WebNotes in Emergency Medicine

ED Management of Pneumonia in Malaysia

2012-01-28T20:25:00.001+08:00

Huge topic. Brief notes on few important points only. Information pertinent for ED practice in Malaysia.

Generally, divided into 1) community acquired pneumonia (CAP) has less dangerous and less antibiotic resistant organisms; 2) healthcare associated pneumonia (HCAP) defined as some contact with healthcare facilities (hospitals, nursing homes, dialysis centers, wound care, outpatient clinics or family member in healthcare) in the last 90 days and develops pneumonia, which tends to be associated with a higher incidence of bad bugs and worse outcomes, and 3) hospital acquired pneumonia (HCAP) and its variant ventilator associated pneumonia (VAP) essentially with the worst bugs of the lot.

Outcomes from pneumonia very much depends on type of infection (type of bug, resistance to treatment) and presence of co-morbidities (DM, structural lung disease, underlying heart disease, extremes of age, immune status etc) and if treatment is initiated early and accurately.

Although exact microbial identification is only possible in a small percentage of cases, and antibiotic therapy is often empiric in nature, different bacteria do produce different presentations, and some knowledge of the differences may be helpful.

Strep Pneumoniae remains the most common organism associated with pneumonia; and still the most common cause of death. Gram +ve encapsulated Diplococci. Produces the typical pneumonia presentation of high spiking fever with chills and rigor, rust coloured sputum, raised TWBC, chest x-rays showing lobar consolidation with air bronchograms.

Staph Aureus infection is much more gradual in onset, but it can cause a much more severe disease. Often it is a secondary infection to a primary viral illness or viral bronchitis. Gram +ve cocci that seems to group in clusters. It also causes lobar infiltrates seen on X-ray but is much more likely to cause lung abscesses and pleural effusions. Must think of this in IVDUs and in immuno-compromised patients especially if they have an indwelling catheter somewhere.

Klebsiella sp. is much more common in alcoholics, elderly patients and those with long standing DM. Typically it causes a "currant-jelly sputum". On X-rays, the bulging fissure sign is specifically associated with Klebsiella infection.

Klebsiella Bulging Fissue Sign

Pseudomonas aeruginosa is much more associated with VAP, HAP and HCAP. (note: although this is commonly quoted, available data from Malaysian hospitals still have other organisms like Klebsiella sp and Strep Pneumoniae ahead in total numbers). Gram -ve bacilli. Much more likely to cause patchy infiltrates on chest x-ray rather than lobar consolidation. Must be considered in patients with structural lung disease esp bronchiectasis.

The "Atypical Pneumonias" were so named because they seemed so different from the Strep Pneumoniae infections. Their onsets were much more gradual, the patients seemed much less sick (leading to the nickname "walking pneumonias"), they never produced anything like the rust coloured sputum and their X-rays were more patchy infiltrates rather than the white-out lobar infiltrates. None of them are seen on Gram staining. And they never responded to traditional penicillin antibiotics ! This group includes Mycoplasma sp., Chlamydophilia pneumonieae, Hemophilus Influenza and Moraxella Catarrhalis.

Hemophilus Influenza and Moraxella Catarrhalis infections are more common in the elderly, and in those patients with underlying lung disease eg COPD and smokers.

Chlamydophilia pneumonieae often causes a dry cough, fever and wheezing. It is much more common in young healthy adults. Another demographic to consider is the few week old infant who develops a staccato like cough; being infection during passage through the birth canal.

Mycoplasma sp. is the primary atypical pneumonia. Affecting younger patients (it is probably the most common organism causing CAP in the younger below 40 population), usually previously healthy, it's presentation of a persistent and gradually worsening dry cough is very similar to some of the other atypicals; in addition to that, it does often produce a mobiliform rash all over the body, it seems to be associated with erythematous tympanic membranes (or even bullous myringitis, or bubbles on the eardrums), a reddish throat without exudates, triggering off asthmatic episodes and extra-pulmonary auto-immune manifestations eg. Stevens Johnson and Guillian Barre Syndrome. Chest X-rays commonly show a multi-focal bilateral patchy perihilar infiltrates (many have said that the X-rays often look worse than the patient).

Mycoplasma sp. do cause outbreaks especially in army camps and college hostels; but sudden outbreaks should bring to mind Legionella sp. infection. Typically related to infections via air-conditioning systems, these patients present with pneumonia and GI symptoms, often associated with Hypo-Na and LFT abnormalities. Interestingly they often show a relative bradycardia.

Infection from Mycobacterium tuberculosis may present as an apparent CAP and must be considered in Malaysia. Our data show about 5 - 15% of our patients with CAP end up with a diagnosis of TB. Last but not least, in rural areas, Burkholderia pseudomallei must also be considered especially if the patient also has DM.

How should the ED doc treat ? Luckily, it is not nearly as complex.

First question would be whether admission is needed. This is a clinical decision; based on the clinical findings, the presence of co-morbidities, support structure at home, hospital policy and some guesswork about the possible bug. Traditionally quoted statistics that about 20% of CAP would require admission, and about 1% would require ICU care is not particularly useful. These percentages refer to the total number of CAP in the community; at the ED, we tend to see the more serious and we should be wary of this fact. I would suggest putting in extra effort to identify co-morbidities and whether it is a true CAP or a HCAP. [HCAP and especially HAP must be treated with extra caution and a much lower threshold for admission] As a decision tool, the Pneumonia Severity Index (PSI) is quite tedious to complete; I do however find it useful to identify the low-risk patient that can be safely treated on an outpatient basis.

Next question is which antibiotics to start, if discharged. Here, I would like to refer you to Prof CK Liam's paper in the Med Journal of Malaysia in 2005. [click to enlarge] or [click here for the actual paper.]

I would say that common mistakes of the young ED doc, is to think that all pneumonias are the same, that all respiratory infections are treated the same, and to prescribe antibiotics blindly and for a too short duration. Atypical pneumonias should be treated with macrolide antibiotics for at least 10 - 14 days !

Hope this "brief" post has been helpful. Whewwwwww !

Credit to Mel Herbert and the EM-RAP team. And the Prof CK Liam.

Life-Saving Information on Hollow Viscous Injury (HVI)

2012-01-12T18:37:00.001+08:00

Pictures speak a thousand words, right ?

But only if some of those words are spoken, from the knowing paramedic to the astute emergency doctor, do these words become meaningful information, that may save lives.

Huh ? Words that save lives ? Are we psychiatrist or psychologists ? Nahhh .... let me explain.

In the pictures above, you see common scenes in a bad accident. "Waaaa MVA teruk-lah" would be a probably part of the information given by the paramedic.

There are much more important and specific information that can and should be conveyed instead. The presence of a STARRED WINDSHIELD would give more concern to the treating doctor about traumatic head injury; a SEAT BELT sign would warn about the possibility of intra-abdominal injury of both the solid organs and hollow viscous injury; INTRUSION into the passenger compartment signifies transfer of high force onto the passengers; and the BENT STEERING WHEEL and the failure of the air-bag to deploy (ahahhh! I betcha missed that one) would give much worry about chest and abdominal injury.

Today's blog would like to discuss one component of blunt abdominal injury today.

Road Traffic Accidents remain the most common cause of blunt intra-abdominal injury; other causes would be non-accidental trauma in children, being punched in assaults or domestic violence esp in pregnant women; and sometimes following Heimlich maneuvers and CPR.

Intra-abdominal injury has 3 basic mechanisms (this is important to know .... so read this part). The external force applied may CRUSH the solid organs caught in between; the solid organs like spleen, liver and kidney are most commonly affected in this way; and is more common in those with lax abdominal walls (elderly, alcoholics). Fatties like myself are "slightly more cushioned". Or a sudden and powerful external force applied locally may suddenly increase the intra-abdominal pressure and BURST a hollow viscous, like the intestines. This is exemplified by the seat-belt injury (seat-belt sign) or the handle-bar injury (handle-bar target sign). Lastly, the extreme acceleration deceleration seen in many road traffic accidents result in varying degrees of deceleration of the internal organs. In short, when parts of the body has stopped, some of the more mobile organs are still moving forward and SHEARS off (usually the vascular pedicles of organs or the large vessels are torn in these situations).

It is not easy to diagnose intra-abdominal injury; and probably the most difficult one to identify (and hence the most commonly missed one) is the Hollow Viscous Injury (HVI). The sudden increased pressure results in varying degrees of injury to the mesentery and intestines from bruising and wall haematomas, to loss of vascular supply, loss of viability or overt rupture. The main problem is that diagnosing this in the first few hours is difficult. Clinical signs are few and unreliable. FAST is often not sensitive enough, and neither is the CT. DPL probably performs better, but tell me honestly, how many of us are going the DPL a fellow purely based on suspicion without some clinical signs ?

Unfortunately many of these patients are not identified early; and sometimes discharged home. What happens next is that the contamination of the peritoneum occurs as the contents of the GI spills out; in younger patients, some natural attempt by the body to contain and compensate results in delayed onset of clinical signs and later presentations. Often these patients are brought back to the hospital in extremis and do very poorly thereafter.

It is really easy to identify it retrospectively; but not at all easy live, in real-time. Needless to say, the medicolegal risk associated with missing these injuries are high.

The only guide to a better pick-up rate is to have a higher index of suspicion. Having information about mechanism of injury, how it happened, was it high force, were some of the situations depicted in the pictures above there, is this a "high-risk" patient, are life-saving information to get. Life-saving for both the patient and the doctor. (lawyers can "kill off" doctors, you know). So, high index of suspicion based on information about mechanism of injury.

Next, in these patients, keep them for a while. Check them again and again and again. If you have seen them several times, and documented your findings, this will serve you well, even if you still end up missing the odd one (or two; hope not too many). Time, repeated clinical examinations and repeated investigations are probably the only way.

And if they are planned for discharge, please please please make sure that they understand that they MUST return to the ED at the first sign of any problems (usually vomiting starts fairly early) or worsening of symptoms (usually pain).

Investigations needed for to rule out the possible HVI is still unclear. Free air on chest X-rays and Chance-type fractures of the lumbar spine are uncommon, but significantly associated with HVI. DPL probably has a role with either visualization of intestinal contents or elevated ALP and WBC counts.

Just remember, don't forget HVI; especially with a significant mechanism of injury. If you do suspect it, please discuss it with someone more senior and experienced; specialists if possible.

Whewwwww !

Do you prescribe Allopurinol ?

2012-01-05T18:27:00.003+08:00

I think she was trying to tell me to write this blog. So here it is. Thanks CK.

Allopurinol is a commonly prescribed drug; usually for symptomatic hyperuricaemia (gout) or treatment of uric acid kidney stones. It is pretty standard care in many patients with cancers on treatment to try to prevent the development of hyperuricaemia.

Its indication is not clear in the patient with asymptomatic hyperuricaemia though. And I think, that in view of some of the following, it should not be easily prescribed to all and sunder.

First No-No is for those who are pregnant or even thinking of getting pregnant. Absolutely no-no for breastfeeding moms.

Next problem is its degree of drug interactions with other very commonly prescribed drugs. Main interaction with the ACE inhibitors. The evidence is not great but reports of hypersensitivity reactions and leucopenia have led to the constant reminder about avoiding prescribing both together. Same goes with many Diuretics, Amoxicillin and Antacids.

But the biggest worry for Allopurinol is the possibility of ALLOPURINOL HYPERSENSITIVITY SYNDROME; a type-III hypersensitivity reaction that often leads to diffuse vasculitis, multi-organ failure and death. It is not very common (granted!) but genetically linked and (me suspects) more common in the Asian population.

The standard criteria for diagnosis are a history of recent exposure to Allopurinol, clinical findings of worsening renal impairment or acute hepatocellular damage, and often a skin rash (either toxic epidermal necrolysis, erythema multiforme, or a diffuse maculopapular or exfoliative dermatitis) with at least one of either fever, eosinophilia or leucocytosis.

In short, a drug that has high levels of drug interactions with other commonly prescribed drugs and potential for severe hypersensitivity reactions, really should not be a drug that is easily prescribed by the youngest doctors for a common asymptomatic condition.

In these asymptomatic hyperuricaemic patients, the much more unpopular medical advice of giving up the beef rendang, the seafood platter and the bak kut teh is much better and much safer!

Whewwwww !

p.s. no professional conflicts of interest declared.

Traumatic Optic Nerve Neuropathy (TON)

2012-01-03T17:54:00.000+08:00

This is not particularly common; but is very often missed. When missed, the potential for medicolegal action is high, and often very difficult to defend. So, listen up.

TON refers to injury to the optic nerve as a result of trauma; which may be direct (often a result of orbital fractures and bone ends that sever the nerve) or indirect (usually as a result of blunt force applied on the orbit or malar eminences - a high force impact over the eye or on the cheek). Nobody can really know for sure why the Optic N gets injured indirectly; shear force injuring the axons, or local swelling of the nerve at that area resulting in secondary injury. But regardless, TON must be considered in every patient with local injury over the eye and / or cheek; especially if associated with blunt head injury.

Which is why TON is easily missed. The main symptom is blurring of vision in that eye; not something the patient will readily complain of when their face is smashed, or their eyes are so swollen that they cannot open it to see. Worse still, if it is associated with blunt head injury and a low GCS. It is NOT easily identified on fundoscopic examination in the initial 24 hours, and the main suspicion will come from a Relative Afferent Pupillary Defect (RAPD) detected by the swinging torchlight test. (YouTube) This is often not done in the ED, for many reasons (none of which will convince the Judge in a medical negligence suit). Therefore, this is commonly missed; and the patient will only notice persistent vision blurring or loss after days to weeks; when nothing can be done.

So what can be done, if TON is diagnosed ? Actually, nothing much. In many patients, the visual loss is temporary and will recover to some extent. Surgical decompression was used for some time in some countries, but very little evidence can support its efficacy (probably unless structural defects that require decompressing can be demonstrated). For some time, the use of high dose steroids (esp Methyl Prednisolone) was promoted as the wonder drug, to be given early for better outcomes. Most recent trials have not found conclusive evidence to support this either.

So what then is the issue, you may ask ? If there is no real treatment, why sue the doctor for missing it in the first place ? The Courts do not work that way, my friend. As long as there is a "potential" for recovery, and that "potential" was not made available to the patient because the diagnosis was missed, it is negligence. Not really how medicine works, but that's why they are lawyers and not doctors.

How then to stay safe ie how to keep the lawyers at bay ? Examine the eye carefully in every patient with injury around the eye and cheek; esp if they have head injury as well. Check for the RAPD. Check for pupillary response. DOCUMENT IT. If you are unable to check (swollen, uncooperative, priority to head injury etc), make sure you refer to the Ophthalmology team for a complete eye examination. And write that down it.

Much, much better than having to appear in inquiry and inquiry after inquiry and then in courts. Stay safe.

Thank you and Good Night

2011-12-28T00:29:00.000+08:00

In a few days time, I will hand over the helmship of the ED which I have had the opportunity and privilege to lead for (almost) the last 9 years. This has been in planning for more than a year, and careful steps have been done over the last year to make it happen in the best way possible. And now that the time is really near, and most of the tasks are already done, I am honestly feeling rather happy.

I will not stop working here; in fact my role will remain even more clinical and at the same time, more planning and oversight as I continue, for a while, the newer tasks that I have assumed. I look forward to this new role with quite a bit of excitement, a little bit like a boy with a new toy.

Now, it is customary to do several things when you leave. And, if you know me at all, you will know that I rebel at anything customary. So I will NOT do the following

I will not leave a long list of unrealized targets for my successor. It is tough enough to do the job; no need the additional burden of what I could not achieve myself

Similarly I will not assume great wisdom and give lots of advice. Most advice is, well, unwarranted and merely reflects unattained goals of the advisor. No sireeee. I am no wiser than everybody else.

I will also NOT assume that the days under my helm was any better than the days to come. The future is always brighter, the younger are always better. A really useful quote comes to mind (Thanks Bro!) "Every new generation outperforms the previous one, despite every prediction that it will fail". To the young, it is your world, your time and your day.

I will also NOT apologize for being rude, for stepping on toes, for making someone else feel hurt nor for doing what needs to be done. I performed my role as best as I could, using the force of my conscience to guide me. I will not have done any differently otherwise as I have not let my conscience down.

I must however thank several people.

My family has been the support structure on which I have built everything else. That foundation has held strong despite the demands placed upon it. I am nothing without this.

My "comrade-in-arms" (you know who you are) have been my pillars; you have held back my impatience, reasoned with my folly, and argued with my delusions; that wisdom, experience and knowledge that I have, is no less a credit to me as it is to you.

So this last post of 2011 is just to say that. Nothing special really, but very special too, to me.

This change is ultimately just a start of a new morning in a new year. A year and a future that I really look forward to.

And on the last night, of the last day of the year, it is appropriate just to say "Thank You, and Good Night"

The Madness of Me, Me, Me

2011-12-21T23:46:00.002+08:00

There is this hospital in a political area (which means that its MP was once a VVIP somebody). A district hospital similar to almost every other, with one significant exception; that it is just about a thousand times more likely to receive complaints from its patients than any other.

Wait half hour to see doctor, some Minister calls you up. Cannot get medical report extra early, the PM's department calls you up. The gardener of the politician sprains his foot, you get called up to wait for his arrival at the ED. Someone comes with a cough and cold to the ED; try diverting that fellow to the nearest health clinic, and you will probably get asked your name and receive the "Don't you know who my relative is ?" thinly veiled threat.

As such, the Emergency Department in this hospital now runs on a manic mode; everything needs to done fast; fast fast fast. Never mind properly, just fast will do. And everybody, just about everybody is seen at the ED. No diverting patients away to the Klinik Kesihatan just down the road.

So now this ED sees 70% of its workload in NON-emergencies. The standard cough and running nose patient will come to the ED and insist on being attended to in good time. A real emergency case will still be attended to immediately, but soon after the initial resuscitation is done, most of the team will have to go attend to the non-emergencies, so that they will not have to answer to complaints !

And when any referral to another specialist hospital needs to be done, the ambulance must send them, even though it is not a critical nor urgent referral. Because the ambulance must, or else ..... Sometimes, true emergencies cannot be sent immediately because all the ambulances are out sending these non-urgent referrals to other hospitals !

It is just a ridiculous situation; a freak result of our complaint culture; and the wielding of political influence on daily life. It is the madness of me, me, me.

In the politics of today, it is ME, ME, ME. We have forgotten that we have but one cake; and pushing for more for ME will mean less for everyone else. Who is everyone else ? Our very own community. So the madness of ME kills our own community.

