a disease as bad as we originally feared. It is definitely not SARS. It doesn't cause severe illness [we hear accounts of children running around the quarantine wards; and adults spending their time playing computer games comfortably whilst healthcare workers fret about them covered in layers of protective gear] and it doesn't seem to be very deadly either [at the current mortality rate, it doesn't seem any worse than any other seasonal flu that occurs each year]. This, we can now say, after 3 months and almost 60,000 cases worldwide.

So, why all the hoo-haa ? Is it really really worth it ? Or the more important question, are we using our resources too early, and for the wrong pandemic ? To understand this, we must understand the normal seasonal influenza.

Influenza strikes yearly; it is highly infectious, not very deadly and strikes with most vigour during the winter months, and usually subsides by summer. Every year a new or new-ish strain appears, and the extent of spread depends very much on how "new" this strain is. Very new strain (antigenic shifts) means many people will get sick, less new strain (antigenic drifts) means fewer people will get sick. We have known this for aeons, sometimes the flu season will be particularly bad, other times it will be mild. But whatever it is, Influenza will be there, each season, every year. The seasonal influenza also kills very few every year; mainly the very old with many other diseases concurrently (co-morbidities) or the very young and susceptible. In short, it sweeps through, it makes quite a few sick, but most people will survive without any problems.

So how does the H1N1 compare with normal seasonal influenza ? Well, it is definitely new and few people will have any kind of resistance to it. So many will get sick. And we also know now that most of them will have a very mild disease; and most of them will survive without any problems. Sounds not too different from the seasonal flu, does it?

So, it is logical to ask, it H1N1 behaves very much like the seasonal flu, why are we not managing it like the seasonal flu ? Why are we chasing people all over town, contact tracing them until the wee hours of the night, quarantining them in wards and causing distress and misery to many ? Why use so much resources, and stretch the capabilities of the health service so much, for something so not-deadly ? Why trace flight passengers, when after 60,000 patients, we really can say that there were very very few people who can be confirmed as having been infected in the plane ? Why continue to screen passengers at airports when it is now everywhere in the world ? Why make the cure, so much more terrible than the disease ?

In my previous posts I mentioned some key issues not addressed. The rational use of resources especially since this pandemic is not deadly, the spread of infection in Indonesia where avian influenza maintains its foothold and the long term engagement of the community so that we all understand what the government is doing and why it is doing so. Our resources are finite; if used up now, we will be at greater risk later if the situation ever gets worse. We must still worry about the 'doomsday' scenario and be ever watchful for it. But above all, we must let the community know and decide. This "talking down to the people" method of communications smacks of high-handedness and disconnection from reality. We have not been told that we must move from prevention of spread, to containment, and probably to the protection of the at-risk group when the situation worsens. We have not been told that if we are sick, stay at home. We have not learnt that good respiratory hygiene and etiquette is the most important step to prevent spread. We have not understood that it is illogical to catch every patient with the flu, and most developed countries have given even trying much much earlier. And after 3 months, people just don't know what they are supposed to know. If anything, we have failed this test.

Let's hope we don't fail the next ones.....

Whataday!!!

It has been a weird sort of day.

Spent the morning planning how to address this worsening H1N1 problem; how to protect staff, how to use the minimal resources that we have well, reducing wastage and maximizing impact; discussing how to manage if the number of patients increased exponentially, which is expected to happen. Discussing, planning how to manage this pandemic which is upon us. Then we spent the lunch hour putting most of the revised strategies into action; we did, we cajoled [and threatened, if that didn't work] and we acted. Quickly. It was quite good, working like that.

Then, just now, we were told of 4 persons who had come to the ED; "having been in contact with a H1N1 case!!". Naturally spring into action, for this could be local transmission, right ? And guess what we came up against ?? A group of 4 young adults who work in an office, all well and seemingly in very good spirits waiting in our screening area. And they said, I quote "someone from the office below them, who they have not met, but occasionally use their photostat machine, went to dunno which hospital for screening for H1N1 today". Dunno dunno dunno dunno was the answer to the next few questions I asked them including why did you come today; answer : dunno, scared of virus !

At that time, I also dunno ! Dunno whether to laugh or cry. Dunno whether to shout at them like my gut is telling me to do, or to admit them to the ward, to show them the 'pleasant' quarantine environment, like my evil half is screaming at me to do.

But I do know one thing .... we probably wasted 4 masks on them.

Afraid of the shadows .....

We are so fearful of the H1N1 influenza; or are we ? The health authorities are very worried, afraid of failing to identify infected persons, leading to a local cluster of infection and the repercussions resulting from that. Cannot sleep type of worried. Doctors are worried, especially those who have not armed themselves with the latest information or updates; fearing that their patient will pass it on to them. So they quickly try to "get rid of them". Healthcare workers are so worried, using all kinds of protective gear even when it is not needed; even though one of the main risks is the lack of these protective gear when things get really really bad. People with flu-like symptoms are fearful as well, of quarantine and being labeled as "infectious". So lots and lots of people are very fearful, sometimes too afraid of the shadows ..... whilst the ghosts surround them !!

What is probably more worrying is how this pandemic is spreading. Very very quickly is a good word. In many countries, they have given up trying to contain the spread, and are concentrating on sustaining their response in a effective way and protecting the more vulnerable population. Other countries will probably have to follow suit quite soon.

The main worrying factor is the lack of positive cases [or is it lack of reporting ???] from certain countries especially Indonesia, Pakistan and India. After all, pandemics and population go hand in hand; especially when the population is poor or weakened by strife and war. Indonesia reports NO cases, would you believe it. This is especially worrying considering that this country is probably endemic of avian influenza H5N1; and if you believe the pandemic doomsday scenarios, it is the very meeting of the swine/human and avian influenza that is most likely to cause the doomsday virus.