This madness is seen everywhere. Another example. At the end of every year, every ED runs a community circumcision program; conducted in sterile operating room environments with sterile equipment and the highest standards, it is done FREE. All that is needed is to make an appointment in advance. Great, right ? Not so great, it seems for politicians. They, instead, want to do hundreds of circumcisions in the open, in community halls, in villages; because it is more "meriah" and they can have kenduris and political events together with it. They will then insist that we provide the staff for it, and the equipment for it. They will not listen to our concerns about sterility; nor to our concerns about having to perfunctorily clean equipment between patients instead of full sterilization; nor to our laments about higher risks of infections. No, these are not excuses they want to hear. Say it, and they will then demand your name and threaten to inform the Minister or Deputy or whoever other politician's name they feel like using on that day. Just madness.

Just pure madness ....

Why we compete

2011-11-09T00:26:00.000+08:00

In just a few days time, we will hold the second edition of the National Pre-Hospital Care Competition awarding the Tuan Gurcharan Singh Challenge Trophy. This time, it will be more difficult and much more challenging, aimed at raising the standards of paramedics to an even higher level. This second edition, coupled with a Pre-Hospital Care seminar, will bring together more than 12 teams from around the country representing different ambulance service providers, and more than 200 paramedics either as competitors, observers or seminar participants. It should be a good one, a true Battle of Paramedics !

You may ask, why compete ? I believe that anyone and everyone that lays claim to some sort of professional standard must have deep within them some yearning to know where they stand; how they compare to the rest; where their abilities lie; what their deficiencies are; and are they really as good as they think they are. Competition is the only way for us all to know this; in a fair and clear manner.

But competition is not merely an exercise in comparison; it encourages a spirit of continual improvement, the reality of self-reflection and a desire to go beyond what we already are. Competitions makes winners of all who participate.

So what can we then say about those who shirk away from competition ? Those who do not take part for reasons unimaginable and immaterial ? Maybe they are just not interested in continual improvement, or maybe self-reflection will conjure an unflattering result. Maybe they just cannot handle the thought that the young may be better than the old. Maybe they are just too comfortable where they now are.

Or maybe I am just too old school. Maybe competition is outdated; together with fairplay, challenging oneself and each other, maybe it is just not part of today's world. Maybe I am just an old fart sour grapes.

Old school or not, to me, competition is about life itself. Life needs us to compete, in order to survive. Life needs us to improve, in order to survive. The adversities and challenges that life throws to us makes us better in the long run. The kite needs the resistance of the wind to fly higher. Competition just creates those similar challenges in simulation; an artificial wind for us to test our wings.

The Tuan Gurcharan Singh competition will have its winners and its losers. On the whole, everyone will end up a winner; ambulance teams will have improved, paramedics will have learnt and practiced more. Friendships will be made; information shared, ideas created. Not least of all, the real winners will be the next patients in their ambulances, who would have benefited from this unique effort at improving our paramedics and the care that they provide.

See you all there.

Rashes in Children

2011-09-26T17:23:00.000+08:00

Exanthems - Greek "exanthema" meaning 'breaking out' refers to widespread rashes often occurring in children and associated with fever. There were originally 6 classical or original childhood exanthems; and they were numbered in 1905 as follows:

First disease - refers to measles (rubeola) which was described aeons ago
Second disease - refers to scarlet fever which was differentiated from measles in the 17th century
Third disease - refers to german measles (rubella) which was described in 1881
Fourth disease - refers to Filatov or Dukes disease which was described by Dr Clement Duke in 1900; but it has not been widely accepted as an independent entity since.
Fifth disease - refers to Erythema Infectiosum which was initially described in 1896 and later renamed as the fifth disease in 1905; currently the only one that retains the original numbered nomenclature
Sixth disease - refers to roseola infantum (exanthem subitum) which was the last of the original list.

Later on, most of the diseases reverted to their original names except for Erythema Infectiosum which is still commonly called Fifth disease today. [sometimes mistakenly accredited to Dr Fifth!!]It is often quite difficult to manage children with febrile exanthems. Firstly it is often difficult to describe the lesion. Secondly, some lesions are more obvious in more obscure areas. More often than not, it is associated with significant parental anxiety and doctor anxiety as well. This is justifiable because hidden in the mysteries of the rashed lurk potential life threatening conditions hidden amongst the common diseases of children.

This diagrammatic flow chart is an excellent way of approaching the child with exanthems. This is adapted from the Royal Children's Hospital in Melbourne.

I thought it would be interesting to review some of the more common rashes that we may come across at the ED. Part One will be the common, probably less dangerous exanthems.

Rash with clear fluid filled lesions
Varicella (chickenpox) - initially papules then vesicles appearing like little drops of water on skin, which rapidly turns into pustules and crusts; often occurs in crops of varying types; starting from the face and scalp, then spreading to trunk and to extremities. Fever initially high, then becomes low grade. Be careful of dyspnoea / breathlessness which may indicate VZ Pneumonitis.
Impetigo - probably the most common skin infection in children, caused by Strep or Staph. Varied presentations, often itchy. One or a few blisters which are easily broken leaving a red raw-looking base, that may crust up. Lymphadenopathy in draining lymphatics. Treat with anti-bacterial cream in mild cases, oral antibiotics in severe cases. MRSA related is becoming more common.

Papular Rash Lesions

Urticaria - aka Hives, Nettle Rash (no nettle in Malaysia; but the same itchy lesions seen with contact to some plants). Highly itchy papular lesions, appears suddenly especially with a triggering incident, and often resolves spontaneously after a day or two. [for the unfortunate few, it can turn to chronic urticaria lasting months, often with an unfruitful search for the triggering cause]. A cool bath / shower help relieve some of the itchiness; so do anti-histamines (but try to avoid this). I've never given steroids, but it is written in the recommendations for severe situations.

Molluscum Contagiosum - viral infection; develops 2 weeks odd after infection; lasts for about 2 - 3 months then disappears. Often disappears on its own after 12 - 18 months. This is the one skin rash that is often treated with home remedies like garlic, etc etc.

Measles - used to be the most common viral exanthem; but very rare nowadays due to the high rates of immunizations in children. Outbreaks still occur amongst immigrant populations. It is a highly infectious disease with symptoms appearing about 10 days after droplet or fomite contact; often with fever, runny nose and sore red eyes; followed quickly by the development of a rash. Koplik's spots ? Wish I actually saw more of them.

--- End of Part One ---

No comments on Malaysia

2011-09-22T07:35:00.000+08:00

I'm kinda passionate about our country - in many ways, I feel that we have gone down the wrong path for many years, and this accounts for many of the ills that we face today. I am passionate because I feel we can be so much better; if only ....

That is why I write so much about Malaysia in this blog. Writing to create awareness, to stimulate thought, to initiate greater community activism and above all, writing to invoke a response, regardless of whether you agree with me, or not.

But in typical Malaysia style, we keep quiet, we let things be. We don't bother to take a stand, and make our stand known. We leave things as "No Comments". Surely this is not the Malaysian of the future, passively waiting as the future sweeps us away, into whichever direction it want.

So, this is what I'll do. These are the links to several articles from before. Let me know what you think, agree or not. Let me know what your stand is - it is your right to have a stand of your own. Just let me know.

The Utter Insignificance of Here and Now
A country with the richest and most powerful ...
To my friends who now live somewhere else
Lost generations in Malaysia
Attitude, Mindset and the Inertia of Change
History Teaches Us Different
Football, the Game of Life
Oh America

Let me know.

Only Yearning is Left Behind - Yeo Jin

2011-09-08T15:38:00.000+08:00

A beautiful song for a soulful day ...

To my friends on two wheels ...

2011-09-06T20:15:00.004+08:00

As an emergency physician, you see terrible things. People, injured in all kinds of trauma incidents and accidents. Sometimes, the incident is the same, or the accident occurred in similar circumstances. In one, the injured patient would have suffered little, apart from wounds, abrasions and a bruised ego; and somehow in the other, the injured would be struggling between life and death; with no hope of recovery, of really ever being the same anymore.

There is really no way to explain that well; maybe it just wasn't their time yet. More likely, the ones that escaped with minor injuries were just damn lucky.

Every day, we will see these patients, injured, bleeding and in pain, brought in to the ED. Registered with different names, and different faces, but almost always, with the same story to tell. Knocked down by another vehicle. Avoiding something and crashed. Pedestrian run over by another vehicle. Cyclist ran off the road and crashed. Same story day in, day out. Why do some live while others die ? Why do some recover, whilst others suffer, incapacitated then die ?

We really don't know. Not their time yet ? Maybe. Just damn lucky ? Probably. But we do know this. The most common injured person, BY FAR, is the motorcyclist! The number of injured motorcyclists just overwhelms all other injuries that we see. And interestingly, the another common injury are the pedestrians hit by motorcyclists !! So, it would be safe to say that motorcyclists are a danger to themselves, and to others too.

But how do you tell this to your friends and family members who want to use their bikes on our roads ? How do you tell them that every day you see many others, in situations similar to that they are in, injured and maimed on our roads ?

Start mentioning injury and death, and quickly you get shushhhed and "Soi ! Soi !" [very much akin to washing your mouth out with soap, by western standards]. Start talking about how much more safe cars are, and you are met with a louder explanation about the "convenience" and "economy" of using bikes in our world. Persist with the topic and you get branded an old-fart who doesn't understand the joys of wind in your hair and the rumble between your thighs.

So, I do this. I nag generally everyone about the dangers of using the motorcycle on our roads. I nag and nag every chance I get. But if ever one of my friends or family ever get in an accident, I go straight to the point. Sell the bike !! My argument is this; if God wanted you to stop using the bike, He would give you a small accident and minor injuries. So, the accident was a warning. Just take it as a message from God. Sell the bloody bike. [Ooops .... sorry God.]

The problem starts becoming personal for the me is when they don't listen. Because, my greatest fear, my absolute worst nightmare, is that one day, God decides that enough is enough; and time's up. Before I can succeed in my argument, God takes the whole point away.

I have come to realize that the people on two wheels are really no better than smokers.

Smokers, for their own fulfillment, are not bothered about the risk their second hand smoke causes to their family, their children, their unborn child. They are not bothered about their reduced life span, about their worsening health and the ultimate need for their family to support them through their illness. They don't think about the suffering that their family goes through, when they are sick and when they die. They just think of the fulfillment from the next puff of smoke.

People on two wheels, for their own fulfillment of convenience, for the fun of wind in their hair and rumbling between their thighs, risk the very same thing. Their injury or their dying makes their family suffer as much, maybe even more. The thought of being incapacitated, and needing full time nursing care never crosses their minds. The possibility that everything could be taken away in that split second of carelessness from anyone on the road never seems near enough to consider. They just think of the selfish fulfillment of convenience.

Now, I do not mean people who cannot afford other modes of transport. I really don't. Many people in our community just cannot afford a car, new or old. Their only way is a bike. That's okay. They have no choice. Ask any one of them; they all wish that if they had the money, they would happily exchange their bikes for an old car. No, I do not mean them. My wish for them would be to achieve their dream.

But most people I know are not like that. They have a car. But they just prefer to use their bike. They are, in my mind, selfish and inconsiderate. No better than a smoker, risking themselves, their future and risking their family's future.

And don't even talk to me about bikers and smokers ....

Haddon's Matrix

2011-09-02T17:49:00.024+08:00

Dr William Haddon Jr. Widely considered the father of modern injury epidemiology.

I have been meaning to write this post for YEARS. Twice every year, after the Ops Sikap, I always get just soooo pissed off with the authorities. They seem just so helpless to do anything about our terrible road traffic accident death rates. Unfortunately, our authorities are not the experts; instetad they seem to only have a one-track mind; a single shot pistol; the only trick up their sleeve. Year in, year out, we are treated to the police, then the Minister or somebody lamenting about speeding, dangerous and inconsiderate drivers. In adverts, these drivers are always protrayed as the evil looking fellow, with dastardly schemes coming out of their every pore. And each year we are treated to police reports about how many saman they issued and the ever-increasing, how many deaths occurred.

Their single point is this. Our high numbers of road traffic accidents and deaths is due to DRIVERS faults and bad attitudes ie. you and me. We are the culprits if we are involved in an accident ! That is their single point. That seems to be the only job of the police at the moment. Determine who is wrong, so that the saman can ensue. And, that is why their main tool, their only tool to reduce the death rate is to saman us, and that is also why when they fail to reduce the death rate, the only excuse is the belligerent attitude of Malaysian drivers.

I challenge this point.

And I have two simple tools to tell you why. First tool, simple calculation. Every year, for at least the past 10 years, we have reported more than 5,500 deaths on our roads. Divided by 365, this averages out to just over 15 deaths per day, every day. So when the daily Ops Sikap reports comes out stating that similar figure, most Malaysians just tsk-tsk-tsk it thinking that it is an increased figure due to the higher traffic during those times. NOT TRUE. Essentially, we have the same death rate every day of the every year, for at least the last 10 years. To put it into context, the wars in Iraq and Afghanistan have resulted in 45,231 deaths of US, coalition, Iraqi and Afghan soldiers in the last 10 years. More than 50,000 deaths have occurred on Malaysian roads in that same time frame.

It is inconceivable that so many deaths are merely due to belligerent drivers with bad attitude. It is improbable that just trying to change attitudes of drivers by saman during Ops Sikap will change this number. This problem goes far beyond a single simple solution.

To me, the first attitudes that need to be changed are those of the authorities. Stop the blame game. Instead, look for the steps that can be reasonably done. And the best way to approach this problem is to use the second tool. The Haddon's Matrix was developed as a tool to consider the various aspects of injury prevention. Usually reported as a 4 x 3 table, it considers factors of the host, the agent or vehicle, the physical environment and the social environment, that can be reversed or addressed.

This would be a good way to start. And since ambulance crashes are in the news lately, I have done up a simplistic Haddon's Matrix analysis for road traffic accidents involving ambulances.

Hmmmm, you may have to click to further enlarge.

To me, the best first step is this. Ensure that EVERY ambulance crash, and EVERY road traffic accident that has resulted in major trauma and / or death, has a Haddon's Matrix analysis done, and reported publicly to the stakeholders and authorities.

Only then, ONLY then, can we possibly hope to make a dent in this terrible war, on our roads.

So, you want to drive the ambulance ?

2011-08-30T11:45:00.003+08:00

First and foremost, I salute you!

Second and even more importantly, you must remember that your primary duty is to go home safely every shift of every day; and that includes your entire crew. And patient. Safety is key.

Now, let me fill you in about why safety is key. Driving the ambulance is DANGEROUS. Somebody's got to do it, and I would like to think that you, being that somebody, would do it with eyes wide open. Ambulances are about 10 times more likely to get involved in an accident compared with other road vehicles, especially when they are running "HOT" on lights and siren. In addition, they are also much more likely to cause accidents, both to other vehicles as they try to get out of the way, and to pedestrians who may run out to look and get hit in all that confusion. So, keeping to safe practices when driving the ambulance is key to ensuring you and your crew go home safely; and that you don't cause an injury to someone else along the way. This is called "due regard for the safety of others" and in my mind, it is the single most important characteristic of an ambulance driver!

OK a good and safe ambulance design would be a good place to start - in Malaysia, I would recommend you take a look at the St John Ambulance in Penang. Their newer ambulances are really well-designed and have many of the essential features for safety. Note the position of LED lights and siren speakers on their ambulances. My only input would be that I wished their seats at the back had the better 5-point harnesses instead of the 3-point one, and I have always wished that ambulances install canvas cargo nets to allow for better emergency grips for paramedics on board.

Next step, use the safety stuff. Seat belts at all times. No exceptions. Drive carefully and conscientiously. Do not rush. Lights and Sirens only on Priority Calls ie. unconscious, breathless, chest pain, seizures, active bleeding, major trauma, road traffic accidents, collapsed patient. It is really pointless to rush for every case. Just imagine rushing for a call from a patient too weak to drive to hospital after persistent vomiting for the last two days; and getting involved in an accident. The matter looks even worse when most current evidence tells us that Lights and Siren priority ambulance calls only save a few minutes in earlier response time. Is that really worth the 10 times higher risk for a non-urgent call ?

How then to use Lights and Siren ? This is our recommendation for our ambulance service. Lights at all times when responding to an emergency call and when there is a patient in the ambulance. Lights increase visibility of the ambulance, allowing other vehicles to give way in a more controlled manner. Lights should blink to attract attention, and there should not be too many nor too bright, or else the "camouflaging effect" blinds the driver of other vehicles. Lights on.

Sirens, however, should be reserved for responding to Priority Calls and on the return journey to hospital, only when the critical situation of the patient mandates it. The priority of the call decides the use of siren on the way there; the condition of the patient decides on the way back. I would give greater consideration to the safety of the patient and crew in the ambulance, and the medic's ability to provide care in the ambulance; than to save the few minutes of travel time to the hospital.

Sirens have always been a source of debate between ambulance people. Most evidence note that drivers can only clearly identify the siren when the ambulance is about 25 - 40 feet away! So generally speaking, an ambulance driver can never be sure if the driver of another vehicle can see them or hear them. Or even know which direction they are coming from. And how far away they are. Drivers either simply can't hear the sirens (because they have their radios on full blast, they have selective hearing or they are just plain deaf) or even if they can hear the siren, they cannot identify where it is coming from (sound bounces off buildings and other vehicles, confusing drivers). So, do not assume your siren gets through to everyone on the road.

Most newer ambulances nowadays have at least 3 basic siren modes; a wail, yelp and hi-lo mode. Many systems can add another siren over and above these 3; either a priority or rumbler or air-horn.The US systems tend to favour the Wail whereas the European systems have traditionally used the Hi-Lo modes. I would suggest using the Wail in wide-open areas on longer distance transfers; and the Hi-Lo on more urban roads as the basic mode. In more urgent cases, many ambulances like to use the Yelp because of its higher tone change rate suggesting a greater urgency. In higher traffic areas, use of the additional mode, or a change in mode is useful to impel drivers to let you through. It is important to change the mode when approaching an intersection; the change making more drivers aware of your approach; and then changing back after the intersection. It is also very important, that if there are more than one emergency vehicle in the area, to use a different siren mode than the other vehicle, so that everyone is aware that there are more than one emergency vehicle around (wash-out effect). But really, try to avoid changing the siren mode too much, okay ? Hands on the steering !!

What about road rules ? This part is simple. ALL road rules apply ! Lights and Siren are essentially requests for right of way, not assumed right of way. So stop at RED and move when allowed by other traffic. Slow down at all junctions, even if the lights are Green. [the confused driver opposite you may think that you are behind them, and run the red light to give way - this is the most common reason why ambulances get whacked by on-coming vehicles even when they are on the Green light]. When on a larger road or on the highway, the ambulance stays on the fast lane (other vehicles move to give way) - no swerving between lanes, and please none of that Schumacher-like overtaking maneuvers.