What is also worrying is the amount of resources (time, effort, money, protective gear, antivirals) that are being used now to manage this H1N1, which doesn't seem to kill very much. If it ever were to worsen, would our stocks run out faster ? Have we false-started ? It is definitely time to think and consider; to re-think our strategies, to look at how we want this to end.

But you know, all this fear is really not pervasive in the community. We still travel, where and when we want to. Even with a fever and symptoms, we only think about how we should take Panadol to avoid the thermal scanners at the airport, paying scant regard to the possibility of bringing home an infectious disease. We still tour [after all, money paid, cannot get refund what]. In the US, many still say "What flu?". In some countries, there are now reports of swine parties where people 'deliberately' try to get infected, thinking that it will give them immunity against the possible worse second wave. We still sniff away, rub our noses, spit everywhere, cough indiscriminately. We still go on. Don't know until when. Really really really wake UP !!!! Look at this list, and if it doesn't yet strike a bit of fear ....

These are NOT countries with infected patients; these are countries where the local transmission of infection is sustained, and most of them have had infections exported to other countries. See many countries with close links and direct flights to our land ? See some close neighbours ? Still not worried ? What is in hold for us all ?

Come to think about it, when does a pandemic really end ? Influenza is seasonal, often occurring in the colder months of the year. But with air travel so prevalent these days, the end of colder months in the northern hemisphere is the start of the colder months in the southern hemisphere. So the traditional end of the influenza may not end with the coming of summer. It probably just shifts south; and then north again in a few months time.

I see actually only two ways of it ending. Nope, it is not going to end like SARS, when control of the spread of infection coupled with the subsequent decrease in the ability of the virus to spread, led to the end of the epidemic. But this is different because it is far more widespread than SARS ever was, and it remains highly infectious, luckily still not too deadly. And it is not going to end with the summer months. So the way this ends is probably one of the following. One, when enough people get infected and develop the natural immunity to H1N1. Or two, the virus mutates into something much weaker, less infectious where the infection control measures that we can get everybody to do will work. Actually scenario two may also be the virus mutates into something much much stronger, and many many people die. We just don't know.

Not knowing is difficult. Too much fear equal paralysis and inappropriate response. Too little fear works out to apathy and heads in the sand. It is time for wisdom, and leadership. To make decisions based on available information and expert advice; then using common sense to make the next move. It is time to re-look the protocols wisely without fear; looking past the shadows, at the ghosts that still haunt.

QSL, 收到, Roger, Puriyethe, Mesej Diterima

I have been in such a mood recently. I guess much of it stemmed from seeing progress actually regress, from seeing one's work hijacked, from seeing narrow-mindedness in people who should be the very opposite. And maybe from questioning myself if I can actually go on, in this environment, and still make a difference.

But I have been humbled by your comments. And your message is received, loud and clear Q5. Keep to the Emergency Medicine topics ! So, QSL, 收到, Roger, Puriyethe, Mesej Diterima !

But I am still so much in an ANTI mood.

So what can I write about ??

















Ahhhh got it !

ANTI-histamines. Arguably the most common over-the-counter drug in use; unfortunately often wrongly used or even abused. Histamine has been recognized as a mediator of the allergic process since the 1920s; and anti-histamines have been in clinical use for more than 60 years. As our knowledge of receptors improved, we could identify 2 main histamine receptors ie the H1 receptors [which we will discuss further] and the H2 receptors which mediate acid production by the gastric parietal cells [we will leave this as a topic for another blog, when I'm in the ANTI mood again !}

Histamine is really a mediator of the protective response. It helps our body fight off foreign objects like bacteria, viruses, allergens (things that cause allergies eg pollen, dust) etc. Thus, it is found mainly in the areas where exposure to foreign or external objects are likely ie the upper respiratory tract, lungs, skin and gut. In the lungs, when exposed to allergens, histamine released will cause several effects depending on the area of exposure. In the upper respiratory tract and lungs, it causes irritation and sneezing [aimed at removing the allergen], watery eyes and running nose [aimed at diluting the effect of the allergen], some constriction of the air passages [to reduce further entry of allergens] and increased sensitivity overall [probably aimed at getting you out of the environment where there are lots of allergens]. In the skin, it causes pain and itchiness, redness and swelling (medical students will remember this as the typical red-wheal-flare reaction). All this brings more of the protective mediators in our blood to the affected site; thus protecting us. In the gut, it causes hyperactivity leading to increased movement of the possible allergen through the gut and out the other end ! So histamine is really a good fellow protecting us.

But unfortunately, too much of a good thing is also no good. During the spring / summer months, the high levels of pollen in the air cause distressing symptoms to many people [seasonal hay fever]; many persons working in dusty environments are inconvenienced by their responses to dust. Continual irritation and sneezing leads to a later development of mucosal oedema (our noses feel stuck); the continual discharge leads to running noses and teary eyes; and sometimes the severe bronchoconstriction may kill [as in anaphylactic shock]. The excessive skin reactions leads to a vicious cycle of itch-scratch-more itching, resulting in weeping skin lesions and infections. So, too much of the histamine reaction is no good.

Essentially, Histamine produces all those symptoms by combining with the H1 receptors; and if we could block these receptors with an anti-histamine drug, we could reduce those distressing symptoms. So, many many anti-histamines were developed. In fact, most of the first generation of antihistamines produced are still in use today. Drugs like promethazine (Phenargan), chlorpheniramine (Piriton), hydroxyzine (Atarax), diphenhydramine (Benadryl), dimenhydrinate (Dramamine) are really very very similar and are often referred to as the 1st generation anti-histamines. [so please don't prescribe more than one at a time la]


The first generations are effective for the early phase (itching, irritation, discharge) but really not effective for the late phase reactions (nasal congestion). That's why the antihistamines never work in clearing the stuck nose la. Also, the first generations often cause drowsiness. This is significant especially, in people who work with heavy machinery or drive public vehicles; so seriously, before prescribing 1st generation antihistamines, please ask about the patient's job. Nowadays, studies have also shown us that children prescribed 1st generation antihistamines do poorly in school; most likely due to impaired cognitive function and sedation. But seriously, do you really need to prescribe antihistamines in the first place for children ?