Other good habits to observe - Never speed in residential areas. Don't ask for police escorts and try not to use bike ambulance escorts (it is too dangerous). Read my post on escorts. Don't ask family members to follow the ambulance. They are worried, they are stressed, they can't see anything and they want to follow the ambulance as closely as possible. That is a recipe for a high-speed backender crash. Just tell them which hospital you are bringing their loved one to. If you are stuck in heavy traffic and there is just no immediate possibility to move, turn off your sirens [keep your lights on!]. The drivers around you will appreciate it; and will try their best to give way once the traffic moves again. Go easy on the air-horn; give people a chance to move, without shocking them into an accident.

Lastly, when arriving on a road side scene, park after the collision, so that you can load your patient and move off. If you are the only emergency vehicle on scene, then park in a "fend-off" position to protect your crew and the patient. Always get someone to step out of the ambulance and guide you if you are reversing the ambulance. ALWAYS. Your ambulance reverse sensors are worth shit!

And finally, most accidents are NOT the fault of the emergency ambulance driver. In fact, worldwide, ambulance drivers report significant frustration at all the difficulties they have dealing with traffic, trying to get to the scene as quickly as possible. Whilst it is important to have a safe ambulance (so that accidents do not result in injury or death), and it is important to have safe practices (to reduce the incidence of accidents in the first place), it is absolutely essential that the public be EDUCATED about what to do when you note lights and sirens of emergency vehicles.

Did we ever learn this under the Undang-undang Jalanraya ? And did our driving school ever teach us this ? Were we ever tested on this during the on-the-road sessions ? No ?? no wonder we are now in this situation.

This is my simple suggestion for public education on "What to do when You note Lights and Sirens of Emergency Vehicles". Slow down, not speed up. Keep your hands on your steering wheel and your eyes on the road in front of you, and in the mirrors. Try to identify where the emergency ambulance is coming from. After you have done that, try to slow down and give way. Any change in lanes at this point must be indicated with your indicator lights. After the ambulance has passed, show your intention with your indicator lights again.

Never tail-gate the ambulance. Never intentionally block the ambulance. Always try to give way. Assuming that ambulances are abusing their siren just to get out of a traffic jam is a no-win situation; not giving way in these situations earns you bad bad karma.

That's it. I wish you all a safe shift, and a safe journey home.

Read some other stuff on emergency ambulances here and here and here.

Hypertensive Not-So-Urgencies

2011-08-29T22:49:00.134+08:00

Hypertensive Emergencies - severely raised blood pressures with evidence of acute end-organ damage. Usually treated with IV drugs to bring down the BP aggressively.

Hypertensive Urgencies - severely raised blood pressures with NO evidence of acute end-organ damage. Often treated with oral drugs to control the BP slowly.

Hypertensive Not-So-Urgencies : Raised blood pressures in asymptomatic patients that everybody seems to want to refer to the Emergency Department !!!

You know the story. 45 year old patient had blood pressure checked. It was sky-high. Re-checked and re-checked. Still high. Refer the ED immediately, with some scare story about "if you don't go now, you may get a stroke or heart attack" [which makes the patient's BP go even higher!] The patient then practically runs to the nearest ED.

So you get this patient, who is somewhat anxious, but otherwise, asymptomatic; and with a high blood pressure. What should you do ?

Well, measure the blood pressure again. If there is agreement with the first reading, that's it. If the second reading does not correlate with the first, do the third reading after adjusting cuff and position etc etc. Then, take the average of the two lowest readings as the blood pressure recorded.

Still high. What to do next ? I would search for end-organ damage. A fundoscopic examination to look for papilloedema (but really more to look for haemorrhages and vessel wall changes characteristic of hypertensive retinopathy), blood for renal function and a Urine examination for microscopic proteinuria. An ECG would be great.

Nothing remarkable comes back. Now what ? I would like to consider if it is due to a secondary cause eg. phaeo, thyrotoxicosis, renal artery stenosis, renal diseases, etc etc. Which needs to be considered if the patient is young (< 40 years) and does not have a family history suggestive of young-onset hypertension. If this is so, probably some discussion with the Internal Med people as to how they would like to investigate for this. Sometimes, it is done as an in-patient, other times as out-patient.

So, your asymptomatic 45 year old patient is still here. By now, you would have put the patient in observation, and repeated readings would have indicated that the BP is still high. Do we need to bring it down urgently ? I would argue against the idea. Not unless the BP is persistently above 180 / 120 mm Hg. [absolutely no evidence for those figures]. Giving the patient Captopril or Nifedipine or Metoprolol now would not help; well, maybe will bring down the doctor's BP a bit. So, then what ?

Well, start them on anti-hypertensives. According to the nice British people at NICE (NHS National Institute of Health and Clinical Excellence), who have just released the NICE Clinical Guideline 127 on Management of Primary Hypertension in Adults (August 2011), we should be starting them off with an ACE or "low-cost" ARB.

In essence, Guideline 127 says the following:

If BP > 135 / 85 and target organ damage or diabetes or renal damage or high cardiovascular risk, start anti-hypertensives.
If BP > 150 / 95, start anti-hypertensives.
If age < 55 years, start with ACE or low cost ARB.
If age > 55 years, start with a CCB.
If CCB is not suitable (due to intolerance, oedema, heart failure) use a thiazide-like diuretic (preferably Chlorthalidone or Indapamide). In Malaysia, available preparations are Apo-Chlorthalidone and Natrilix SR.
If the first line drugs don't work well enough, combine them ie ACE / ARB with CCB / Thiazide-like diuretics.

Wowwweeeee. Whatever happened to all the older evidence supporting the beta-blockers and thiazide diuretics ? I think for reasons of cost and tradition [and pretty significant previous evidence] many hypertensive patients are still on beta-blockers. In view of the high reported cases of cough with ACE in our population, I wonder if this guideline can be used at all. Furthermore, I can't think of a "low-cost" ARB; well, at least nothing as low cost as the current beta-blockers.

Anyways, our 45 year old asymptomatic should therefore be started off on an ACE (once-daily), with some aggressive talking-to about lifestyle changes (exercise, sodium control, relaxation, weight loss, stop smoking and no more watching English football! ~wink~) A discharge from the ED with a followup within a week with the GP and a repeat renal function test.

So where do the beta-blockers come into the picture ? According to them, only if the younger hypertensive patient has an intolerance to both ACE and ARBs; or in women of "child-bearing potential". Sheesh. I really really don't know how to ask this. "uhhhh are you still doing it? uhhh you know, it ..... IT ??" This is a reasonable concern though, because both ACE and ARBs have evidence to show harm to foetus in the first few weeks of pregnancy.

So, the final word on the not-so-urgent hypertensive patient ? OK-laaa keep on sending them to us; we'll sort it out. Just don't scare them too much before that ....

Whewwwww !!

Dear Malaysians,

2011-08-27T19:21:00.000+08:00

I'm SORRY I've acted too busy to really listen ...

Group A Beta-Haemolytic Streptococcus (GABHS) Sore Throat

2011-08-22T22:40:00.092+08:00

Scenario: Patient with a sore throat, goes to see a doctor. Doctor takes out tongue depressor and torchlight (because that is what they have been taught to do) and patient sticks out tongue and says Ahhhh (because that is what they have also been taught to do). But what is it that the doctor is looking for ? And why is it more important that the doctor feels around the neck rather than listen to the chest ?

Streptococcus were first categorized based on their ability to haemolyze RBCs on blood agar. Alpha-haemolytic meaning partial haemolysis, beta-haemolytic meaning complete haemolysis (which would lead to a clear patch surrounding the sample on blood agar). It was later on, with the Lancefield classification, that the various groups (A to G) came about. Historically, Group A Strep led to significant morbidity and mortality; but after the antibiotics became commonplace, these infections now cause much fewer deaths - but their adverse impact persists, especially if they are not diagnosed.

The Group A Beta-Haemolytic Streptococcus (GABHS) were the group of Strep most associated with severe infections and sequelae. They would cause "suppurative infections" ie pus-causing, in most tissues from sore throats to pneumonia, ear infections to CNS abscesses, skin impetigo to necrotizing fasciitis. In addition, this GABHS could cause two main non-suppurative sequelae; ie acute rheumatic fever (ARF) and its dreaded complication of rheumatic heart disease, and acute glomerulonephritis (AGN) and renal failure. The marked impact was that it tended to affect a population of between 5 years and 15 years old; most of them starting off with a "simple" sore throat.

Imagine that. A sore throat that would, in 2 - 4 weeks time, lead to heart disease or kidney disease that may kill the child or leave long-standing complications. Worse, it was all treatable with antibiotics in the first place.

Then why not treat all sore throats with antibiotics in the first place ? Why take the risk of the sore throat turning out to be GABHS ?

The main problem was that the vast majority of sore throats (90% in adults, 70% in children) were idiopathic (no confirmed cause) or viral in origin and not GABHS. Even if it was a bacteria causing the sore throat, only between 10 - 30% were due to GABHS. Treating all with antibiotics was just not reasonable.

How could we guess better then ? One of the strategies was the use of diagnostic criteria; the most common one used was the Modified Centor Score and Clinical Decision Rule.

The idea was that 4 main symptoms and signs were suggestive of GABHS ie sudden onset of high fever and a sore throat, swollen and tender anterior cervical lymph nodes (that's what your doc is feeling for), enlarged red and suppurative tonsils, and an absence of cough (which would have indicated either a viral problem or a problem lower in the respiratory tract). And if the patient had other symptoms like coryza (runny, congested nose), conjunctivitis (reddish, tearing eyes) or diarrhoea, it would have indicated a viral problem (which wasn't a problem at all!)

The real problem was that it wasn't very accurate; and many clinicians were more inclined to do either throat swab and cultures (which would take a day or two, at least) or the rapid antigen detection test (RADT). In our context, we have neither. So it is the Modified Centor, or nothing.

I would play it this way. A score of 3 or more would earn a course of antibiotics. And I am biased toward tonsillar exudates; so I am even more likely to prescribe antibiotics whenever I see red exudative tonsils.

Treat or don't treat, GABHS pharyngitis would self-resolve within a few days. The argument to treat was to prevent those suppurative and especially the non-suppurative complications. And probably no harm to speed up symptom relief (we all want to be known as "good docs", right ?) So, initiating antibiotics reduces the duration of symptoms by 16 hours, and the NNT (number needed to treat) for symptoms relief at 72 hours is 4 (which means every 4th patient gets full symptom relief at 72 hours - not very impressive, huh?)

Which antibiotics ? The general recommendation is Penicillin V 250 mg 3 times per day for 10 days (adults 500 mg tds 10 days); but I don't even know I can prescribe Penn-V. So the most common alternative is Amoxicillin in pretty standard dosing for 10 days. For 10 days, okay ? For those with penicillin allergies (real or imagined), Erythromicin 10 days or Cephalexin 10 days. And for those who just cannot take meds for 10 days, the only alternative is Azithromycin (for 5 days) or IM Benzathine Penicillin single dose (which I'm told makes your butt hurt for more than 10 days!)

And really, they need someone to look at them again after a week, so write that referral letter.

On a personal note, you just need one of your patients that you have sent home, to come again in a couple of weeks with Acute GlomeruloNephritis, to fully regret and REMEMBER to look for GABHS; I've had mine, and I hope this article may prevent you from having yours.

I can ??

2011-08-18T22:39:00.003+08:00

I have the dark in me, a void
that seems to take away all feeling
leaving emptiness that just aches;
and wants to pull me away into its world
away from this one of grief
This one of unbearable unbearable loss

It will get better, I can feel again
you say I can ?
you say it will ?
I don't know it still
But do tell me again tomorrow

This loss will always be, but I will continue on,
this pain may yet stumble me, but I must still soldier on,
the thoughts shall still crash through, and I will endure,
Life will move on, even if I resist, I will live on.

You say I can, you say it will,
I still don't know it now,
But please, tell me again tomorrow.

Dedicated to Friends, struggling bravely through adversity.

Emergency Physician: Communicator, Collaborator ...

2011-08-09T18:36:00.015+08:00

I have often been asked "What is the future of the Emergency Physician?" and "Why should I specialize in Emergency Medicine?". Many years ago, my enthusiasm was often met with quite a bit of skepticism. But things have changed.

If anything, Emergency Medicine is going places. Its scope of practice is changing at a pace not seen in any other specialty, creating new areas of specialty and interest, and really pushing the boundaries of acute care beyond even acute care itself.

In the recent ACEM conference, we heard varied references to the many roles of the Emergency Physician. At different times and in different situations, the EP was a :-

'resuscitationist' - all things critical care and resuscitation;

'proceduralist' - managing many of the common procedures done, even in the wards; simply because in a few years time, many would have had too little exposure to these procedures to do them well;

'diagnostician' - in most EDs in more developed systems, acute presentations are diagnosed completely before a more complete "packaged" is handed over to other teams. This must surely be one of our main aims as we develop EM here; and I think it will only be limited by our ability to perform the necessary testing, and our willpower and confidence to walk this path;

'hospitalist' - in smaller hospitals, the EP takes a greater role in the management of in-patients, both by virtue of their greater all-round experience, and probably because they are the only senior doctor around during off-peak hours.

'researcher' - it was just a few years ago, when the community was still lamenting the difficulty of getting good research done from the ED; but wowweee, in these few years, ED research have affected practices and standards not only in Emergency Medicine, but in other fields as well.

'teacher' - if anything, this has been, to my mind, the single greatest leap for Emergency Physicians in the last few years; the involvement of EPs in academia, in the training of students, nurses, allied health staff, residents and specialists in various fields.

This was definitely not the situation a short while ago. Honestly, just a few years ago, EM was very much like a child. We had childish notions. We wanted attention. "Here, here, look at me. I can do this, I can do that. See, see. Look at me!" A bit of a noisy, hyperactive kid. Lovable though [i'm biased!] because all we wanted to do, was to help; to do a part that we knew we could do, that would make a difference. But it was difficult convincing the 'adults' at the time [ie the other specialties] and especially the 'older grandparents' [ie. internal medicine, general surgery] that this noisy little fellow could actually amount to something, much less help make a difference.

But that noisy little fellow grew up; and began to make a difference. No more the ignored child, we are now often part of the adult specialties. Part of the team. A player like any other. But in some ways, this isn't necessarily a good thing either; we can too easily become "just another specialty"; just another unremarkable adult. For it was in our child-like enterprising unchallenged mind, that we managed to achieve so much; and it would be sad to lose that spirit.

So now as adults, we must still strive to make the difference; performing a part that we know we can do, to make that difference. We must learn to work within the team of adults. We must learn to communicate as adults, collaborate with adults, win and lose as adults. We must learn that life is not always a win, never fair and mostly learning to ride the ups and downs. So the EP must now be, in addition to those roles above, the communicator and collaborator.

We should learn to LISTEN to what other specialties are trying to say and understanding what they are trying to do; and we are inclined to do this well; for who else can get a history and working diagnosis from that delusional patient who is ranting away.

We should learn to TALK to say what we want without emotion, without the child-like anxiety to be understood. And we are similarly inclined to do this well too; for who else can convince the receiving teams to take our patients when we have not figured out their diagnosis yet?

And we should learn to collaborate with others, to work as a team. And here is where we shine. For we, from the first day that we stepped into the ED, have always worked in a team environment; and we have never known me, my, mine type of self-centered specialty medicine that is so prevalent in other fields.

What I have NOT heard thus far, is how GOOD we EPs think we are. That I have not heard. Because I think we all believe that we are nothing special. Difficult airway ? Nope ain't difficult; you can do it, with a few tools. Ultrasound ? Not tough, just follow these few views. Everybody can do what we do, as long as they want to. We are nothing great.

But make no mistake. What we can do, is nothing short of remarkable.

The girl that died a beautiful flower ...

2011-07-30T01:59:00.003+08:00

She was the very last patient I saw as a house-officer

On my very last day, on my very last call as an Orthopaedics House-Officer in University Hospital. I was all ready to go. I had my leave planned out. I was on the door-step to being an MO (which in those days in a huge teaching hospital like Univ Malaya meant that you were no more the smallest entity, the single cell amoeba; you were now an MO ! which was probably equivalent to a multi-cell microscopic worm or something. More advanced, but not by much!)

I was all ready to go.

She was admitted to the ward late at night. The nurses knew her well; who could forget an 8 year old with an amputated leg due to osteosarcoma, who has been in and out of the ward for the last few months.

She was severely breathless. Her X-rays were terrible; showing a white-out of the entire Left lung field and partial white-out of the Right. Haemothorax ? Pneumonia ? Those were not the days of emergency CT and ultrasound. But somehow, we got the radiology MO to do a bedside ultrasound for her that night (it was probably past midnight when it got done). It was tumour. All that white-out was the damn osteosarcoma that had taken over her lungs.

The feeling was that there was nothing much that we could do. She couldn't lie down; so we propped her up with pillows on the cardiac table, so that she could be more comfortable. And gave her oxygen. I don't remember giving her sedation or pain relief, I think it is because I didn't think she was in pain. I was sooooo wrong.

We commonly think that opioids are used in end-of-life care only if there is pain; and we often think that we often cannot give opioids if the blood pressures are low in these patients because it will make them worse. I cannot emphasize now how mistaken these views are.

Instead opioids are often given for their anxiolytic effects, their sedative calming effects; to help calm the dying, and hopefully reduce their suffering. Deep within our most basic nature is our instinct to cling on to life - it is that terrible suffering as this struggle is lost, as life ebbs away, that morphine takes away.

And there is really no contra-indication for opioids in end-of-life care; there is no blood pressure too low to give opioids. The Doctrine of Double Effect describes this - allowing treatment relieving pain, even though, it may contribute to death of the patient. The ethical arguments of the doctrine requires the following: 1) that the nature of the act itself is good (ie. giving opioids to relieve suffering in terminally ill patients is good) and 2) that the intention is the good effect, not the bad (ie. we want to relieve pain and suffering, not further lower the blood pressure) and 3) that the good effect is not the direct result of the bad effect (ie. that relief of suffering is not by means of lowering the blood pressure) and lastly, 4) that the benefit of the good effect gravely outweighs the adverse bad effects.

I will always carry this lesson from her

I now teach my younger doctors that there is no step too far to help a dying person; palliative care or comfort care must be equally aggressive as resuscitative care. I now teach them that Morphine helps a lot; and there is no contraindication, no blood pressure that is too low, no situation too severe that we can only turn away.

But she had more to teach me.

She had in the last few days, when everyone knew that she was dying, including she herself, asked her grandmother. "Why, why did God make all the other children beautiful, like flowers; why was I made ugly?" I cried that night, hearing this; I broke down. I had to turn away from the family so that they didn't see - they didn't cry, I think they had had their cry time; many times and long before.

She died the next day.

In many ways, she taught me that it is OK to show feelings. In my career, I have treated and come across many children; they are all jewels, beautiful flowers in someone eyes. I remember them not. I will never forget, that little girl who lived a beautiful girl and died a beautiful flower ...

I'm not sure I did right

2011-07-25T22:42:00.014+08:00

He was dyspnoeic; it was obvious as he was wheeled in to our Resuscitation area.

A middle aged man, transferred in from another hospital, to the Cardiology Unit; with a diagnosis of almost complete obstruction of proximal triple vessel disease, in cardiogenic shock of 3 inotrope infusions (Dopamine, Dobutamine and Noradrenaline) running. Oh my goodness me

I think the Cardio team's plan was for Angioplasty but when they first set eyes on him, they wanted an endotracheal intubation first. Naturally, the ED team sprang into action. Intubation ? Yeahhhhhhhh.

But I stopped them all. No no wait a minute. This guy only had a O2 sat of max 95% on 15 L/min HFM. And it would drop below 90% without O2. His blood pressure was holding up, he was conscious and responding to commands. But his heart rate was between 120 - 130 and intermittently he was going into shorts periods of Vent Bigeminy.

To make things worse, he had a receded chin, protruding teeth, and his 3:3:2 was only ?:2:1 (couldn't check his mouth opening). Not good at all.

My aim then was to stabilize as much as possible, prepare for the worst as much as I can, and ensure the best person intubate this patient (hoping for the best first-pass success). My instinct was to pre-oxygenate with NIV, and maybe sedate him slightly first. I didn't. So, we prepared RSI, prepared difficult airway and called the anaesthetic team.

In the meantime, we gave him a low dose of 25 mcg Fentanyl to try to reduce the sympathetic response, and loaded him with 100 mg Lignocaine to try to reduce the Vent Bigeminy; which by now was going into intermittent AV blocks and AF.

Who comes from Anaes ? Two Medical Officers. They were good doctors, really. But were they experienced enough to handle this ? I mentioned to them specifically that I think they should consider getting their senior doctors into the fray (after all, I thought that I needed to get someone better, even though I was there) but that was not taken up.

Proceeded with intubation with RSI on Fentanyl. Midazolam and Rocuronium; failed first time, struggled second time and was successful after a short period of desaturation; and then a period of hypotension which responded well to Ephedrine. Luckily, the patient was relatively stable after that.

I was there and I had a Masters student there. And I recognized that this was a difficult and complicated intubation; and I knew that if the patient had deteriorated in front of me, I would have intubated this patient. But because the intubation was "elective" in nature, it was prudent to prepare and get the best first pass success for this patient. It was not in my mind that best first pass success was more likely in the hands of two fairly young Medical Officers compared to myself or my Masters student.

I was quite upset with myself then. I think I should have insisted for the specialist to come, instead of agreeing to let the younger doctors proceed. And then having to watch them struggle in a way no better than I would have done.

I'm not sure I did right for the patient; although I did intend to. What would you have done?

Hhhhhhhhhh !

And for the Emergency Medicine people, would "delayed sequence induction" have been better in this patient ?

At the end of all that hue and cry ....

2011-07-24T00:39:00.001+08:00

... it boils down to what was lost by family and friends on that day.

A letter written by Teo Nie Ching; tears are still coming down my cheeks as I type this.

"Beng Hock, things are going fine here"

Time flies! We have not seen each other for two years. How have you been during these 700 over days and counting?

Er Jia is already 17 months old. He is just like his peers - vivacious, cheerful, active and adorable. Xin Xin, the daughter of my eldest brother, is just three days older than him so I always like to compare them.

Xin Xin is chubby just like me when I was her age, while Er Jia is thinner. I sometimes can't resist asking Cher Wei if she feeds him enough! Come to think of it, perhaps I should have kept quiet. Both of you are on the 'lean' side so I suppose Er Jia would take after the both of you.

After spending time with Cher Wei, I can see that you really 'fell' for a good woman! She has tremendous inner strength. She is taciturn in front of countless well-wishers, always responding in a calm dignified manner that she is well.

However, I did notice her message on Facebook the other day: “I was taking a ride in my male colleague's car to work the other day. Midway into the journey, he called home and asked, 'Have you brought our precious baby home? Is precious asleep now?' … his child is 18 months old. At that moment, I felt a surge of mixed feelings but the deep pain was unmistakable and unbearable…”

I felt her pain... How could such a great loss and void in her life be erased and forgotten easily?

Your mother-in-law is not doing so well health-wise. She has to go to the hospital almost on a weekly basis. Lee Lan is very worried, always telling me how she wishes you were here so Cher Wei could lean on you in trying times. She is not alone in her thoughts and Cher Wei's mum probably feels the same way.

As for your sister Lee Lan, she has been running around for the past two years on matters pertaining to your case. She keeps taking time off work and finally decided to quit her job. Her boss values her though and has advised her to think of her own future.

I also asked her what would be her ideal occupation and she replied to me with an air of innocence - a homemaker! Her reply stunned me! The many years of education provided by your parents might have been flushed down the drain!

If not for the fateful event of July 16 from two years ago, Lee Lan today might just be another carefree lass who doesn't read the news or care about what happens in this country. But of course, we can't keep harping on the 'ifs' in real life and she grew up overnight two years ago.

Your eldest brother is married and he has also become a father. Your parents are so delighted! On the day of marriage, Mandy, Huan Guan and I went to Malacca for the occasion. But our happiness was tainted with a sense of sorrow, seeing as how you cannot be with us on such a momentous day...

Here's a piece of good news for you! Elections for village heads are finally kicking off in Selangor on July 31, 2011! We used to talk about how to return the Third Vote to the rakyat. Now, although we are still way off target, this is a small breakthrough. If you were still Ean Yong's secretary, you would be very busy with this election now.

Huan Guan recently moved house but is still unsuccessful in the 'marriage department'. You've got to help him out! Yoke Kong is still the idealist in Dapsy but his beloved Arsenal is anything but ideal.

Dickson proposed successfully in Fandao's Mr Fat Café and his wedding is slated for year-end. Victor is now a photographer with a newspaper. There are lots of changes in our lives but the one thing that never changes is that come Chinese New Year, no matter how busy they are, they will visit your parents in Malacca together with me. Beng Hock, they truly are your buddies.

As for myself, what has changed? Upon reflection, I think I have gone 'soft'.

A few days ago, DAP organised an experience-sharing session for participants of the Bersih rally. Many 'previously-virginal' protestors came and shared their thoughts with great enthusiasm - how they overcome their own fear and the police barricades, dodging teargas, avoiding the water cannons and playing hide-and-seek with the cops.

They were very courageous but I was not. I am a timid person now. Two years ago, I lost my courage to invite friends to participate in rallies. I am scared.

But Beng Hock, if you were still with us, you would definitely be one of the 50,000 who turned up, wouldn't you? You would be with us together, overcoming our inner fear. I wished so badly that you could be with us that night because like me, you would be exemplified by the heroes and heroines of Bersih such as Auntie Anne, the undergraduates, the ordinary Malaysians, and see a bright future for all Malaysians.

Beng Hock, you would have watched us from afar in the last two years. Do you think our beloved country is getting better or more chaotic? Are the people more united or more divided? How much more of this challenging journey will we as a nation have to travel?

I do not know, Beng Hock, just as I do not know if I will ever find out the truth about what happened to you on that fateful July 19, just as I do not know if justice will eventually prevail. But, what I do know and what the participants of the Bersih rally know, is that we belong to this nation, and this nation belongs to us.

Dear Beng Hock, I hope you can bless and watch over Cher Wei, Er Jia, your parents, Lee Lan, and this country, from where you are now.

From a friend who misses you,
Nie Ching

Dispatched from the land you loved so deeply

Teo Nie Ching is Serdang MP.

MACC - Where is the Self-Destruct Button?

2011-07-22T05:28:00.004+08:00

Yesterday's released RCI report on Teoh Beng Hock's death was a damning report on the MACC; essentially calling them arrogant liars and willing to resort to unethical means with widespread brutalities and abuse of powers. Worse still, after just about everyone (other than the odd PERKASA ostrich) thinks that the MACC are in the wrong, they all conspired to hide the truth leading to a "blue wall of silence", a brotherhood of wrong-doers and people willing to turn a blind eye to injustice.

So here was a organization meant to reduce the crime of corruption, an instrument of the society; that had turned against the very society that it was meant to serve; torturing the people it was supposed to protect, breaking the principles of justice it was supposed to uphold, and using every means to hide evidence even after it had been found out. This was an organization where the majority of its officers exhibit a "total lack of consideration for human sensitivities."

Being wrong is forgivable. Being wrong and trying to hide it is despicable. Being wrong and trying to hide by doing even more wrong, is hell-bound.

The MACC had become the rogue robot. The bad seed. The nila that will spoil the milk. The cancer.

It needs to be taken out. Removed. Deactivated. Before it does worse. Before another Teoh Beng Hock. It needs to be destroyed, so that another, a better body can serve the needs of all Malaysians. It needs to go.

So, where is the self-destruct button ?

ACEM Day 3 - Everybody's looking forward to Tokyo 2013

2011-07-07T01:34:00.001+08:00

Well, it ended with a bang. ACEM 2011 certainly lived up to all expectations.

Day 3 started off poorly though. An Innovations in Emergency Medicine talk that had so much potential; but fizzled out a bit. It would probably have been more powerful if recent innovations were emphasized, instead of a list of changes implemented over many years by the speaker. Then the FIFA Medical Director came on to talk about emergency management during major sporting events. Sheesh he came up with a presentation I thought a EM resident would easily be able to prepare. Quite a let down.

But the day progressed on quite well; and the lunch symposiums by the Japanese on their response during the recent earthquake tsunami disaster was a real eye opener. I really take my hat off to the Japanese; they really think problems through, implement plans locally then nationally once the plans have been shown successful, and importantly continue to collect data and audit their performance.

Example. The Japanese DMAT team consist just of 4 - 5 persons team; about 2 doctors, and the rest allied health professionals. Their aim deploy quickly to disaster base hospitals, support those hospitals in the early hours, and finish off their duties within 72 hours. Really good laa. We must think more about this, in terms of supporting our district hospitals in times of need. Actually, if in true Japanese style, we must not just think about it, we must do and try and see if it works. Ganbatte !!

Anyways, wife then says we are going to Ayuthaya, by TRAIN !! 2 hours trip, no reserved seating, no aircond, but a true blue Thai common man experience. So off we go to Hualampheong Station, buy the ticket and jump on board within 5 minutes. It was great. Good views, clean, safe and nice. For only 30 baht for 2 of us. Free for Rui Han. The weather was quite hot for her; but she probably needs toughening up a tiny little bit !

Note the sweaty foreheads and the hand-held fan.

Arrived at Ayuthaya Station, walking to the river, sat on a boat across it for 3 baht per person, and had a nice dinner overlooking the river.

A barge pulled by a tow-boat was carrying stuff down river, probably to Bangkok. Didn't know that it was still a route for trade till today. Now blogging for a 100 teak wood guest house. Roof, walls, floor, bed, chairs, balcony, door and windows are made of teak. A truly Thai experience. Another million thanks to the wife. [trust me, she's counting] Heh heh heh.

And thanks for the comments all of you. I can be so unabashedly "fishing" for comments, huh ? But not too difficult to comment either, right ?

Heh heh heh

ACEM Days 1 and 2 - What a conference !!

2011-07-06T00:26:00.000+08:00

Honestly, the Thais are amazing. They have put together a wonderful conference, well-run, professionally coordinated and totally enjoyable. And I really don't know how they can provide so much. Really fantastic.

And the Thai people are just too nice; so much so that I want to bow to everyone and clasp my hands together all the time.

Day 1 started off very well with a highly inspirational plenary by Prof Sant Hathirat, the President of the Thai Association for Emergency Medicine. He spoke on the need for Emergency Physicians to be more active and involved in preventive medicine, campaigning to reduce injury and illnesses. Lean, safe and seamless EM is preventive EM. Lesson number one for me - start being more vocal about dangerous behaviours in Malaysian society that lead to ED visits. He talked about "more touch and less technology" medicine; and about mindfulness about our patients wishes even in dying and death. And "Sammaditthi" (Right Understanding in Buddhist terms) of hospital administrators about the roles and priorities given to emergency patients. It was nice, and it set the tone well for the conference. A conference of a growing specialty, more confident of itself, expanding its services mainly to serve our patient's better outcome, and being their advocate within the healthcare system. He couldn't help but whack commercialized medicine. Well done Prof !!

Then it was running here and there trying to catch up with the different sessions, and meetings. Managed to sit in at the RCA meeting (which was great) and I'll try to blog about that at a later date.

Before I knew it, it was the end of D1. D2 started off very well too with Assoc Prof Eillyne Seow talking about what is an Emergency Physician. I can tell you one thing; that presentation has changed markedly in just the last few years, showing me the amazing strides that the EM world has progressed in just these few years. She put in a nice touch too, having video interviews with different staff members about what they thought made an Emergency Physician. And ended it beautifully with a tribute to her teachers, and our teachers, who made us who we are today. Nice, nice, nice !!!

And suddenly, after quite a bit of running around, trying to get to as many sessions that I can, it was my turn. GULPPP !

And there I was in the same session with David Cone, who is the Immediate Past President of the NAEMS, Russell McDonald who I recognize for all the papers that has come out of his Toronto group, Taku Iwami who has done great work in improving the Bystander CPR rates in Japan to over 40% (!!!), Dr Wen-Chu Chiang from Taipeh and Assoc Prof Atilla from Turkey. Whewwww !

Had a great session over protocolized medicine with speakers from Singapore, Hong Kong, Australia, Thailand and Brunei. Finally heard some comments from Thai Emergency Physicians; speaking of their frustrations when dealing with other specialties. Exactly like what we used to do just a few years ago. My words of "encouragement" to them, exactly as I received them those few years ago is this; don't worry, you will out-grow them, out-number them, out-rank them, out-persevere them and out-work them in just a few years time; and it will just get easier then.

Ended the day with the Congress Party (no, not the Indian political party). It was the conference dinner; complete 4 course Western dinner with Cultural Show entertainment and some ad hoc stuff (including some unabashed showcasing by our delegation, I might say).

Even the desert was "gaya" with chocolate printed with the name of the conference. A nice touch, really!

Had a very useful discussion after that about the possibility of setting up an MCEM pathway here in Malaysia. Will blog about that later too. (Maybe I won't, considering nobody reads this blog anyways; at least nobody comments, so I think nobody reads it) I syok sendiri only!

A really nice 2 days; and looking forward to a great final day tomorrow. Only one regret. I haven't met the Thai Emergency Physicians. I know there are many of them around, but they are quite reserved; and I am not particularly good with social skills either. This conference would have been so much better, if they were front and center (where EPs always want to be, right?) but I think their politeness, reservedness and hospitality may have put them away from the limelight. It would be a huge shame if I go away from this conference only knowing that handful of Thai EPs that I now know.

The adventure begins

2011-07-02T22:32:00.001+08:00

Going to Bangkok to speak at the Asian Conference of Emergency Medicine 2011. It will be an adventure, and a start of a 2 week holiday. Going with the wife and daughter. Why adventure, you ask ?

Not because we are traveling in luxury on this Star Cruise Libra

Actually we are taking the Butterworth to Bangkok Train; apparently, the closest thing we can get to the Orient Express (it was previously known as the Eastern and Oriental Express) or at least that's what the wife tells me. I think some part of the truth may have been inadvertently left out to persuade me to take this 22 hour journey.

Yup, 22 hours; leaving Butterworth at 1440 and due to arrive in Bangkok at 1245 the next day. The train arrived late. All my imagination about the Orient Express, and massive decorated trains with old style charm, was immediately let down when 2 coaches pulled up. Just two.

Apparently, these two coaches, belonging to Thai Railways, will be pulled by KTM's train head to Padang Besar, where the Thai Railways train head will take over. And when the train reached Hat Yai, the other 8 coaches will be added to the front.

It was NOT the Hogwart's express. But it was actually quite nice. It was comfortable and clean, and the service was good once we got across the border. Heh heh heh. Why does all the fun start after crossing outside Malaysian borders ? The coach attendants suddenly whips out the beer and starts taking orders for food.

On the whole, it was comfortable, and enjoyable and really a treat. So much so, that we'll probably take the trip back as well in about two weeks. Thanks a million to the wife.

The train, despite leaving late, arrive at the suburbs of Bangkok at around 10 am the next day. People started getting off; except the foreigners who were aiming to get off at Bangkok's Hualampheong Station. It would have been perfect if the train did not get held up for almost an hour just 1 km from the station because of some technical fault.

Finally the train conductor just instructed everybody to get off the train; there we were lugging around our luggage across train tracks, and trying to hail taxis in the middle of a highway.

So we were quite hot and sweaty by the time we got to the hotel. But just look at what was waiting for us at the hotel room ?

No wonder people just LOVE Bangkok.

Who deserves the use of YOUR emergency ambulance ?

2011-06-20T23:41:00.001+08:00

Yes, it is YOUR emergency ambulance.

After all, if you or any of your loved ones ever developed a stroke or heart attack, or been involved in a severe accident, those few ambulances with those few paramedics in them, which constitute the emergency ambulance services of your community, will have a vital role to play in whether you lived or died. So it is important for you to know about YOUR emergency ambulance service.

So, who deserves to use your emergency ambulance ? You can probably rightfully have a say. But before you decide let me tell you a few facts first. Then you decide.

Your emergency ambulances are mainly situated at the nearest government hospital; they are mainly staffed by the Medical Assistants (MA) who also work in the Emergency Department at the same time. In a typical hour, in a typical shift on a typical day, there are 5 - 6 MAs on that shift; one will triage about 20 patients in an hour, another will manage about 4 - 5 emergency calls at the Call Center dispatching ambulances and coordinating their arrival. Another MA will be suturing about 3 - 4 patients with lacerations, leaving the last 2 - 3 to handle the 20 odd patients that are already in the department and the 20 more who have just registered during that hour.

Ooops where is the MA for the ambulance service ? Well, it's going to be one of these 5 or 6 MA. There's no one else. So when ambulance requests come in, someone leaves the floor for that period to attend to that ambulance run. And if two come in at the same time, then the second MA leaves, resulting in the remaining MA struggling to hold the fort. This is a situation that occurs all too often; we manage more than 800 runs every month; making it between 25 - 30 ambulance runs every day. We are therefore the single largest emergency ambulance service provider in the country. Not a fact that we are proud of.

So who deserves the use of your emergency ambulance needs to be considered more carefully. Because abuse of emergency ambulances not only means there may not be ambulances for use when true emergencies exist; it also means that the Emergency Department may not be able to function as well as it wants to, because the MA is out of the department on the ambulance run.

I say this because yesterday night, our ambulance responded to an emergency call from a distraught caller for a patient who was very breathless. The "patient", when our ambulance team arrived on scene, was the family dog! The dog was, unfortunately, dead.

It is difficult not to either laugh off the whole thing (which is what the MAs did) or be pissed mad with the caller (which is probably what most of us are feeling at the moment). To their credit, seeing the distraught nature of the caller, our team advised them to call the vet, and left without incident.