Second generation antihistamines eg. cetirizine (Zyrtec), loratadine (Clarityne) are non-sedative, more expensive and don't cause much learning impairment in children. Nowadays, the release of the 3rd generation (which are active precursors of the 2nd gen) bring interesting possibilities; because they have been shown to be effective in reducing the late phase reactions as well [ahhhh gone are the days of stuck noses ??]

Whatever said, antihistamines are really useful for allergies; NOT really useful in upper respiratory infections (URI). So, the normal cough, cold, fever, running nose and sore throat don't really improve with anti-histamines. None of them relieve any of the symptoms because URI symptoms are probably not histamine related. Maybe .... Benadryl has some effects with improving cough, but really not much else. So, anti-histamines really should not be frontline therapy for the common URIs. Especially for children. In fact most antihistamines are not recommended for children below 6 years. Considering the possible adverse effects of urinary retention, interstinal obstruction, angle closure glaucoma and asthma, these are really not drugs to be considered lightly regardless of age.

OK ??

So message received loud and clear. Some nice words in return ..... "Life is not just about waiting for the storms to pass; it is about learning to dance in the rain"

La Marioneta

If for a moment God would forget that I am a rag doll and give me a scrap of life, possibly I would not say everything that I think, but I would definitely think everything that I say.
I would value things not for how much they are worth but rather for what they mean.
I would sleep little, dream more. I know that for each minute that we close our eyes we lose sixty seconds of light.

I would walk when the others loiter; I would awaken when the others sleep.
I would listen when the others speak, and how I would enjoy a good chocolate ice cream.

If God would bestow on me a scrap of life, I would dress simply, I would throw myself flat under the sun, exposing not only my body but also my soul.
My God, if I had a heart, I would write my hatred on ice and wait for the sun to come out. With a dream of Van Gogh I would paint on the stars a poem by Benedetti, and a song by Serrat would be my serenade to the moon.

With my tears I would water the roses, to feel the pain of their thorns and the incarnated kiss of their petals… My God, if I only had a scrap of life…
I wouldn’t let a single day go by without saying to people I love, that I love them. I would convince each woman or man that they are my favourites and I would live in love with love.

I would prove to the men how mistaken they are in thinking that they no longer fall in love when they grow old–not knowing that they grow old when they stop falling in love. To a child I would give wings, but I would let him learn how to fly by himself. To the old I would teach that death comes not with old age but with forgetting. I have learned so much from you men….

I have learned that everybody wants to live at the top of the mountain without realizing that true happiness lies in the way we climb the slope.

I have learned that when a newborn first squeezes his father’s finger in his tiny fist, he has caught him forever.

I have learned that a man only has the right to look down on another man when it is to help him to stand up. I have learned so many things from you, but in the end most of it will be no use because when they put me inside that suitcase, unfortunately I will be dying.

"La Marioneta" was authored by a Mexican ventriloquist called Johnny Welch as a speech for his puppet. A beautiful piece to be read and re-read when life deals us difficult hands, when the way forward seems stuck in reverse, when the soul needs a beefing up. A lot to learn from this puppet.

INFLUENZAAAAAAA

Wow ! Pandemic Phase 6. In my mind, it meant deadly virus causing huge numbers of sick persons, shortages of staff, lack of anti-virals, personal protective equipment and resources, severe absentism from work and the morgue piling up. Boy, am I glad that it is not that ....... yet !

But this is the most important time for right information, right action and right reaction. First and foremost is how to protect yourself and your loved ones. Read the information on the internet about respiratory hygiene. This cannot be stressed often enough. Cover your nose and mouth when coughing, sneezing; especially if you are not feeling well. Wash your hands often. Influenza spreads by respiratory droplets and via fomites (ie droplets that land on things that you touch that you then spread to your nose and mouth and get infected).

For medical staff who work with patients who may have a fever, wear a mask [you should have been doing this from late-April !!] Wipe surfaces often, wash hands between every patient. Watch your respiratory hygiene.

And do you really really need to go to those countries now ??

The next bit is to determine if you have influenza or not [versus the most common mimics of this disease, allergies and upper respiratory infections] This table may be of help. [Please click to enlarge]


Finally, God help us all. Let us hope that this will not mutate into something worse; and let this bring out the best in us all.

Cheers

Hello ...... is anyone out there ?

It must be said, that blogging should be for one own self. But I am human after all; and my ego [which I have been trying to suppress] still wants to be fed. Aiyoh .... unfortunately nothing feeds the ego more than having comments in one's blog.

But really, this blog seems to have strayed recently; from Webnotes in Emergency Medicine, we have tackled social issues, political and leadership upheavals and even great music from a different time. Even vulgar jokes were included, my apologies. But I tell myself that this is understandable; we are never alone, we cannot stand as an island and we must always be many layered and varied.

If anything, this blog somehow morphed into a crusade, to get its few readers to speak up, to find a position where we can disagree with others and still maintain comfort and peace with yourself, to get involved. Maybe this crusade did not sit too well with you, and the comments [or lack of] showed it.

Quite amusing really, to look at the recent posts. Two posts on music, one post with a vulgar joke, one post about democracy in our country and one about the hoo-haa over housemanship. All with no comments. Zilch !

The really amusing thing is this ..... the last post that was commented on was the rant about "A Time Comes when Silence is Betrayal". The silence after that was deafening.

Cute !

Nessun Dorma "No One Shall Sleep"

Nessun dorma (English: No one shall sleep) is an aria from the final act of Puccini's opera Turandot, and is one of the best-known tenor arias in all opera. It is sung by Calaf, il principe ignoto (the unknown prince), who falls in love at first sight with the beautiful but cold Princess Turandot. However, any man who wishes to wed Turandot must first answer her three riddles. If he fails, he will be beheaded.

In the act before this aria, Calaf has correctly answered the three riddles put to all of Princess Turandot's prospective suitors. Nevertheless, she recoils at the thought of marriage to him. Calaf offers her another chance by challenging her to guess his name by dawn. (As he kneels before her, the Nessun dorma theme makes a first appearance, to his words, "Il mio nome non sai!") If she does so, she can execute him; but if she does not, she must marry him. The cruel and emotionally cold princess then decrees that none of her subjects are to sleep that night until his name is discovered. If they fail, all will be killed.

As the final act opens, it is now night. Calaf is alone in the moonlit palace gardens. In the distance, he hears Turandot's heralds proclaiming her command. His aria begins with an echo of their cry and a reflection on Princess Turandot:

"Nessun dorma! Nessun dorma! Tu pure, o Principessa, nella tua fredda stanza, guardi le stelle che tremano d'amore, e di speranza!"

(English translation: "None shall sleep! None shall sleep! Even you, O Princess, in your cold bedroom, watch the stars that tremble with love and with hope!")

"Ma il mio mistero è chiuso in me; il nome mio nessun saprà! No, No! Sulla tua bocca lo dirò quando la luce splenderà!"

("But my secret is hidden within me; none will know my name! No, no! On your mouth I will say it when the light shines!")

"Ed il mio bacio scioglierà il silenzio che ti fa mia!"

("And my kiss will dissolve the silence that makes you mine!")

Just before the climactic end of the aria, a chorus of women is heard singing in the distance:

"Il nome suo nessun saprà... E noi dovrem, ahimè, morir, morir!"

("No one will know his name... and we will have to, alas, die, die!")

Calaf, now certain of victory, sings:

"Dilegua, o notte! Tramontate, stelle! Tramontate, stelle! All'alba vincerò! Vincerò! Vincerò!"

("Vanish, o night! Set, stars! Set, stars! At daybreak I shall win! I shall win! I shall win!")



This video of Pavarotti at his peak, singing Nessun Dorma; one of the most famous tenor arias sung by one of the all-time most famous tenors. Enjoy.

Growing Old

When the songs that you used to listen to, had an "era"; mine was the 80's. This beautiful piece was from CHESS written by the ABBA geniuses, Bjorn and Benny. Performed by Elaine Paige and Barbara Dickson.

The Torture during Housemanship ?

There has been so much hoo-haa over this issue recently; especially in the press, parents of house-officers and medical students have been writing in complaining about the ill-treatment suffered, house-officers claiming that they have been treated without respect and made to work long inhumane hours, and just about everybody asking why house-officers cannot be treated better etc etc.

I just had to join in the fray; and maybe risk some adverse comments. But discussion is good; and therefore views from all sides is important, I guess. I write this openly, in my blog, expressing my views and my stand. I would love to hear many sides, and I respect everybody's right to disagree, but I do believe in making your point openly and standing up to review. So comments are very welcomed, hopefully not anonymous ones.

Let us first consider the original intentions of the housemanship program, then and today. Housemanship was always considered a bridge between the theory of medical schools with the reality of hospitals, the information gathering of medical schools to the real-life applications in hospitals, and between the protected world of a student to the life-in-your-hands responsibility of being a doctor. At the end of housemanship, the original impression was that the doctor could work safely and independantly. Those were the key words, safely meant knowing what you could do, and when you couldn't and needed to ask for help; independantly meant being on-call alone in the district hospital without on-site or on-call specialists. Yup, that was the situation then .....

In many developed countries, where many of our house-officers received their primary medical training, the situation has changed. There, due to their large number of doctors in hospitals, and large number of specialists available, notwithstanding the significant threat of medical litigation, registrar level doctors are always available; house-officers are accorded minimal responsibility and even medical officers do not often work alone. Senior registrars, clinical specialists and consultants take up the main responsibilities of the team.

In Malaysia however, new medical officers often find themselves assigned to peripheral hospitals the very next day after completing their housemanship; where they are soon placed on call, alone with minimal or no readily available back-up. They are thrown in the deep end, and must sink or swim on their own. Needless to say, a house-officer who is not yet competent to work safely or independantly, will sooner or later endanger a patient's life or adversely affect their clinical outcome. Hence the importance of training during housemanship, to achieve this ability to work safely and independantly. Therefore, it must be obvious that our house-officers must be that much better at the end of their housemanship compared to that same fellow is another more developed country.

What has happened in the medical education field must also be considered. For millenia, medical education has been an apprenticeship; one expert, a few apprentices. Medical students would follow the consultant around everywhere, with the rounds, in clinics, for tea (if nice consultant, tea is free) and they may actually wait patiently outside the loo when the consultant reliefs himself. They learnt so much more than medicine that way; they learnt the intricacies of history-taking, the reward of proper clinical examination, the analysis of information and the beauty that laid deep in the practice of medicine. Along the way, they learnt communication skills, and professionalism. [this had its bad points; a grouchy bad-tempered consultant always managed to produce grouchy bad-tempered followers - Darth Sidious always made a Darth Maul or a Darth Vader - and honestly there are a small handful of these consultants who definitely deserved some kind of "Darth" title before their name !]

But in recent years, with the growth in medical knowledge, the blooming of specialty and sub-specialty medicine, and the greater numbers of medical schools and students, the "apprenticeship" system have broken down. There were just too many students with too few consultants doing too many things. It became a touch-n-go medical training. Come, teach, show, growl a bit, and go. Medicine is now taught virtually, lectures may be given without the lecturer and at the end of the posting, consultants would not even know the names of their charges; much less their ability. Exams now told us if students were good enough, or not.

That unfortunately meant that medical students had no mentor, no si-fu. Who they copied from, who they mimicked, who they wanted to be was left much to chance. [If Dr House was the flavour of the day, God help us all!] Medical students were now mass-produced and graduating doctors were so much less prepared to be able to work safely and independantly. So, a lot of "pressure" was now being passed to the hospitals to complete the training of these doctors; housemanship was the final bastion. And answering that clarion, was the extension of housemanship to two years; all compulsory postings including Emergency Medicine.