But the real issue is who deserves our emergency ambulance ?

Nobody doubts the validity of almost all the emergency calls that we get; from road traffic accidents, to medical emergencies at home. Nobody doubts the use of emergency ambulance to pick up the sickly old man from his home because he can't come by any other means. Or the bed-ridden nursing home resident with pneumonia. Sure, we'll go pick them up.

But how about the girl with a headache with family members at home and a car ? Get the ambulance or get into the car ? How about the patient already at the clinic, seen by the doctor and possibly needing admission in hospital ? Get the ambulance or get into their car outside the clinic ? How about the VVIP who wants an entire ambulance team to follow them around, just in case they collapse from all those years of over-indulgence ? They even insist the ambulance follow them around, but just out of sight, so that they don't "lost face" for having need an ambulance following them.

So, for YOUR emergency ambulance, are they deserving ? You decide. Just remember, one day, if it is your time and your turn at the Emergency Department, and your MA leaves you unattended whilst he runs off on yet another call; or when you call for an ambulance and it just doesn't come because it is somewhere else, catering to yet another non-emergency, just remember, it was your decision and it is YOUR emergency ambulance service.

At the moment, I'll present your point of view, I'll take the flak on your behalf; I can't do much about the VVIP though; you have to change that.

My MAs are just great. Despite all that is thrown at them, they can still see the bright side of things; they can still find the laugh in an outrageous situation. They're great and I'm truly proud of them.

Happy Medical Assistant's Day.

Universal Donor FFP ?

2011-06-07T19:31:00.028+08:00

Yeah, we know about the Universal Blood Donor ie the O-Neg donor whose blood can be safely transfused into almost any patient. The reason that they are 'universal' is that in O-Neg persons, there are no major blood group antigens on the surface of their Red Blood Cells; thus any major blood type antibodies that may be present in the recipient's blood will not act upon and destroy the donated blood cells.

That's why O-Neg blood is often used as Safe-O blood ie blood that can be transfused in the exsanguinating trauma patient immediately without needing a cross-matching procedure. So, the person with O-Neg blood is a highly valuable resource; someone with the true God-given, parent-delivered ability to save lives.

In Malaysia however, Safe-O blood is NOT O-Neg blood; it is most often O-positive blood. This is quite understandable considering that more than 98% of Malaysians have a positive blood group. So O-Neg, and in fact, all negatives are rare; which would make it logistically impossible to maintain Safe-O as O-Neg blood. Although this works out well most of the time, it is in the 2% where it may cause a problem for the patient. It is predominantly the Indian community where Rh-Negative blood is relatively more common (up to 15% in some reports). Therefore what I would suggest is that if the trauma patient is a young Indian lady, do not give her Safe O blood. The risk-benefit ratio needs to be weighed extra carefully. Come to think about it, give it a second thought anytime we deal with a young lady of child-bearing age and has not yet potentially completed her family.

In short, universal blood donor is O-Neg. In Malaysia, O-Positive [almost] boleh-lahhh.

But this only applies to packed cells transfusions. Yup, only to the red stuff. Not to plasma.

Recently a lot of attention has been given to the role of plasma transfusions (in the form of FFP - Fresh Frozen Plasma) especially in trauma resuscitation; where its role in assisting correction of coagulopathy and in "damage control resuscitation" has sparked lots of interest. The magic ratio of 1:1 of plasma to packed cells transfusions has been mooted as the most physiological replacement in trauma resuscitation. Some have even gone to 1:1:1 where platelets are added in too. [1 pack of platelets equiv to 6 units of packed cells or plasma]. The use of plasma is increasing rapidly as a result of this new knowledge.

So, is there a universal donor for FFP ? is it still the same O-Neg ?

Interestingly, NO ! The O-Neg people have no major blood group antigens but their plasma is loaded with every major antibody !! So the universal donor for FFP is in fact, at the other end of the spectrum - the AB-Positive guys. People like ME ! Heeheehee ! [I used to think my blood was quite useless to help others!] So the AB-Positive guys have essentially NO antibodies in their plasma which will react with the major blood group antigens in the recipient's blood.

And when I say the Universal Donor for FFP are the AB-Positive guys, i really do mean guys! For some not-too-clear reason, HLA antibodies found commonly in women, especially multiparous women, often cause damage to the lungs leading to Transfusion Related Acute Lung Injury (TRALI), the most common transfusion related death.

See, women just have something in them that gets under your skin, into your lungs ...... heh-heh-heh ! Boy, am I going to regret saying this !

The question is, is the FFP transfusion going to achieve a protocol somewhat similar to the packed cells transfusions - will we see a Safe FFP transfusion protocol one day, similar to the Safe-O protocol ? One day soon, I hope.

The argument seems quite strong for its use in trauma resuscitation. FFP contains all the clotting factors, fibrinogen (400 - 900 mg/unit) and plasma proteins (esp albumin). Frozen soon after collection, it can be stored at -30C for upto a year. Thawed in 20 minutes in a water bath (or microwaved for 2 minutes; FDA approved) and given soon after, even the activity of labile clotting factors (V, VIII) are relatively maintained. Also, plasma transfusions are much much safer than packed cell transfusions with a much lower risk of transmissions of infectious diseases.

So we may soon see a Safe-FFP transfusion protocol one day. I suspect when that day comes, all the gals whom I've pissed off with my earlier comment, will come march me to the Blood Bank to bleed me dry!

OK laaaa for a God-given Parent-delivered ability to save lives !

"Today"

2011-06-03T05:58:00.004+08:00

Today had all inklings of being a good day.

It started off with a Mass Casualty Incident (MCI). Hahaha. Only Emergency people would consider an MCI in good day terms. But well, for an MCI with 2 critically injured and 8 with minor injuries, all managed well; it went smoothly and it ended well. That must be considered good.

So we treated the patient with Le Forte II fractures and bilateral zygomatic arch fractures (I suppose that would make it functionally a Le Forte III) who was bleeding away. Intubated for airway protection. CT done. Throat and Oral Cavity packed with gauze. Nasal cavity packed with the Rapid Rhino (quite happy with the ease of its use laaa). Sedated and paralyzed. Fresh Whole Blood transfusions and DIVC early early on. Stabilized the patient quickly; then waited almost 2 hours for ICU bed (aiyahhhhhh). Never mind, it went well, it was good.

Then there was the other patient who felt giddy, and fell a couple of times; bumping his head. On initial look, he was not really "with us". His GCS was scored initially at 15, but corrected to 13 on review; where we thought he may have had a stroke / bleed. CT ordered. Whilst waiting for CT to call, his GCS deteriorated further to about 9. So he too was intubated and ventilated. The CT later showed a deep intra-cerebral bleed with mass effect and midline shift.

Another man walking in, fully conscious with full neurological functions, complaining of persistent headache following a punch-up with a family member 5 days ago. Just headache. So we CT scanned him. Lo and behold, a tentorial area SAH. I tell you, these type of patients give me the shivers. No decision rule would have picked him up. On the other hand, these are the patients that tell us clinical acumen of the emergency doc is more important in deciding whether a CT is needed or not, rather than a radiology MO on the phone. It is definitely time to take the Radiology MO out of decision-making for emergency CTs.

We had a patient that we diagnosed with posterior circulation stroke; based on abnormal Head Impulse Testing, unidirectional nystagmus and a squint which only revealed itself on the cover-eye test. [will blog about this soon!]

We also had the patient in severe shock with wide QRS complexes at a vent rate of 140 bpm; who was transferred in from a private hospital with a referral for sepsis and hyperkalemia. The documented K level was 6.5 and the ECGs didn't improve with Calcium administration. On the monitor, we saw P waves; so there was some discussion whether we were dealing with VT or LBBB with Cardiogenic Shock. Anyways this patient required inotropic support, non-invasive ventilation (CPAP) and quite a lot of worry. I think will need to research and blog a bit more about differentiating VT from other conditions.

We had old people the whole day too; as with any other day here in Penang. Many old people in Penang live along; many live with very little social support, some with none. Many old people are taken care by equally old people. We need to be better at how we support them. We need to.

We had people with advanced cancers and chronic diseases walking in with peace on their faces. We had people with minor injuries coming as if the gates of hell had opened in front of them.

We even almost diagnosed a starvation ketoacidosis! She did look like the UNICEF pictures of starving children.

It was interesting. You know, it was one of those days that you would have gone home tired, but happy. One of those days that you would have wanted again and again. One of those days that made you an Emergency person.

But for me, it was spoilt by afternoon. I had to answer and meet complainants; who had a wound from a fall, and that wound did not heal. They went to a private hospital and then all kinds of allegations came up. I did not fault them for seeking redress for the non-healing wound. I apologized repeatedly on behalf of the whole department and hospital; although I had nothing to do with this patient in the first place. But I was most disturbed that they were saying all kinds of things without any backing what so ever; things like "the doctor didn't even see me" and "they didn't clean the wound properly" and "it is negligent if small foreign bodies are left inside - similar to leaving a gauze in the body post-surgery". Saying all these things, just to get their money reimbursed for private hospital care.

At the end of the day, I wondered to myself, for the RM 1 that they paid, they got haemostatic suturing of bleeding vessels, doctors examination, X-ray with doctors review, wound cleansing, wound irrigation, wound closure, medications, appointment for follow-up, all within 2 hours. Find me another place anywhere else in the world where that happens. What did we get out of it ? A complaint. Many many many hours of reliving the trauma and dis-satisfaction of having to answer queries again and again. Even more hours of wondering why we do all this in the first place.

So I did not go home tired and happy. I went home DEFLATED! I was a dejected flat tire. In these situations, before actually reaching home, I usually try to "take a break"; spend some time alone, with a teh tarik or something. Just so I don't bring back home that unhappiness and feeling of wanting to lash out. Teh tarik works wonders in these situations.

Had dinner out with the wife and daughter. On the way home, daughter slept off in the car. As I carried her home on my shoulders, everything bad just washed away. Everything was right with the world again; with my world, at least. And I had the energy again, to do it all over.

Thank you, my Chabou and my Chaboukia.

Give me your tired, your poor ....

2011-05-23T23:06:00.003+08:00

The famous words of the sonnet by Emma Lazarus in 1883 engraved on a bronze plaque mounted on the Statue of Liberty, rang throughout the world,

"Keep, ancient lands, your storied pomp!" cries she
With silent lips. "Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"

I have always felt that Emergency Departments are somewhat like that; we hold out our lamps beside our door, calling out to all to come, whenever and why-ever.

And they do come; but not the "storied pomp", not the rich and powerful, not the high and mighty, not the First Malaysians. The true people of Malaysia come to our doors. The sick and injured come, the young and old. The poor come because they have no where else to go. The homeless are brought in when the powers-that-be want to clean up the streets. The disheveled and disowned come in at all times dirty, smelly and often injured; before going back to wherever they came from, I hope they would have received a bath, and a change of donated clean clothes. The abused land up here. The old are often "dropped off" here. The "crazy" are dispatched here as well, often to keep out of sight, out of mind.

"Give me your tired, your poor, Your huddled masses yearning to breathe free, ...". Don't you agree with me ?

But sometimes, even we, holding out our lamps, welcoming everybody, whenever and why-ever; sometimes even we cannot tahan !

We are after all, merely human. Sometimes we just don't know what to do. What would you do .....

... for the old man who calls for the ambulance 2 - 3 times per day, every day ? We have responded to him more than 30 times already, admitted him several times [just to stop him calling], arranged psychiatry review and followup [absconded] and even had discussion with his son and family members [they washed their hands in abject ignorance].

... for the foreign tourist who comes seeking for anti-rabies vaccine [which we don't have because we don't have rabies] after being bitten by a dog in Thailand; and then scolds you for not having it ? [We even returned his RM 50 !!]

... for the private hospital patient who comes in with disgust and disdain on their face, looking down at everything that you do, after they ran out of funds to pay the private hospital ?

... when your fellow doctors in private practice feel the need to criticize the Emergency Department just because they feel that we are "taking away" their patients and their livelihood ?

... when your colleagues in the hospital insist that only "good house-officers" are sent to Anaesthesia; leaving the others to you at the ED ?

I really do not know. I am just a simple doctor; and I only know one thing for sure. We try to be a beacon of hope, of help, of care. We may not be what you expect, or what you see on TV; but then we live in a real world, don't we ? We may not be as good as you want, but we are not as bad as you think. Isn't that the same as everything else ?

At the end of the day, a beacon like the Status of Liberty is strong in its appeal and its perseverance. Simply because it asks nothing of you; but to see its light in your darkest hour.

Misi, Visi and Tbilisi !

2011-05-05T01:31:00.003+08:00

If I wanted to claim to know about Tbilisi, which incidentally is the capital city of Georgia, one of the former Soviet Baltic states, I would think that I would have to know much more than merely the words describing it. Knowing that Tbilisi is a capital city of a former Soviet state does not equate with knowing anything about Tbilisi itself. It takes much more than that; it probably would take quite a bit of deeper reading, maybe some questioning of persons who have been there, and most likely some time actually living there experiencing it first hand; to be able to say that one knows a bit about Tbilisi.

We have been engulfed in a "quality" storm over the past few years; held hostage by administrators and pseudo-experts, all trying to implement so called quality systems. And apparently, all quality systems must start with knowing the Misi and Visi [Mission and Vision] of the organization.

Now, I always thought that Misi and Visi statements should be simple, so that everyone can understand and remember it. Visi should be something like "We want to be GOOD at what we do; and we want to get better at it!". Now that's a good Visi. And then Misi would about 4 - 5 lines about how we can be good and get better. Easy, right? But nooooooo. Not in Malaysia. Our sense of political correct-ness and boleh-ness makes us write long Visi sentences full of "excellent" and "world-class" and "world leaders" etc etc. And all in English, which means that the vast majority cannot understand any of it, other than knowing it is the Misi and Visi poster, pasted on the wall, here, there and everywhere.

And then, it gets worse; much worse. Now if you have ever been struck by this "quality" plaque, my commiserations and condolences to you. If you have not, run away; run now, don't look back. Go! Go! Goooo !!!

Essentially, quality systems worldwide have gained huge prominence; in Malaysia, we are just following the trend, I suppose. For some reason, the people attracted to it are often retired hospital administrators, who seem to have missed the sadistic joys of torturing people during their time in service. [Heh heh heh.] Furthermore, as government pensions are not enough, these systems are ...well, a way to make an extra buck.

For years, as generations of administrators retired, one after another quality system has been espoused and "implemented" in our services. They all have several things in common;

They start but never end; quality systems that were out of fashion 20 years ago, still exists in some form within our system today [don't believe me ? QCC (quality control circle) = KMK; QAS (quality assurance system) = that "Q" sign you see everywhere, esp on Hari Q days; ISO / TQM were all quality systems that were developed in the 1980's !!! 30 years ago. BEFORE the internet. BEFORE your handphone. BEFORE most of you were born even. They just don't go away !
They are all about "documenting" how we do our work; who cares whether the work is done right or not, as long as the documents are OK, semua boleh !! And since most of our staff are now busy documenting how they are supposed to do their work, they simply don't so their work. Damn good quality nowadays ! Not so sure about the work, though.
The auditors / surveyors are pseudo-experts ! They are no reference person, no expert in the field. Their only claim to expertise is work experience as an administrator; and a couple of days training session. [most likely learning the best ways of torture]
There is always an element of sado-masochism; we pay these "experts" to come and torture us. Then we must grin widely as they bugger us. And then we have to pay them even more to come back again in a year's time ! And these pseudo-experts make their own rules. If you dare oppose their views or even ask them why, or to show some evidence how their suggestions are actually better, their lips turn into grim, thin lines, they keep quiet and scribble onto their clip-boards, and you are CERTAIN to be called up later for non-compliance. So everybody is taught to just bend down and .... [and think of the Queen of England, as they used to say].
Thus far, quality systems for manufacturing have been "modified" to suit the healthcare environment. QCC and the early quality stuff was mainly Japanese manufacturers; ISO was mainly manufacturing, TQM came from Toyota. Even newer ones like Six Sigma came from Motorola and LEAN is from again from Toyota; having morphed through various versions including Just-in-Time and Kaizen. Until very recently, nothing, absolutely nothing, have been primarily meant for Healthcare. Surely making a car through a production line is very different from a clinical care pathway through an Emergency Department.
All this morphing and modifications, all these versions, all these changes in various quality systems just mean one thing and one thing only. There is NOT a single good quality system. Why change if it was good in the first place ? Why improve when it worked ? The very point that quality systems continue to change speaks loudly of the very failure of these quality system. Or worse, people just want to implement another system, just for the fun of torturing others, or making even more money.

I am not against quality systems. I am fully supportive of making continual changes for better outcomes. Here is where my view differs. It is the outcome that I am interested in; not the process. In manufacturing, the principle of correcting process in order to produce a consistently good outcome, cannot apply to medicine and healthcare. Here, outcomes have other factors involved. Hence the need for evidence. Everywhere in medicine, evidence is KING. But quality systems seems immune from this need; applied more on the whim of administrators and auditors / surveyors than real evidence. This cannot be correct. The quality system before being applied, must undergo some rigorous process to show that it makes a difference to outcomes. Or else, it is as good as anything a road-side peddlar with a sweet tongue can sell from Chow Kit road.

And Misi and Visi, like Tbilisi, requires deeper reading to understand its core intent; questioning and probing to answer doubts, disagreements and to resolve conflicts with personal values, and the actual "living" of the concepts containing within. [The Bahasa Malaysia word "menghayati" is much better than any other English term I can think of]. Only then, will we know, really know, our Misi and Visi. Only then, will we truly "Menghayati Kualiti".

Bro Felix J Donahue

2011-04-30T23:38:00.002+08:00

I will always remember him as a white haired man, in a white robe. A quiet sort of man. I didn't really know him well. Bro Felix was the headmaster of LSPJ when I joined in Form 1, a young boy. And he was still there when I left seven years later after Upper Six, a young man.

To me, he has come to represent all that is good about the Christian brothers schooling in Malaysia. The understanding that children learn by example of their teachers, not merely by their words. That children grow when given the opportunity to try out, and to fail. Be it in sports, drama, public-speaking or even in entrepreneurship during canteen day events. That children must learn the value of working hard for money. Be it washing cars to raise funds for tables and chairs; or doing odd jobs for charity. That children learn the meaning of being a friend and a brother. Be it in class or outside; and for the many years thereafter.

I am truly thankful for all that I had the opportunity to learn and experience. I am truly thankful of all my friends from school {tomorrow, we celebrate 25 years to the day when we entered Lower 6]. In some ways, I do regret that I really did not know Bro Felix very well. My last few experiences with him weren't favorable. I had been "upset" with him from not turning up for the Librarians Annual Photo Session. Looking back, I think all my unhappiness was because I really really wanted recognition from a man that I admired very much.