The consultants in the hospitals took this very seriously; after all, doctors who were not good enough were liable to make mistakes that would harm patients; and the consultants would then have to solve the problems created. So, it was in the interest of consultants to try to prepare house-officers as well as they could. And I think, most consultants really did try. And are still trying. From their point of view, house-officers who are not good enough need more training, more exposure, more work. So the consultants want more on-calls, more ward rounds, more hours at work for house-officers. And if they are still not good enough, even more on-calls, more rounds, more hours at work. Until they become good enough; or they collapse trying; or the consultants finally give up or give in. This point of view is probably totally not wrong; after all, hard work never really hurt anybody. Against the option of allowing inadequately trained doctors on their own in district hospitals, and endangering patients, any reasonable person would say that extra doses of hard work, longer hours and more exposure is needed and necessary.

Maybe what we need to do more is to provide actual dedicated training, and rely less heavily on on-the-job training. More hours on CMEs, interactive sessions, quizzes, simulations and practice scenarios; so that knowledge gaps can be identified and corrected. Maybe merely longer hours could not do what we wanted, nor achieve what was needed. Longer hours yes, more days at work yes, but maybe if some part of it was dedicated training time, much of the dissatisfaction would disappear.

And what we really need to do is to dissect out the main complaints of house-officers. Main grouses include too much work, too long hours and weekends being spent at work. Interestingly, studies on workload ratios in the 90's compared to now show us that there are many many more house-officers per patient bed now and numbers of on-calls have also reduced markedly. And since we have established that hard work is needed and necessary to ensure safe and independant doctors, this grouse cannot really hold much water.

On the other hand, the other complaint about maltreatment and verbal abuse of house-officers must be addressed. Yes, there are consultants who are verbally abusive and downright unprofessional. This should really not be condoned in today's world; everybody deserves to be respected as a fellow man and a fellow professional. Unfortunately we are unprofessional to our fellow doctors at all levels, not merely at the house-officer level. This is a problem that must be addressed, and maybe this is the perfect time to look at it. After all, how to be courteous to our patients if we cannot even be courteous to our own collegues ?

I would look at it in two ways; one, all abuse is always a cyclical process. The abused often become the abuser, creating new generations of abusers. Tough consultants who are abusive to their charges probably went through a similar (or worse) harrowing experience ages ago. Maybe it is time to break the cycle; by consciously reviewing the situation, understanding it and letting it slide. After all, its only words and words are all I have .... Two, only those who care will actually bother to correct and teach. Tough consultants are often the best consultants, the ones who care the most. House-officers must learn to understand that sometimes what was perceived as verbal abuse, was actually a consultant scolding you, trying to teach you something. Here, some guidance can be sought from the Hippocratic Oath

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art. [cont'd] "

I think we are in a tough situation here. We have had suddenly large numbers of house-officers, of varying backgrounds, from universities all over the world. Generally, we would like them to be good, responsible and capable of working safely and independantly. The future of medicine in our country is in their hands; let it not be said that, those hands are weak for the lack of trying, or the avoidance of hard work.

Class Invariants By Abstract Interpretation

It has been quite a while; and the last few posts have been extra "heavy". So have been carrying quite a bit on the shoulders lately. Today was a good chance to share some fun.

Microsoft recently revealed a new product, based on some research paper titled Class Invariants By Abstract Interpretation. So, Microsoft, worldwide leader, ground-breaking innovators and almost God-like to the IT generation, decides to call name it by its initials ..... Cibai !!! Yup Microsoft Cibai !!

Apparently, on Twitter, it is already the top 3 trending topics and Cibai jokes are spreading like wildfire. Just a few to share with you all .....damn funny la.

"I've got so many friends who already own Cibai. You're not gonna make a profit, Microsoft!"

"Ayoh .... My Cibai got virus laa !"

"Damn Cibai is so complicated? Fear not, maybe they'll publish a manual: Tools and Shortcuts to Cibai !"

"I wonder if Microsoft's CIBAI is LAN-enabled?"

Sorry sorry to the offended ........ ROTFL !!!!

Whew !

Oh America !

"Four score and seven years ago our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.

Now we are engaged in a great civil war, testing whether that nation, or any nation so conceived and so dedicated, can long endure. We are met on a great battle-field of that war. We have come to dedicate a portion of that field, as a final resting place for those who here gave their lives that that nation might live. It is altogether fitting and proper that we should do this.

But, in a larger sense, we can not dedicate -- we can not consecrate -- we can not hallow -- this ground. The brave men, living and dead, who struggled here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us the living, rather, to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced. It is rather for us to be here dedicated to the great task remaining before us -- that from these honored dead we take increased devotion to that cause for which they gave the last full measure of devotion -- that we here highly resolve that these dead shall not have died in vain -- that this nation, under God, shall have a new birth of freedom -- and that government of the people, by the people, for the people, shall not perish from the earth."

Abraham Lincoln, Gettysburg, Pennsylvania. November 19, 1863


Ask anyone about DEMOCRACY and they will say ELECTIONS; the rights of the people to select their representatives; so that these representatives do right by them, represent their will or at least the will of the majority, for the betterment of all. Seems quite reasonable, right?

Some, better read, may comment about a government formed of the people, by the people and for the people. The recent crisis and inpasse forced us to read more and made us understand more about the concepts of democracy, the separation of powers, the check and balances and the main pillars that hold a democracy together.

Elections, it would seem, forms one of the main points about democracy; but surely not the only one. The recent reluctance to holding elections seems quite contrary to our contention that we are democratic, in any which way we would want to spin it.

But I think democracy is about how the country was formed; how the idea of us all living together in this common land came about. It is about how we agreed upon the basis of our existence. I think democracy is about our CONSTITUTION; the original document, the original agreements. Abe Lincoln said it well "...our fathers brought forth in this continent, a new nation, conceived in Liberty, and ...". It could almost have been our own forefathers saying the very same things.

We were a new nation, conceived in Liberty [what else does that mean, if not MERDEKA] and dedicated to the principles of democracy. We have a great constitution and a great effort to promoting that constitution [remember our Rukun Negara?] and all that it stood for. We were a new nation with great promise and a desire to be a respected nation of the world.

Somehow, we did not really get there, did we ? Along the line, our constitution got changed, many many times; altered; diluted; superceded; ignored. Along the line, our democracy of the people gave way to democracy of the politicians [what was in the interests of the politicians was primary, all else secondary], our government of the people gave way to democracy of the parties. [position in the party determined position in the government; parties' needs speaks louder than the people's needs] We ignored the rights, we avoided the check and balances, we demolished the separation of powers, and we forgot the people.

And where do we stand now ? Was it worth it ? Is this what we want, now, or for our kids ?

I think democracy only exists when we can agree to disagree. When my opinion, different from yours, will not result in anger, argument nor anguish. People come first, regardless. I think democracy only exists when we have the ability to question it, to ask questions of our leaders, to rightfully deserve a reply. I think democracy only exists when we have the common man in positions of government, not members of political parties. And I really really think democracy only exists when we have a smooth and responsible change of government.

Only then, will the main criteria of DEMOCRACY be tested and proved. Only then will it be a government of the people, by the people and for the people.

"A time comes when silence is betrayal"

"The truth of these words is beyond doubt but the mission to which they call us is a most difficult one. Even when pressed by the demands of inner truth, men do not easily assume the task of opposing their government's policy, especially in time of war. Nor does the human spirit move without great difficulty against all the apathy of conformist thought within one's own bosom and in the surrounding world. Moreover when the issues at hand seem as perplexed as they often do in the case of this dreadful conflict we are always on the verge of being mesmerized by uncertainty; but we must move on.

Some of us who have already begun to break the silence of the night have found that the calling to speak is often a vocation of agony, but we must speak. We must speak with all the humility that is appropriate to our limited vision, but we must speak."

Dr Martin Luther King, 4th April 1967

I really felt ill today; with anger, disbelief and disgust. And for some reason, I felt dirty. Unwashed, stained. For the first time in my life, I truly felt ashamed of this, my country.

Like everybody else, I moan and groan about how bad things are, how everything doesn't seem to work, how "boleh" is often understood as "boleh-laaaa"; but I love the country, for its beauty, its people, its ways. I was always willing to work toward a better tomorrow, serving my people, my community, my country; because it is home. Until today.

Today, a line was crossed. A line of hope. A line that meant despite all our weaknesses, there was a possibility of better things, of reason, of justice, of respect and of caring for your fellow countrymen; with scant regard for their beliefs, appearance or behaviour.

But today, I saw hope being trampled, reason swamped by self-interests, respect and justice just deserted this part of the world. And I saw the worst, when politics, greed and power threatened to overwhelm us all.

Many are unhappy, but many somehow seems too few. It seems so difficult; struggling to achieve such simple ideals seem far beyond us. What can we do? After all, if there was going to be a "Million Man March", many would not hesitate to join is, such in the level of unhappiness in most of us. But, a million man march hardly needs the millionth-and-one person. And there no million people marching along with you. It all ends up seemingly just too much for us. We just cannot make a difference, why even try ? We end up being struck with the apathy of conformist thought; and we try to go on, heads bowed, hoping against hope again.

But No! A line was crossed today. And it was my line. It was my last line. And I realized that a time comes when silence is betrayal. And that time has come for us.

Written on May 7th 2009 Black Thursday

Quarantine: "Why me?" in the H1N1 world

It is a different world we live in today; for many years, our range of antibiotics, medical understanding and improved treatment capabilities have meant that we were not really afraid of infections. We thought infections were just another differential diagnosis, another disease amongst many. We are sooo wrong.

We had forgotten the great plagues in history, where towns were deserted, entire generations were wiped out and where there were too few who lived to tell the tale of what happened. We had forgotten that steeped in our history were many accounts of collapse of entire civilizations due to infectious disease outbreaks. We had forgotten.

But like all other things that we forget, or ignore, it came back; and whacked us hard. SARS was a huge wake-up call; here was a novel virus (ie new, never seen before) exposed to a population that had no immunity toward it. So we had no immunity to the SARS virus, no test for SARS and no known treatment. And the first reports were of accounts of its highly infectious nature, and its high mortality rate. After all, in its initial phase, SARS killed more than 80% of its victims. And most of the initial victims were either family members or healthcare workers. We were soooo worried.

But we were lucky as well. For some reason, the SARS virus then became less virulent (less easy to spread; and less dangerous); measures like using masks, gloves, respiratory hygiene and isolation of cases started to become effective; and almost as suddenly as it appear, SARS went away. We realized how lucky we were; and how lucky the world was.

Then we seriously started looking at which of the viruses out there, could actually cause another pandemic; and INFLUENZA kept on coming up. Was influenza going to be the next SARS ? Was the common flu going to kill us all ?

Influenza is caused by the Influenza virus which is a human virus ie it is suited to humans; therefore it spreads like wildfire amongst human populations especially in congested areas, during winter months, amongst the young, weak and infirmed and it kills quite a few people every year. But its mortality rate is low; so the seasonal flu was always thought of as a part of life, the yearly inconvenience of winter.

But this influenza virus is one smart virus; well adapted to infecting humans. Every year, these viruses will undergo some changes in their antigenic structure (think of it as the virus changing clothes). This is done to fool the immune system of the body. Usually these changes will be minimal (antigenic drift) and therefore most people who had that infection before would still recognize the virus and be immune to it. (virus change clothes, but our immune system can still recognize it). But once in a while, large changes happen (antigenic shift) and now the new virus is hardly recognizable to our immune systems. In this case, widespread infections will occur as our immune system cannot recognize this virus with its new antigenic structure. [think of the virus as having changed clothes, put on a wig, used disguise makeup and changed sex]

Now antigenic drifts are fairly common and don't cause much worry; antigenic shifts come along once in a while and cause many many people to come down sick with the flu; but again, this doesn't cause too much worry either because most people don't die from the seasonal flu. But worry comes with the story of the bird and the pig.