Bro Felix turned 80 today. Happy 80th Sir. Thank you Sir. God Bless.

I was so tempted ...

2011-04-21T03:38:00.002+08:00

I was driving my 22 year old Ford Laser; and was held up in traffic. Which I soon discovered was due to a convoy of Lamborghinis [at least 10 of them] which had a police outrider holding up traffic for them. So there I was, stopped by the police outrider, at the head of an increasingly long line of cars, similarly held up.

I tell you, I was soooooo tempted, really really tempted, to just surge forward and crash into the convoy of Lamborghinis ! At the very least, I can take out a few of them. Heh heh heh heh. My 22 year old Ford Laser, road value of less than RM 3000, taking out a couple of million bucks worth of Lamborghinis ! Heh heh heh heh ! It would have made the news; maybe even Reuters ! Oprah may have wanted to interview me. Heh heh heh !

Before you report me as potential pengganas or psychopath, let me tell you where I come from.

Everyday, I see sick and injured people brought in to the Emergency Department in varying degrees of distress. Some of them were brought in too late. They were dead on arrival. I'm sure the ones bringing them in would have wanted to come in faster, and not be stuck in traffic. I'm sure they would have said a silent prayer for a green light and a clear road. I'm sure any police outrider at that time, would have been like an angel sent from God himself. But life, at least for we common folk, is not like that. The world we live in is not one of Lamborghinis and outriders.

Today, there was a huge discussion about the high incidences of police summonses on emergency ambulances for speeding and for driving through red lights. Ambulance drivers would have to pay the fines; head of departments were hauled up for explanations. These ambulances were responding to emergency 999 calls or bringing sick and injured patients to the hospital. They were not out on some joy-ride, speeding and running red lights for fun. Look, I am NOT cordoning dangerous ambulance driving. Safety is always first for ambulance teams. But to SAMAN our ambulances ?

How about all the convoys of VIPs with outriders and sirens blaring; racing at speeds way above the speed limit, on their way to their next political event ? How about the Minister of so and so who insists on outriders so that they can save 10 minutes of travel time because their time was more valuable than the rest of us ? How about those Lamborghinis waved across the red lights, whilst the rest of us stopped on green ?

My friends. I come from a simple place. I truly believe we should be fair, a nation of ONE people, ONE system. But we are not. There are separate rules for VIPs, for Ministers, for Lamborghini owners. For these favored ones, their Malaysia is not our Malaysia. Their Malaysia is their playground, we their serfs. They First Malaysians; we all Second. And that is what pisses me off.

So, on behalf of all the Malaysians who have died on the way before reaching hospitals, hoping for that police outrider that never came; on behalf of the ambulance drivers who have to pay police summons when trying to reach the emergency patient in good time; and even on behalf of the outriders, past and future, who have been injured and killed on the job. On behalf of all of us Second Malaysians held up waiting as Lamborghinis zoom past us; I say this to them First Malaysians, F=== you !

Sarawak Girl

2011-04-10T23:03:00.004+08:00

Oh Sarawak Girl, you young unsullied beauty
Guys are coming a-courting
They want you; they all seem to
Pick me ! and not them, they chime away
They want you not; only the prize of you
The trophy that you are

In T-shirts they come; grinning to reveal their molars
Old tainted fools trying to look fresh and new
Promising you the world (and the afterlife if they could)
Just pick me ! and not them, the chime becomes a chant
They want you not; only the prize that you hold,
The trophy that you are

This side of the sea, we are your older sisters
We were once young and wanted
We had once been wooed
We picked them again, and again,
thinking their promises were truth
We are older now; some of use are wiser
But we are trophies no more

Oh little sister Sarawak
Pick carefully
Listen not to old promises from white-haired men
It is time for new
It is time for change

Show us the way; show us you can
We want to be young again too
Oh Sarawak Girl

A chance to touch another life

2011-03-22T18:26:00.001+08:00

Working in the Emergency Department, we sometimes get caught up too much with the idea of "saving lives". Sure we do our bit, but most patients who are meant to live, will live. [despite our best efforts to kill them!] Heehee. And many patients who are likely to die, will die. [despite our best efforts to save them]

In many ways, the actions and interventions done [or not done] at the ED changes the lives of our patients. It is a unique, and heavy, responsibility; which all too often is under-emphasized. It goes far beyond impact of missing a diagnosis. It includes the opportunity to correct a bad habit (eg. smoking) in a patient who has had an unexpected chest pain episode. It includes the possibility of getting a young man to change to a car instead of his bike after a road traffic accident injury. Even being able to pick up the abused child or the victim of domestic violence, and knowing what to do, may touch another life, or lives, in such a big way.

When I think about it, this applies in other areas as well. I, in my short professional career, have tried to be gushing in my praise and recommendations of my friends and colleagues, whenever they need it. I have always thought that being free with praise and recommendations would open doors for them, and it has for so many. I have never thought that it would affect whatever reputation or name that I may have; and I don't really care. Honestly I wouldn't mind being known as gushingly supportive of my friends and colleagues. It is just my small way to help, and maybe make a difference in another person's life.

We had a patient the other day; who was a Chinese national, brought in by the police for dysmenorrhoea. Apparently she was held for prostitution. Her card showed her to be 21 years old; she looked in the 30s to me. Life must have been tough; and must still be tough for her. According to the doctor who saw her, she came because she wanted someone, anyone, who could speak Mandarin, to pass a message to her friend that she had been caught by the police. But nobody helped her do that on that day. She got her medications and she got sent back to the police lock-up. I think nobody believed her; and nobody seemed intent on helping someone who comes in inmate garments and handcuffed. I think it was sad.

What would we have lost by calling a number ? credibility ? reputation ? a few minutes of time ? What would we have risked ? looking silly ? being a hopeless optimist ? the police thinking that we are helping a criminal ? I think we lost a chance to touch another life, almost a chance to save a life. I think, the risk of appearing to care for a prostitute, led us to hide ourselves; letting her down and letting ourselves down as well. I think it was sad.

Being able to touch another life is not very different from saving lives at the Emergency Department. The opportunity comes rarely, often at the most unexpected time. And the chance to do so, only lasts for that fleeting moment. And for that fleeting moment, that chance only appears to you. Grab that chance, my friends. You have really nothing to lose.

Think of it as "You can, therefore you should" and "I can, so I must".

Hung out to dry in the radiating sun

2011-03-07T19:39:00.001+08:00

Whewww ! It has been a while since I blogged. Not really because I had nothing to say; more because I had no time to say it in a blog. And unfortunately sometimes too angry to say anything at all.

Today another issue cropped up. Young 6 month pregnant lady comes to the ED after a road traffic crash, in which she sustained some injury to her face, nose and chin with some superficial bruising over her left shoulder. ABCDEs check. Although she came with a GCS of 15, she definitely had retrograde amnesia, and continuing bleed from the nose. The base of the nose is swollen, and the inter-canthal distance is 35 mm. No evidence to suggest intra-orbital injury. A quick bedside USS showed nothing remarkable and normal foetal parameters.

X-rays ? CT ? Hmmmm needs some discussion; better yet, let's discuss this with the other teams. What was a shocker was how the other teams responded. Surgery comes and says "It's ED's patient; and Surgery does not want to decide whether any imaging is required or not". Obst and Gyn comes and says the same thing.

And radiology comes up with a form that they insist we fill up if we wanted any x-ray imaging done. That form essentially requires the patient to sign and say that they have been informed about the risks of x-ray imaging (which includes miscarriage, mental disabilities of the newborn, physical deformities and fatal cancers; but without any hint of numbers indicating degree of risk). Worst of all, that forms insists that the patient, upon signing it, absolves the department, hospital and all its staff from legal action if such x-ray imaging is agreed upon and performed. Yeahhhhh, true patient advocates laaa !!!

That form needed the signatures of 2 specialists also.

My problem with the form is this. In an emergency, a true blue emergency, when the x-ray imaging would need to be done to come to some potential life-saving decision, the same form applies !!! The ED doc would need to either sign it, taking all the legal risk in doing so (and being hung out to dry), or ask the family members to sign it if they are around. Would you sign that form when it says that x-rays will cause all those terrible things ? And at all times, these difficulties will just result in delays to action, and leading to a higher likelihood of death or permanent disability.

So, any pregnant lady who comes in after trauma can expect a slower response, more red tape and a shit load of misinformation. We will think we are lawyers and we will argue about safety as the patient dies. This is just ridiculous.

We know that most x-ray imaging performed at the ED has levels of radiation exposure that is much lower than the lowest limit known to cause foetal death, foetal deformities, abnormalities to organogenesis and risk of teratogenicity in later life. We know that. It is well documented in the evidence.

And yet, we are surrounded by wimps who are all too willing for ED docs to be hung out to dry for trying to save the patient.

That is a truly deplorable situation. The day when doctors decide to want to be lawyers, is the day we should be ashamed to call ourselves doctors.

Sheeeeshhhh !!

The birth of the Malaysian Ambulance System

2011-02-08T00:13:00.000+08:00

I have written about this before several times here and here and here.

Sometimes, my ideas get blurred, my arguments incoherent and blunted. At these times, blogging is a great resource; allowing me to re-explore the issue and reinvigorate the argument. And gain some energy to fight again, and fight on.

So the Malaysian Ambulance System (for want of a better name) may actually soon be born. At least we have been hoping for its birth for some time already. As with any newborn, we look forward to one with 10 fingers and 10 toes, we hope for an ambulance system that meets our ideals and lives up to our dreams. And be the apple of our eye.

That is not easy; at the very least, in terms of fingers and toes, it must have the following ten.

1. It must start somewhere. For years, a comprehensive ambulance system was not possible because of a chicken and egg dilemma. No system could exist because there were not enough resources. Resources could not be created because there wasn't a system to create it. But now, circumstances are favorable to actually forge a new beginning. And only the government can do it. Whether it has the willpower to do so, remains to be seen. I certainly hope so. What is important is for the government NOT to listen to all those people hoping to make money out of the service. That decision will have bearing on the future of the ambulance service, and of our own health in particular.

2. It must use existing available resources. Over the years, St John Ambulance, the Red Crescent Society and even the JPAM have shown that they can run a professional, well-disciplined service delivering very good care. This experience should be used and built upon; adding clinical protocols, medical direction and structured training to their experience to enhance their services further. Considering that we now have a national single emergency number 999, and multiple MECC (Medical Emergency Coordinating Centers), the most difficult initial steps are already accomplished.

3. It must be hospital directed. Almost all patients using the ambulance services end up with the Emergency Departments. It only makes sense that the service must be in line and complementary to the protocols of the ED; hence being hospital directed especially being Emergency Physician directed is necessary at this stage. Later on, as in most other countries, Emergency Physicians will have trained enough paramedics to such a level that they can take over the reins entirely; essentially training themselves out of their job! But not yet, and not now.

4. It must fulfill the wishes of the people. The community they serve is the master; not the individual patient, not the health administrators, not the financing people, definitely not the politicians [and wanna-be big shots, who are really the worst]. And the people want an ambulance to help them during their time of need; rapidly, professionally and better able to save life and limb.

5. It must concentrate of primary emergency response first. That is, it must be focused on its primary objective - providing an emergency ambulance in rapid response to a 999 emergency call. Inherent to the primary emergency response, it must be ready with a disaster response system and a medical team mechanism. But it should NOT deal with inter-facility transfer of patients. That is a primary responsibility of all healthcare facilities both government and private; and definitely not the primary objective of the emergency ambulance services nor the requirement of the people they serve.

6. It must address urban and rural differences. Urban areas with high-density populations offer higher workloads for emergency ambulance services; but travel times are often impeded by traffic congestion. Multiple ambulance stations, strategically placed, is the only way to solve this issue and maintain a good response time. Rural areas with a much more widely spread out population is have a much lower workload; and may often not be economically viable for emergency ambulance services to exist. Response times are hampered by greater distances that need to be traveled by ambulances. The issues, being different, means that approaches must be different as well. In smaller towns, centrally placed ambulances must cover a much wider area; in more rural areas, the need to community ambulance services, which may be voluntary (but supported with basic equipment and training) is reasonable and often fulfills the wishes of the people.

7. It should be comprehensive. It is not easy to start a national ambulance system. It would just not make any sense for it to be used only for government hospitals or the government healthcare system. Instead, for it to the viable in the long term, and for it to fulfill the wishes of the community it serves, the Malaysian Ambulance System must be for everyone including those who want to go the private hospitals and university or armed forces hospitals. Sure, self-funded patients may be charged for the service, or private hospitals may be charged instead (which they will surely pass on to the patient anyways), but it cannot be a national system if we do not address that many many Malaysians consider the private healthcare system as their primary healthcare providers.

8. The patient must pay for it, in some way or another. Emergency ambulance services are extremely expensive to run; in local standards, each ambulance run at its most basic would cost at least RM 200 for a 30 minute run. [do trust me - I have looked at the numbers!!] In many countries, a charge ranging from RM 1000 to RM 6000 per ambulance run is charged; and even then, the entire system just manages to barely stay in the black. Imagine if you have a good system with good ambulances that arrive in very good time, bringing patients to the hospitals whenever they want to; without them having to pay for it. What would happen is that more and more patients will use it, whether they really need to or not. Costs will skyrocket; ambulances will be ferrying around non-emergencies and when the real one comes along, there may not be enough ambulances to respond. This is called abuse. Abuse is the death knell of any fledgling emergency ambulance service. And there is no end to abuse; no way to stop it. Other than making the patient pay for it, in some way or another. I am not saying that they should pay thousands of RM. Nope. They must pay indirectly via taxes, via insurance schemes, via workplace or industry benefits. And they must pay directly; just enough to be more than the local taxi fare to the nearest hospital. That should be enough to prevent most abuse. I think!!

9. It must be paid for, somehow. As I said, it is expensive. And there is always a potential to expand into a huge black hole of costs; swallowing larger and larger chunks of the healthcare budget. That is not long-term viable. So, clear mechanisms must be in place at the beginning to ensure that the ambulance system is paid for. For one, insurance payment mechanisms is a possibility; our health insurance industry is terrible, charging high premiums but not including ambulance services within its coverage. [come to think of it, the emergency care coverage is terrible too!] But insurance coverage, with its no-claims incentives, with its group coverage, employer or industry covered premiums, is one possibility. Another would be compulsory coverage for working persons and their dependants, something already practiced in the US. [then everything is good, until you lose your job!] The Australians use a transportation based "tax" where part of your road tax and vehicular licensing costs go to subsidize the ambulance system. Quite good for Malaysia, considering the number of road accident victims that we treat. Even better, all those traffic saman may be used to subsidize the ambulance services as well. Some places use various versions of the tax from land taxes, to municipal fees to even a tax on vehicles. Now that may be very interesting in our context since our vehicle taxes is so high [wonder where it all goes to] Whatever the solution, it would probably be many versions of the same, it must be paid for, somehow.

10. It must never be a way to make money for anyone. The emergency ambulance system is just too important to be a commercial enterprise. The potential argument between making profit versus doing your expensive best is not a good place to be. The Malaysian Ambulance System is one that bleeds money; and gains merit. Sure the government can financially support it in the beginning; it must look carefully, very early on, at how to share the burden. The only return is a safer community, more productive, more prosperous and less threatened. Hopefully also, a community that is more aware and more careful. There is just no way for there to be any financial return. If there is, the money is not going where it should.

So there. 10 fingers and toes of the perfect newborn. Let's watch and see.

What do you think ?

2011-01-25T13:54:00.001+08:00

Your typical Emergency Department. Busy. Hectic. Mid-morning crowd.

Your not-so-typical patient. 54 years old Malaysian man, about 5 foot 6 and 80 kg. Registered at 1029 hours with complaint of upper abdominal pain for 1 day. Previous history of IHD with LVF, HTN and Upper GI bleed. Triaged Green-2. Seen at Secondary Triage at 1037 hours with BP 140/92, HR 89, SpO2 98%; and examined by doctor at 1045 hours. Quite good, right, a 16 minute waiting time ?

Now this fellow comes into the Green Zone and gets seen by our 26 year old doctor; just over 5 foot tall; I don't even know if she is 40 kg; and says to her, "I don't want to be examined; just give me my gastric medications!" Our doctor tried to explain that she will need some history and examine his abdomen; to which he refuses. After some persuading, he agrees to lie down for his abdomen examination. As the doctor is about to examine his abdomen, she gets called to answer a call from the lab, informing her about an abnormal blood investigation result for another patient. So she goes. And she comes back in a minute. And gets an earful from this fellow, saying things like "You should have apologized to me for going away" and "My niece is a lawyer" and "My cousin is a politician" and most irritatingly of all, "I'm a tax-payer; and you should serve me!"

Our very good natured doctor (I must say) still tries to explain to him that in view of his history of heart disease, an ECG is needed; the fellow refuses, shouts some more abusive stuff; and decides to leave.

Now, my question is this. What do you think ? There are many things that I'm perplexed about.

Do we really "owe" anything to this fellow ? Or is this a fellow just trying to "sneak" through a short-cut avoiding the hours long wait at the Outpatient Dept ? Can we black list them ?

Where do people like this get off by name-dropping lawyers and politicians or even KKM big-wigs ?

Can patients demand this and that to be done, simply by claiming that they, the patient, have the right to demand it ? Why can't doctors, at least government doctors, say no without worrying about the hierarchy jumping on their heads ?

This is what I think. I truly believe that a doctor patient relationship is a professional relationship ie it should be professional (courteous, communicative, aimed at arriving to a commonly agreed decision) and a relationship (which can be formed and can be broken). So, an abusive patient would have severed any possible relationship between a doctor and that patient; and in that situation, the doctor owes nothing to that patient.

But this does not mean that one abusive patient allows the doctor to be abusive in return. Doctors should never be abusive to anyone, at any time. We are doctors at all times; meaning that we must be professional at all times. So, the abusive patient should be "instructed" to leave. Leave now.

Can we do this ? What do you think ?

The Difficult Airway in Emergency Medicine

2011-01-17T12:40:00.044+08:00

All airways in Emergency Medicine are difficult.

Obviously; since most endotracheal intubations are not planned, and often further complicated by the deteriorating condition of the patient. To make things even worse, we have to deal with patients with full stomachs, trauma situations where flexion of the neck must be limited and all sorts of complications from abnormal facial structures to bleeding / secretions / airway foreign bodies.

Let's look at the basics again.

Endotracheal intubation (ETT) is only indicated in 4 emergency situations. 1) When the patient is not breathing and requires ventilation, intubation is done after initial cycles of BVM ventilation. 2) When the patient is in severe respiratory difficulties, and is not improving, or appears to be tiring, or is worsening, endotracheal intubation with positive pressure ventilation will improve oxygenation and reduce the metabolic demand for oxygen from all that respiratory effort. 3) When the airway is compromised or immediately threatened, intubation allows for airway protection. 4) When there exists a specific need eg. going to OT, decision for cerebral protection, need for high levels of sedative drugs etc.