Bird flu (avian influenza) is also caused by a virus; it behaves similar from human influenza except that, in birds, it is highly FATAL. Bird flu can kill off entire flocks of birds overnight. So here is another virus, that is highly infectious, highly virulent and highly fatal as well. Luckily for us, it doesn't normally infect humans. The pig however gets avian influenza. The pig is also susceptible to human influenza. So, a pig that is infected with both the avian influenza and human influenza is now a ideal mixing pot, a meeting place for viruses. In that pig, there now exists a possibility of the avian influenza virus "learning" from the human influenza virus how to infect humans; or "telling" the human influenza virus how to kill many people. Imagine, a virus that spread like wildfire as the human influenza virus; and can kill huge numbers of its infected victims like the avian influenza virus can; it seems the perfect recipe for disaster. Hence the hoo-haa over the recent swine flu.

So, if this new virus were to emerge, with its ability to spread easily, and its high mortality rate, and the lack of any form of immunity in all our immune systems to this new virus, don't you think that it could very well spell the end for humankind ?

And let's see what we can all do about it, if it were to happen. Blood tests to confirm, nope. New virus, no confirmatory blood test. Antibiotics, nope. They don't work. Anti-virals, yup, may possibly work; if there's enough to go around. That's it. Nothing else. That's why the mainstay of infectious disease outbreak management is to reduce on-going infections ie identify patients with the disease and isolate them early; monitor the people they have been in contact with and instruct the general public to stay at home. Quarantine is still the main crucial step.

Now, we are not super-human beings; we cannot see the virus to decide whether a person has the disease or not. That's why we follow case definitions to the letter. These are detailed definitions by the World Health Organization detailing how suspected infections are to be screened and diagnosed; and how to treat probable infections. Using these case definitions, sometimes we will be correct; other times wrong. But these methods are the safest methods to ensure that an infected person is not going around the community spreading the infection to unsuspecting others. You see, our hands are pretty much tied; and we really don't have that many weapons to use against this pandemic causing virus.

Furthermore, the first people who will get infected (often unsuspectingly) and sometimes die, are the healthcare workers. It happened during SARS in China, Vietnam, Hong Kong and Singapore. Healthcare workers were the first to die; only then was the virus diagnosed. We, the healthcare workers, were the lightning rods for the pandemic.

So, for the patient who may or may not have the H1N1 flu, the truth is this. Quarantine is really not pleasant; in the context of the possibility of you having a life-threatening infection, it is really horrible. Worse, when it seems that everybody thinks you are infectious and need to be avoided / isolated. But it is for the greater good; and it is the only thing that we can do to help the situation. And really, we don't want to quarantine anyone; it is tedious, tough work and a danger to our own lives and health. But we have a job to do; one that the community expects from us; to protect and heal them. And similarly, we aim to protect and heal you as well. All the time, we are still putting ourselves at risk. Can you name me another profession where loss of life is a significant risk ? where your next breath may kill you ?

So, why me ? Honestly I ask myself the same question everytime an outbreak occurs....

To know more, reliable sources include the WHO site, CDC site, Ministry of Health sites from Malaysia, Singapore, Hong Kong and the Pan American Health Organization.

The Beggarly Emergency Ambulance Services

Yes, beggarly we are. Undeniably. After all, whenever we need something to improve the ambulance service, we actually have to beg for it. Which is something I just cannot understand. Why is begging necessary ? After all, ask any Tom Dick and Harry (or in the more local context Mr L, M and N) and they will always say that ambulances are very important; that there should be enough of them, with sufficiently trained staff and well-equipped. And L, M and N will justifiably think that their tax dollar would earn them a good emergency ambulance service.

However, when requests are made for budget to improve the ambulance services, it is like going up against the Great Wall. No money. Wait for the next budget. Write me justifications, workloads, statistics and if your local politician is supportive of it. [God help you if your local politician is not on the "right" side] Or the most vulgar phrase of all "Do your best with available resources!"

That phrase is the silliest and most idiotic of phrases; just imagine us struggling away, providing an emergency ambulance service, already using every resource that we can think of, both conventional and some really out-of-the-box ideas; when advised "Do your best with available resources", doesn't that make you just want to bite somebody ?? After all, saying that implies that 1) I was not already doing my best and really needed that phrase to ooomphh me to a higher level 2) I had some secret supply of resources that was kept in hiding to be used on a rainy day or 3) I had available resources, which I don't !

The thing is this. Whilst we are in our beggarly mode, there are several quarters going around proposing this and that to the powers-that-be for helicopter services, boat ambulances, flight transfers, super-duper ambulances, state of the art call centers (wonderful and fantastic, my foot! More like wan-tai-foo and fanta-bombastic, if you ask me). This just puts salt in our wounds. Here we are trying our level best with the measly resources that we have scraped off the bottom of the barrel; providing the actual service to the community; and there they are, handing out money freely to anyone with a sweet sounding promise.

And then all those CONsultants, after having had money thrown to them, will then come over back to us, seeking our advice on how to actually run and manage the service and all that money they have just gotten. And to really rub salt into our wounds, they will come bearing letters from the higher-ups, demanding that we give them the fullest cooperation and everything that they want. So, the CONsultants come, smugly, with the foreign CONsultants and their business suits, telling us, to teach them what to do; so that they can earn huge amounts of money off the government. I think naming them CON-sultants is really appropriate.

How would you feel if you were in our beggarly shoes ? Old tired, our teeth gone. Begging away for gruel, porridge anything will do. And here the fellas come and throw crumbs; whilst they grab your shanty hut and your land ..... Hhhhhhhhh !