Before intubating anyone at the ED, one of these 4 indications MUST exist.

Next step will be to determine if that particular procedure may be a difficult one. Here the 3-3-2 rule is often applied. Normal anatomical structures that usually result in uncomplicated ETT placement often follow the 3-3-2 rule ie the patient's open mouth should allow the width of 3 patient finger-breaths; the distance between the tip of the mandible and the junction between the chin and neck (thyro-mental distance) should be another 3 finger-breaths; and lastly 2 finger-breaths between the thyroid notch and the hyoid bone.

Explained in Vimeo here.
The 3:3:2 Rule for predicting The Difficult Airway from resustv.com on Vimeo.

The whole assessment is part of the LEMON approach

L - Look. We should always look for readily apparent characteristics that may predict a potentially difficult airway include obesity, recessed chin, evidence of previous head and neck surgery or irradiation, presence of excessive facial hair, dental abnormalities (poor dentition, dentures, large teeth), a narrow face, a high and arched palate, a short or thick neck, and facial or neck trauma

E - Evaluate the 3-3-2 rule [already explained]

M - Mallampati rule [which I find quite useless for the Emergency Airway]

O - Obstruction. Evaluation for stridor, foreign bodies, and other forms of sub- and supraglottic obstruction prior to intubation.

N - Neck mobility. Patients with limited neck motion will hamper efforts to intubate. The ability to adequately extend the neck should be assessed prior to intubation. Patients in whom traumatic cervical spine injury is suspected, and in whom the cervical spine has been immobilized by a cervical collar will limited neck mobility by definition; which is another reason why I say every emergency airway is a difficult airway !

Once proper preparations are made, the procedure proceeds much according to protocols. Once vital step that I must stress here (and I have stressed this again and again) is that we must ensure that we are able to ventilate the patient [ie BVM with good chest rise] after providing sedation and before we give any paralytic agents.

Ultimately, the airway in Emergency Medicine is very much a double-edged sword; treat it with due care, and intubations are often a good friend, providing good respiratory support and airway protection when it is most needed.

Treat it callously, and it will bite back with the worst possible scenario that you can ever face in Emergency Medicine; the cannot intubate cannot ventilate scenario.

1Malaysia, as I see it ..... really

2011-01-11T23:11:00.132+08:00

At 11:11 hours on 11th January 2011, I really really must talk about 1Malaysia. What I really think about it; really really really! [haha .... nobody who says "really" so many times should be heard] [reeally !!]

You know, I like 1Malaysia. I do. Saying it like we are One People, One Nation just seems so right. And it is so what we need now.

What is wrong with it, though, is the people saying it. The people who have gone around talking about 1Malaysia have been the very people who have been central to dividing us all in the first place. A little bit like asking the fornicator to talk about chastity and the institution of marriage.

The people who have gone around talking about 1Malaysia believe that Malaysia is made up of Malays, Chinese, Indians instead of just Malaysians. A good example of this thinking is the recent decision to revert the teaching of Science and Maths back to the language of instruction in schools ie BM, Mandarin and Tamil. The reasoning was that pupils learn best in the language that they are most comfortable with, the language that they speak at home. And the powers that be, who only seem to think in Malay-Chinese-Indian teams, decided that only these languages can be used to teach. So, all the Malaysian families who speak English at home are no more classified; no more within the mould of Malays must speak BM, Chinese must speak Mandarin and Indians must speak Tamil.

That's what I mean, by the people proposing 1Malaysia not understanding anything about being truly Malaysian. As a people, I think, we are really already there. We are already 1Malaysia; without the slogan. We are already 1Malaysia, not by celebrating each others festivals, not by wearing each others clothes and costumes nor by eating each others food. We are already 1Malaysia because we have shared this country since we were born. We have lived together since we were young. We have never been of one race at any time; instead we have been of all races at all times. What is truly amazing is that we have gone through all that hatred and divisiveness that our politics have impregnated into our lives, without hating each other at all.

But can we really really be ONE ? Do we really want to be ONE ?

This has been approached in many ways; decades ago, some countries tried separation of its different peoples; the assimilation; then integration; then unification. Some tried genocide, others cleansing. Whatever it was, it all failed. Trying to change someone is just too difficult; let alone trying to change a whole culture and community; and a country.

Nowadays, most progressive countries use a totally new approach; they celebrate diversity and instead of letting diversity be a hindrance, it becomes a strength. Hence, it is OK that we are of different races; even better we just don't bother about race at all; we are just simply Malaysians. The approach calls for celebrating similarities, reducing differences, and removing classifications of people into race-based groups. This must be the way forward, if ever 1Malaysia were to succeed.

But what about social justice, and "social contract" ?

This is what I think. At our most basic, we as human beings, must commit to helping our fellow man, who are less fortunate than we are. It is a function of humanity. So we must actively pursue governmental policies that give the less fortunate, the ones with fewer opportunities, the ones with unfulfilled potential, better chances to make a better future. Many years ago, it could be argued that opportunities were fewer and the future was bleaker for Malaysians who lived in the rural areas; who mainly were from the Malay community. This no longer holds true. Our economy, our cities, even our rural areas are no more classifiable by one race. Our poor no longer are of one race. Our rich are no longer of one race. In fact, for many many Malaysians, we probably cannot even call ourselves of one single race !

So, as a function of humanity, we must commit to helping our less fortunate fellow man, regardless of race. We must help the poor and disadvantaged; not the person next door who grew up with you, has as much as you have, lives very much like you do; but wants the government scholarship or assistance just because he / she is from a BN party or from one particular race. That would just be social injustice. Worse, that would rob that same opportunity from the true less fortunate who are still there.

And social injustice cannot be explained off as "social contract" simply because all contracts must abide by the laws of natural justice. And in no way any of this can be accepted under natural justice.

So, 1Malaysia ? Lovely to look at, nice to hold; too much talk and too much crap; and not nearly enough in our soul! Have a good 2011; may it be the year of the true 1Malaysian.

Thank you Mr Ambulance Man

2010-12-29T18:13:00.001+08:00

He was not your typical big tough burly paramedic. In fact, he was shorter than most; and the bigger-sized more burly paramedic that he always seemed to work with, made him look even smaller. It was sometimes quite comical to see the two bring in patients to the ED. But no one doubted his good work in any way, always enjoying the fact that patients were always brought in well-managed, with the proper sense of urgency, and the professional way that he and his team-mates always carried themselves. And the fact that he was, always full of questions, and always eager to learn more, made us all like him very much, and very quickly, come to respect as an integral part of the team. He was a St John Ambulance volunteer paramedic; a group of very young and passionate volunteers, unique in that they were very much self-taught and self-trained; and along the way, they really achieved much more that anyone could imagine. A group of people with a bit of super-hero in them, "Ambulance Man" you might say.

I was a much younger doctor back then, with more hair and much fewer worries; working on the floor in a larger ED. And I really knew nothing about the emergency ambulance services; they were to me, just another way yet another patient would come to the ED. But I would learn much more in the years to come; in many ways, he and the other Ambulance Men taught me. And together, we worked to make a difference. Or at least, we tried to.

I suppose we had our successes. We have many more ambulances on Penang roads today than just 3 years ago; which was more than 5 years ago and 8 years ago. We have many more trained ambulance medics. We have a semblance of a state-wide trauma system; and a disaster activation system that seems to work [I hope I have not just jinxed it!] And the ambulances today are very different from when it just started out 5 years ago. That one single borrowed ambulance has grown into a fleet of 4 new ones; that few patients treated per day has now crossed the 5000 patients mark. The scoop and run to hospital has given way to a complete range of resuscitation and vital signs monitoring capabilities. And St John Ambulance can proudly call itself an emergency ambulance service provider once more.

I think a lot of credit needs to go to this young man, and his Ambulance Man friends. They took a problem of inadequate ambulances and tried all means to solve it. Admirably they did it without whining about the Government not having enough money or trained paramedics. They did it without thinking about whether it could be made into another project to fleece the government and the rakyat of more money. They did it not for publicity, without too much hoo-haa. They did what they could, when they could, and at the time with whatever they could. That is admirable. Not too many people would do that these days.

Back then, EMAS [the emergency ambulance service] was driven by the pure passion and volunteerism of these Ambulance Men, held together by friendships and common experience. I know they had a good time; I did too, whenever I could join in. Enthusiasm, comraderie and fellowship, mixed in with the difficulties of sleepless nights and distressing scenes, seemed to give the entire group more energy and passion. Like a bit of a stock market bull run, it was good when it lasted.

But slowly, the raw excitement of volunteering in a new emergency ambulance service gave way to the brutal reality of daily routine and efficiency required to run it continuously. Slowly too, the Ambulance Men drifted away; to pursue their careers, to pursue further education, to pursue politics and romance ...

And now he is drifting away too. I think realism and a tinge of pessimism has caught on; career choices in other fields beckons. But it is not a time to be sad, or disappointed. It is a time to recognize effort and contributions; his and the others. Because of him and them, we have today something different, something better. Now, how many of us can say that of ourselves ?

So, Mr Ambulance Man, thank you for being you and for being there. Best wishes in all your future undertakings; and may the wind always fill your sails. And if your ship ever sails this way, you should know that we will always be a welcoming port of call.

A country with the richest and most powerful ...

2010-12-16T18:58:00.003+08:00

... gardeners, toilet cleaners, security guards and laundrymen.

Yes, we are the country with the richest gardeners. On a normal day, we drive along the tolled highways and we see gardeners; trimming the hedges, constantly cutting the grass even though it wasn't even long enough to see, planting flowers that last for 1 month; and then replanting new ones each and every month. The ones doing the gardening are not rich, not powerful. They are often poor workers that we import from other countries to do this menial work. But behind them, the politically-linked companies that contract the "family and crony" companies that sub-contract the local small business that employ these poor foreign workers, earn millions each year. Millions of our tax-payers RM every year pays these rich and very powerful "gardeners" who's only claim to knowing gardening more than you and me, is .... uh .... nothing. They don't know anything about gardening, except they do know the Government of Malaysia is willing to pay millions of RM each year to plant flowers that last for one month [some for only one week], cut grass in the middle of nowhere where a couple of cows would have done the job for free, and shape hedges into various politically-correct shapes [the current fashionable shape is "1"]

Same thing goes for the Bangladeshi worker who cleans the JPJ office public toilet. He's the front-end of an operation that earns millions for another rich, powerful, politically connected Tan Sri. Ditto the security guard at the front of your kids school. Ditto the patients' clothes and hospital linen that are washed by another Tan Sri's company. Millions earned by employing cheap foreign labour to do menial jobs at an exorbitant cost to the tax-payer !!!

Millions lost. Absolutely nothing gained. We don't need manicured gardens. Toilets are cleaner, true; but for that price, it should have been a 5-star toilet with a attendant, towel in hand. Security guards still sleep. And laundrymen wash clothes for a contract that earns a million RM every 2 days just washing clothes. [in contrast, the department where I work receives RM 100,000 per YEAR to purchase consumables items for patient care!!! And we see 140,000 patients per year!]

Millions lost. Absolutely nothing gained.

And we still want to continue doing the same ?

What can you give, after having lost it all?

2010-12-13T19:32:00.004+08:00

Saving another life is not a small thing; most of us never have that chance; some of us let it slip by when the opportunity comes by. Working at the Emergency Department, I often think that it is not us who save the patient's life; rather it is the system, developed and refined, that does it; or more often, other circumstances determined by God [in whichever form you want to refer to] who decides who lives and who dies.

But we are only thinking of one side of story; one view of the image; one frame of the movie. Being able to save lives may be possible by the patient too, especially the dying patient. Huh ? What can you give, when you have lost it all, including life itself ? Why, you can give yourself. Giving of yourself to others when your life cannot be sustained anymore, saves more lives than you can imagine. More lives than I have saved even.

Organ donation must be viewed in a different way. Often it is thought of in the context of death; early, unexpected death of someone young; rarely is it considered as an opportunity for life; longer, more fulfilling, for many more. In a field like Emergency Medicine, where we are often in a fight to continue life; sometimes when that struggle is lost, we may still be able to help so many others, in a different fight, but still to continue life.

There are many many factors in favour of organ donation in this country. We have a very good intensive care service. We are becoming much much better with our emergency services and ambulance services. We have a very good distribution of hospitals around the country. We have very good roads. Unfortunately we have a very very high rate of sudden death from trauma and head injury from our phenomenally high road traffic accident rates. So, simply said [I do apologize for the insensitive way, though], we have a large number of potential donors, we can get to them in time, to try out best to save their lives; but if it was not meant to be, we have the system that can [potentially] harvest tissues and organs that may save others' lives.

So why is it that we have such low rates of organ and tissue donation ?

Is it the system ? We have a voluntary organ donor program where a person volunteers and holds onto an Organ Donor Card. All too often, they don't discuss with their family members; so when the time actually comes, family members rescind their wishes; or just didn't consider it in the first place.

Is it the options ? We have an Opt-In system, where trained medical staff will speak to the family members of potential donors about the possibility of donation; unfortunately this is often hampered by the failure of the medical team resuscitating the patient to consider the possibility of organ or tissue donation once that resuscitation has failed. [some countries in Europe use an Opt-out system; where all are considered potential donors, but family members can opt-out at any time without any reason]

Is it the doctors ? I have to admit our defect here. All too often, many doctors are under the impression that organ donation is only for brain dead patients [vital signs stable, brain neurologically dead] whereas most of our patients at the Emergency Dept are the dead-dead ones [no vital signs, no brain function]. In this matter, some clarification is needed; whilst it is often true that too much damage has been done to the heart, lungs, kidneys, liver and pancreas to allow for feasible donation from dead-dead patients, often tissue donation is still possible [corneas, skin, bone, heart valves, tendons, veins]. We just need to do the difficult bit of broaching the subject with the family members. This is particularly difficult, especially during the acute grief period. That's why some added attention, some pre-requisite information, some missing step in the process must be done here.

Is it the process ? Again, it cannot be denied that there is a whole lack of championing of this cause. Very few doctors go the extra mile to do this; few want to come in to harvest tissues and organs at odd times. I think very often doctors don't think of it as life-saving; that's why I'm arguing that it is almost as important as any other life-saving that doctors do.

Is it the nitty-gritty details ? Yet again, we have failed. We have not put together a good enough register of potential donors and potential recipients. All that potential benefit is not seen; and thus that has led to a loss of energy in the whole process.

So can we really blame the patient, when we have not played their part ? After all, they who have lost it all, is trying to give some more. The least we could do, is to try help them.

Living in Opposition-land

2010-12-11T16:34:00.004+08:00

I find it amusing when friends and people I know, from other states in Malaysia, come up to me and ask "Eh, how is Penang, ah?" and "How is Guan Eng, ah?" quickly following that first question. Everyone is curious; and somehow Penang has become the symbol of being in Opposition-land. Part of that curiosity comes from all that bad press that Penang always gets in the mainstream media (MSM = BN controlled); everything bad in Penang gets on national news; thus the impression of a collapsing Penang under opposition rule. But the thing is that most Malaysians don't believe the national news or the MSM anyways. So any chance they get, they ask about Penang and Guan Eng.

I find it very amusing that although 5 states were won by the Opposition in 2008, only Penang is considered Opposition-land. Nobody goes to the Selangor folks and asks them how is living under Pakatan now, do they ? Nobody asks Kedahans, or Perakians, even before the illegal frog-induced coup-d'etat.Nobody ever bothered to ask the Kelantanese, simply because they just cannot do imagine life without the moon. Everyone asks about Penang, and only about Penang.

So I thought maybe I'll have a go; describing how it has been, living in Penang since 2008, living in Opposition-land.

Firstly, it is way way waaaayyy better than living in Boleh-land !

I think we all know that Penang is being punished for going Opposition; no money, no allocations, the least trickle of entitlements. Never mind that Penang is the single largest earner of foreign revenue for the whole country in the industrial sector; all earning and taxes paid still go to the BN Federal Govt; and the crumbs come back here. At first, the state government harped a lot of this; but you know, to their credit, they stopped blaming the Federal government and got on with it. They carried on with their limited resources, doing very well, I must say; showing that blaming was not the name of their game, and showing us all that it could be done. And you know, being careful with the money that they collect from the rakyat and spending it wisely has good effects at many levels. I feel so much happier paying parking tickets!

On the ground, the members of the Penang State Government have been keen to show that they are "of the people"; they have been team players, they have been very inclusive and have tried to keep any potential political differences away from the table. I really like it that they have been listeners; and have been open to suggestions and opinions. This was very different under the previous government; at that time, they were clearly the "leaders" and the rest of us were their serfs.

On a personal note, I have not had a single Pakatan ADUN or MP or Political Secretary or whoever else, call for special favours ! That I truly appreciate. No special favours asked for. No special treatment. No special standby. No special nothing. In one stroke, to me they have shown me that they are like you and me. How not to continue supporting them ?

I like the increased open-ness; I like them coming out to say what they have tried to do, even though it had failed; I like the absence of illegal benefits and kick-backs to themselves; I really like the fact that they have gone out of their way to help set up small businesses, recognizing that many of us need another source of income in these difficult times.

Some things I don't like so much. I think since Guan Eng is kind of the branding face of Penang's opposition government, they protect him too much. Guan Eng should not worry too much about his detractors; they will always be there. He should go out to the public more often; openly, without his team. The people of Penang will love to have him on the roads with them again. Imagine Guan Eng on a daily jog or early morning kopitiam and late evening makan on the roadside or stroll on the pasar malam. That's what the people want. Someone with them, nothing special nothing great, but with them.

And if during his time out with the public, any of his detractors want to give him "black-hearted cakes" or whatever else, no problems; all his housewife supporters will never let him down.

So what do I think ? For a 2 year old first time government, they have done admirably. And I have been proud to have done my itsy-bitsy little bit to have made it happen.

Stop prescribing Cough and Cold Medications to Children !!

2010-12-10T18:29:00.002+08:00

Yes, stop prescribing cough and cold medications (CCM) to children ! Stop it NOW !

I blogged about this before [here]. Recently, the FDA issued a public health advisory stating "questions have been raised about the safety of these products and whether the benefits justify any potential risks from the use of these products in children, especially in children under 2 years of age." This has come into the public eye following deaths from fatal respiratory depression following taking promethazine hydrochloride.

Generally, cough and cold medications have varying combinations of drugs; almost all of which belong to these 4 classes: a Nasal Decongestant (some types have been withdrawn in the past due to adverse events), an anti-histamine (the main culprit now, especially the 1st generation sedative types), a cough suppression drug (no likely side effects; but not so common in Malaysia due to abuse) and a expectorant (not likely to cause side-effects).