All the time, all the Emergency Ambulance Services needs is just more budget. That's all. Don't give money to buy ambulances; give money to run the service. Some money for the service providers (govt, NGO, volunteers groups) so that they can do better than they already are. How much money ? Much, much MUCH less that what was agreed for the CONsultants.

Is that really too much to ask ? Spend less money, better overall service. Just that it will be less glamourous, less sexy; no CONsultant parading around saying this and that for the media. No ceremonies for the politicians. But on the ground, the only place where it matters, the people will be happier; because the service will be better.

That, if it happens, would have made all that begging worthwhile.

It is what's in your heart that matters

Let's say something happened, you injured yourself; and you are now at the Emergency Department (ED). You don't really want to be here, right ? It's not a "comfortable" place; and you don't remember anyone having anything nice to say about the place. You see what you kinda expected, lots and lots of people around, many looking quite ill and distressed. You start feeling uncomfortable. But, still you are here, and you remain, because, here is where you can count on help. Help 24 hours a day, every day.

Now, let's just say that when you arrive at the ED, you spot 20 people in the waiting area. Oh noooo! Horror stories from newspapers and local politicians flood through your mind, about long hours spent waiting, and poor service from lazy and rude doctors; and your mood just takes a nose-dive. [Never mind that, of that 20 people, only 4 were patients, the others were actually family members or relatives of patients who were either waiting or already in treatment.]

You are already grumbling away. Now you decide that, you just cannot wait. You open the door of the consultation room. And you look in. First thing you see, is NO doctor in the room. You are now ready to explode. "What? No doctors working? 20 patients waiting outside and no doctors working ???" [Never mind that there are actually 3 doctors working very hard at that very moment, trying their level best to resuscitate two patients in the critical area, one with a heart attack, another with severe injuries after an accident on the road}

You decide that enough is enough. You shout at the passing nurse, about waiting 2 hours already (actually 15 minutes) and you get even more mad when she walks off (actually, your crazed look made her really scared, and she ran off to search for the doctor, so that you could get what you were shouting about).

You are still fuming mad; and then you spot today's papers on the doctors table. In your mind, the lazy doctor must have been reading the papers whilst patient waiting outside. Ohhhh those heartless doctors, can't they see that patients were suffering outside !! [Never mind that those papers actually belonged to a patient who had left them there earlier; and doctors working in that ED easily manage more that 50 patients per shift; leaving them scant time to read today's papers]

So the doctor finally comes over (you are still fuming) but she really treats you well. You grumble a bit about waiting and explain that you were only complaining for the sake of the poor suffering souls waiting outside. You calm down somewhat when she tells you that she was resuscitating someone in the critical zone and unfortunately, the other patient died. And she treats you well, considering that she was just trying to save someone else's life just a minute ago. You start to feel a bit sheepish about your minor injury.

Well, you get your medicines and prepare to leave, feeling a lot better. You realize that you have just spent less than one hour in total at the ED; and have just paid RM 1. For which, you got treated, got some medications and an MC for the next two days. You realize that this was much, much better than anything available anywhere else. And you start feeling more silly about your outburst just now.

But why were you so upset, so angry, so out-of-control earlier ? Most likely it was due to the pain of your injury; or the feeling of loss-of-control; or even the realization that you needed help, from someone else. And most likely it was because of the HORROR stories that you have read before, in the press, about government hospitals, and the supposed disastrous states they were in.

Well, you now feel even more sheepish. And you decide that, maybe, after all, government hospitals were really not that bad after all; and emergency departments were really really good; and did do their jobs well. After all, you, being the reasonable person, would be the first to say that someone else with a heart attack or a road traffic accident would need to be treated first.

You feel sheepish, and feel that you should apologize. But, well, you realize, you are already home. And never mind, they know I meant well .........

Now, let's just say, that all the above happened, except for one significant difference. You are now a high-flyer politician and a member of the high command in government. Exact same thing happens to you; but now you don't merely get angry, you get "irked" ! [which I suppose means angry, but used solely for the upper classes] And you start reprimanding the ED staff, about long waiting times, poor urgency, reading newspapers etc etc. And because you are ranting away, the nurses and doctors shun talking more to you, fearing more reprimanding. [btw, "reprimand" is another higher class word] Someone tries explaining to you about the other two patients, with heart attack and the accident, but you would not hear a word of it. After all, you were reprimanding them, and really not interested in knowing the situation. After all, you must have been right.

Worse, seeing that you may not have made much impact on the staff (ie they were not shivering enough) you decide that it was time for the big guns to come out (and score some brownie points with the highest command). You call a press conference, and blast away; talking about napping, lazy doctors reading newspapers whilst patient suffered outside. You feel good, after all, the story made front page. You feel good, having done what a good people's representative would do. You think, never mind, if some doctors get scolded, or the ED's image is destroyed, or that doctors trying their best are now de-motivated; you think, never mind, they know I meant well .......

But what happens to the doctors and the staff of the ED ? Demotivated, and probably quite angry about the whole. They have no options for redress, nor any possibility of remedy. They just bury the hurt, as deep as they can. And they continue working, serving the public, and still trying their best despite the continued poor perception of them. Once in a while, this question still pops up in their minds "What wrong did we ever do to you, to deserve such poor perception?"

My friends, man is judged by his actions and his words. These must reflect what is in his heart. For it is what is in his heart that matters most.

It is difficult to build, tough to achieve, tedious to maintain; but all to simple to destroy.

In the first situation, the man has made an honest mistake and realized it. He is a child, learning a lesson. He must be understood and forgiven, although he has made no apology. In the second, the politician is just plain mean, seeking to destroy others to build his own image. And he is a fool, for a fool learns no lesson from no mistake admitted. A mean fool, even if he apologizes, should not be forgiven; until his words and his actions reflect something better in his heart.

Sadly, whew !