The FDA has recommended no OTC sales for under 2 years old; the manufacturers themselves are labelling cough and cold medications (CCM) are NOT meant for under 4 years old; and Health Canada is insisting on avoiding these CCM totally in under 6 years olds and specialized labelling for 6 - 12 years olds.

So are you sure you still want to prescribe these drugs to kids ?

What are the alternatives ? Drink lots and lots of fluids (water, unsweeted fruit juices, soup and porridge), lots of rest, warm baths provide humidified warm air and relieves blocked nasal passages, and normal saline nasal drops help (homemade NS recipe: half teaspoon table salt into 1 cup of warm water; use within 12 hours)

C'mon, stop prescribing CCMs; stop it NOW !

Difficult times ....

2010-12-08T19:07:00.001+08:00

In many ways, the last month can be considered to have been a difficult time

But in many ways too, difficult times like dark clouds almost always have a silver lining. Family members have lent their support in amazing ways. Friends and colleagues have taught me what it means to be a friend.

In so many ways, and at so many times, I have felt that I was undeserving, my mere expressions of gratitude woefully inadequate.

But it has also been a time to think. One is forced into looking at the wider, longer term picture of perspectives and shades. Of priorities. Of reflection. Of outlook.

In many ways, I have been very lucky thus far; "shielded" you might say, from the worst that life can throw at you. And maybe that is why I just seem unprepared, and ill-equipped.

At this moment, after this difficult time seems finally "over", I am just soooooo ....... tired !

Maybe work just isn't fun anymore. At least for now.

Each day brings ,,,,, nothing new. No new challenges to conquer, no new obstacle to overcome, no new mountain to climb.

Instead, each day brings ..... same old same thing same same shit ! Problems that we thought we solved, crops up again; beckoning us to fight the same battle yet another time. Problems that are unsolvable, morph into complications with different faces; leading us down yet another path to that similar unsolvable dead end. Even the optimist in me is ready to throw in the towel.

Working in an Emergency environment does not help the least bit. Nothing ever ends; it just varies from scary excitement to boring preparedness. But the toes are always clenched, always ready, and somewhere in the mind, always thinking. And the thinking nowadays just seems to whirl around unsolvable problems. And silly adaptations to deeper core issues.

So, each day just seems to start tired, and end tired-er !

I don't need a holiday.

I don't need to accept what I can do and what I cannot,

I don't need to hang on and wait for a better day

I need some SUCCESS ! Something that makes one go YEAHHH ! Something done, accomplished, finished, over ! Something to make me smile before I sleep at night, and spring our of bed the next day saying, "What's next ?"

Sadly, at the moment, nothing looks promising.

Fluid Resuscitation in Trauma

2010-11-15T22:16:00.000+08:00

Severe blood loss is one of the most dreaded complications of trauma. Rapid loss of blood leads a drop in the intra-vascular volume and pressures, triggering off a series of compensatory mechanisms. The veins constrict, pushing more blood into the active circulation. The arteries, both large and small, also constrict, trying to maintain the pressure gradient within the arterial system, so that blood will still move within them. In addition, smaller vessels supplying blood to non-vital organs eg skin, intestines, limbs, become highly constricted; thus reducing their blood supply in favour of vital organs like the brain, heart and lungs. Blood supply to the kidneys is also markedly reduced [making urine is losing fluids, not what the body wants to do at the same time as losing blood].

All this has huge unseen impacts. In many tissues and organs, the amount of blood reaching their capillaries is now a mere trickle, and the amount of oxygen supplied drops dramatically. This leads to organ dysfunction; the dysfunctional brain makes the patient agitated and then drowsy, the dysfunctional heart leads to heart failure and the other organs start failing one after the other. The chaos extends to the cellular level where the lack of oxygen leads the cells to convert their metabolism from an aerobic system (using oxygen to produce energy) to an anaerobic system (not using oxygen, but producing huge amounts of acids as a by-product). Thus, the levels of these acids measured directly (serum lactate) or indirectly (ABG - high negative levels in Base Excess) is a useful measure of the severity and extent of the tissue impact from blood loss and shock.

Our previous understanding was that this entire process could be prevented or even reversed as long as we maintained the intra-vascular volumes; thus fluid resuscitation was the mainstay of initial therapy of severe acute blood loss. Essentially, for many years, believed that we could replace blood lost by replacing its volume within the intra-vascular space with fluids. Lost blood was replaced with salt water, or short and long chain polymers dissolved in water. Doesn't seem right, does it ?

Well, we now know better. We know that the replaced fluids often leak out of the blood vessels very quickly, not maintaining intra-vascular volumes for very long. Worse, it dilutes the blood, causing the coagulation factors (the stuff in the blood that makes our blood clot naturally) to be diluted and less effective. In the context of a patient that is actively bleeding, this is very bad news indeed. These fluids, being usually colder than body temperatures, often cause the body temperature to drop, further weakening the blood's ability to clot. This hypothermia, coupled with the metabolic acidosis and the dilution of coagulation factors that occurs with fluid resuscitation, often leads paradoxically to a failure to resuscitate, poor outcomes and death.

And now, we know even more. Apparently, replacing fluids does not help improve delivery of oxygen to the tissues. In poorly perfused tissues, fluid administration results in better flow, but mainly of the fluid component of blood; not the vital oxygen-carrying red blood cells. And the onset of the inflammatory process in poorly perfused areas will result in leaky capillaries, causing fluid accumulation in the lungs and other tissues, further compromising their function. Worst of all, when the situation finally improves, reperfusion to blood starved areas of an abnormal concentration of blood results in reperfusion injury and end-organ damage.

So, what can we do ? Is there really no role for fluid resuscitation in trauma ?

Actually, there is still a role for fluid resuscitation. In early resuscitation, IV fluids provide a quick, relatively safe and effective way to compensate for initial blood losses. But, blood loss can only by replaced by blood. Very quickly, the ED team must be able to recognize that initial amounts of fluid resuscitation is inadequate or insufficient; and or that the patient is continuing to bleed. In the regard, the immediate next step would to identify the source of bleeding, in order to stop it. In severe acute blood loss, this often requires early surgical intervention.

Very early on, the decision must also be made for the lost blood to be replaced by blood. Now, here is the thing. Trauma causes us to lose blood ie RBC, plasma containing coagulation factors and platelets. But, many protocols suggest replacing only packed cells ie replacing only the RBC component. This can't be right. The coagulation factors and platelets are equally important. Even the plasma is hugely important, being the best fluid for the intra-vascular volume, bar none.

Why is this so ? We separate out the blood products for our convenience; but we should really start looking at whether our convenience is harming our patients. The practice of giving "fresh whole blood" used by older doctors many years ago is probably the correct method after all.

So what is the right fluid for the trauma patient ?

In some patients, the need for fluid is secondary to the urgency of getting them to the operating theatre. We know that penetrating injuries to the chest in an unstable patient is probably in this category.

Most patients benefit from initial fluid resuscitation of 1 - 2 litres of Normal Saline. [the myth that Hartmann's and Ringer's Lactate is better for shock remains an unproven myth]. Following this, a review of their response to initial fluid resuscitation is needed. If the patient is not responding to initial fluid resuscitation, or they are only transiently responding, or worse, you know that they are continuing to bleed, the significant thrust of emphasis and effort must go toward stopping the bleeding immediately. Directly, surgically or with angio-embolization.

And replacing the lost volume with blood. Here, the ideal ratio would probably by a ratio of 1 : 1 : 1 of crystalloid fluid, packed cells and fresh frozen plasma. In many situations where surgery may not be easily and rapidly available for the acutely bleeding patient, addition of coagulation factors to this ratio, in the form of platelets and cryoprecipitates, will be needed as well.

At the end of the day, resuscitation carried out in the initial hours after injury is far more potential impact on outcomes than all that care provided in the days and weeks following it. It is about time that we give more emphasis on where it makes the most difference.

Whewwww !

BN: Dulu, kini dan ...

2010-11-02T17:42:00.002+08:00

The BN of today in not like the BN of years before. Not at all alike. In fact, worlds apart.

Then, the BN was a party that symbolized hope, the hope of a young nation, trying to make it on its own. It carried the hopes of the people on their shoulders; and with true intent, the BN then aspired to achieved those hopes of the people. In those days, the people in the BN were the average person from our community; that young man who always tried to help, build schools, run activities at the community halls and help the uneducated masses with the government red-tape.

That is not so today. The BN of today does not carry the hopes of the nation any more than it carries its own wishes for personal and party gains. The BN of today is no longer in our community; separated by their wealth and apparent disdain of all things the common man does. The BN of today lives in the world of the first class cabin; on the same plane as the rest of us, but separated. And it is by their choice, that they live a separate life, having fallen into the guile of the rich and famous and powerful.

The BN of years before was filled with young, energetic and inspiring people. Our first Cabinet was filled with people in their 30's ! They were young and they were highly educated. And they, having had the benefits of education, shared with the Malaysian public, working toward the common good of the community.

Today, our Cabinet is old; young energetic people who join politics are left to linger in the Youth wings, where their talents remain untapped, and they finally learn that the only way up, is to say YES and brown-nose the higher ups. And when they in turn become old and worn out, they will have finally achieved their goals; but continuing the vicious cycle, will continue to suppress the young, energetic and talented.

Many years ago, the leaders helped the poor with government grants, projects and loans; to ensure that they could grow economically and be self-sustaining. This was an amazing success; BN governments led an entire generation of Malaysians out of uneducated poverty and into sustainable middle-class educated demographics.

This is no longer true today. Today, government projects are meant to benefit the well-connected within the BN; the public is now their victim in many ways. Look at toll rates. Look at our unfavourable housing purchase schemes. Look at all the government projects with one-sided contracts. Look at the poor returns on your investments in government bonds and trusts.

Most of all, the BN of before, was forward looking; keen on long term outcomes and daring to make changes, even if it was unpopular at that time. Look at the Commissions that were created to address the issues of education, citizenship and housing.

What was the last commission you remember the BN creating ? Lingam's Royal Commission ? Instead we have chicken-shit decisions like the reversion to BM for Science and Maths.

BN of before deserved our support; and they got it.

BN of today .....

So, what will it be ? BN: Dulu, kini dan tak lama lagi ???

It's up to you

Dealing with Hypotension & Shock: The First Few Steps

2010-10-10T10:10:00.003+08:00

Let's just get a few facts straight. Hypotension and Shock is BAD. It is death in waiting. It indicates a failure of all compensatory mechanisms meant to maintain viability of our internal organs and sustain life. Identified and treated early, hypotension and shock is reversible; but any delay of any sort, or any duration, will significantly worsen outcomes and often result in death. It is, a one final chance poker draw, in a duel between Life and Death; with Death already holding a strong hand. Get it right, Life wins the hand. Wrong, Death quickly but silently sweeps the stakes and clears the table.

Whilst the final failure of the life support systems of the body is terrible to watch, the circulatory system in the body is in fact an amazing thing; it maintains a circulation of blood at exactly the correct pressure and amounts that is necessary to maintain life. The heart pumps and creates a pressure "head" throughout the arterial system; whereas individual organs regulate the amount of blood that they need and take. The heart pumps and the blood moves. In small areas of the microcirculation, small adjustments are made to take what is needed to maintain it as much as possible.

When SHOCK occurs, either the heart starts pumping harder to try to maintain this pressure head, or the circulatory system diverts blood away from the non-vital organs to the more vital heart, lungs, brain; maintaining life as much as the system can. These compensatory mechanisms are mainly mediated via the sympathetic nervous system. For actual hypotension to occur, the compensatory mechanisms must have already come into play, and failed. Hypotension and Shock is BAD.

There are only 4 types of shock; that's all. It should be easy to remember. See a patient in shock, think of 4 types of shock. Either the heart is not pumping as it should, or the blood is not able to move in and out of the pump as it should, or there's not enough volume of blood to pump around, or all that circulation is just going to all the wrong places. In medical terms, cardiogenic shock, obstructive shock, hypovolemic shock and distributive shock. Only 4 things to remember when trying to figure out what type of shock the patient has.

Dealing with Hypotension and Shock is really not too difficult either. But all too often we are not very good at it. It is probably OK not to be successful at reversing hypotension and shock; maybe God just wanted his way, then and there. But it is NOT OK to have missed making the diagnosis, and definitely NOT OK to have not attempted to treat the cause in the first place.

The first thing is to suspect the presence of shock in the first place. We may have guessed it correctly from the presence of high-risk mechanisms of injury, from worrying symptoms (sudden chest pain, breathlessness, sudden loss of consciousness, worsening anxiety, sweating, feeling like Dr Doom is looking over your shoulder ... that kind of thing) and some extraordinary physical findings.

Signs of shock are a fast heart rate and rapid breathing, the feeling of anxiety often deteriorating to restlessness and confusion, cold and sweaty limbs and torso, bluish discolouration of the skin of the hands and feet leading later on to the deterioration of the blood pressure, altered conscious levels and decreased urine output.

If the patient shows signs of shock, the best thing that one doctor can do, is to get as much help as possible. Call for it. Shout for it. Demand for it. Resuscitation of a patient in shock, especially if hypotension is also present, is not effective and cannot be viable for more than the initial few minutes without significant additional help. The faster help arrives, the more help the better, the more experienced the help is, the more likely the right thing will get done.

Then the Airway takes precedence. Ensuring that oxygen can get in; and CO2 can get out. Once that is done, give Oxygen. Loads of it. There is NO shock that doesn't benefit from oxygen. But that alone is not enough; we should at least look at if it really is getting into the system; whether the breathing is effective and adequate, and whether the work of breathing is sustainable in the immediate period.

Monitors. Oxygen. IV lines and Fluids running in on full blast initially [we must must at least rule out Cardiogenic Shock first before this full blast of fluids. All 3 other types of shock would benefit somewhat with fluids; but the patient with cardiogenic shock will just die with additional fluids]

Then the search begins. What is the type of shock ? Cardiogenic from a structural heart problem, a rhythm problem or an ischaemic heart problem. Obstructive shock often has other associated points from the chest wall injury or severe asthma leading to tension pneumothorax, or the stab wound resulting in cardiac tamponade, or the risk factors of pulmonary embolism. Similarly, distributive shock has its own list of associated points from the high spinal injury leading to neurogenic shock, to the evidences of sources of infection in septic shock.

Hypovolemic shock needs further exploration and some further thought. If the volume loss is due to blood, it is decidedly easier, because it must be external bleeding [on the floor] where it can be seen; or only in 4 areas of the body that can bleed in sufficient amounts to cause shock. They are the chest and pleural cavity (often due to injuries to the larger vessels causing a massive haemothorax), pelvis and retroperitoneal cavity (often from fractures of the pelvis), soft tissue spaces of the thigh (from fractures of the femur) and the intra-peritoneal cavity (usually injuries to the liver, spleen and other peritoneal organs). This search will need some additional assistance from the Ultrasound (FAST scan) and X-rays of the Pelvis and Chest.

Hypovolemic shock may be due to fluid losses instead, externally from excessive sweating, urine or fluid in the stool; or internally from fluid losses into the GIT, or the most dreaded fluid losses into the third spaces from excessively leaky capillaries. It is probably less important to try to find where the fluid is leaking from, but much much more important to correct the lost volume in good time.

This search must end with a decision on what to do. If the patient is bleeding, it must be stopped. And there are only two ways that bleeding can be stopped. Stop it manually or hope that the coagulation process works. Stopping it manually is easy for external bleeding; but it requires surgery for internal bleeding. At the same time, we must keep in mind that coagulation requires adequate coagulation factors, a reduction in the flow and pressure at the area of bleed, some tamponade effect and the absence of hypothermia for it to work well.

The decision on what to do may also include emergency procedures like needle thoracocentesis followed by a chest tube insertion, a guided needle pericardiocentesis, a surgical airway or other heroic procedures. It may also be as simple as getting the surgeon to be there in good time [and in a good mood]. It may be getting blood and coagulation factors early in the resuscitation process; or it may be just putting broken parts back in position to stop bleeding. It may be just doing the ABCs. Or it may be all of the above.

That's it. The first few steps in dealing with Hypotension and Shock.

Resuscitation of the patient in shock may be successful, or it may not. Sometimes, God says it is time to go, and all He wants is that you have tried valiantly and respectfully. Sometimes, it is not yet time, and God really needs you to have a good go at it, saving that life that He wants saved.

Sometimes, dealing with Hypotension and Shock is God's work; other times, it is just part of the job.

At all times, it is worth doing it well.

Never a boring moment

2010-10-06T13:27:00.002+08:00

Case investigations and morbidity review
Heart attacks 3 years after CABG
100 year olds with hip fractures
3 year olds with stubbed toes
14 prisoners in the holding area
a 17 year old inmate who probably ran away from the ward
a lady with schizophrenia claiming rape by a known person 3 weeks ago
online conferencing going on
looking at a mathematical model for the use of ED resources
thinking about computers and Bayesian Network
trying to get better documentation from everyone
early depolarization worries
feeling hungry
stretchers full in Yellow
double parking in Green
heart failures side by side
trauma in Red
fighting with other doctors
fretting over our own doctors
preparing for tomorrow and the day after

... and this is just the morning in the Emergency Department

There is never a boring moment working at the ED
But sometimes, I could do with a bit less excitement

Hello God ...

2010-10-05T19:07:00.001+08:00

Deep booming voice reverberates.

"Hello Doc. You just died. And this is judgment."

" Uh .. hello ...G G-God "

"I made you into a doctor; so that you can help others. Were you a good doctor? Did you help others? "

" Uh .. I tried. I worked, G-God. I put in many hours, with the government hospital .... until I died just now "

"But that's your JOB. You earned a decent living for it, earned respect of your fellow creatures, had a comfortable life. The question is, were you a good doctor? Did you really help others? "

" I don't know, God. In my many years, I'm sure I have saved a few; I know I have killed a few as well. I know I have made a difference in some people's life; and I know I have also done poorly for many others too. I don't know, God. "

" Yes, many have sacrificed to make you better as a doctor. Your teachers worried about your learning. Many endured pain as you practiced your skills. Many more suffered when you made mistakes. Some died. Was their sacrifice worth it ? "

" I tried, God. At times, it seemed just too much. Many times I gave up. But God, I always came back; I always tried to make changes for the better. Many times I failed. Once or twice, I succeeded. I tried, God. "

" I made doctors to show the face of God by their kindness, compassion, humanity, tolerance and understanding. That is my medicine. "

" I ... I ... I tried ..."

God remains silent

" I really tried, God; really "

" Really. G G-God ?? "

... and the silence reverberates all around ...

Charge for New Doctors

2010-10-03T23:14:00.001+08:00

Actor Alan Alda [Hawk-Eye Pierce from M*A*S*H] was asked to give the commencement speech to the Columbia University College of Physicians and Surgeons 1979 graduating class. This would be worth reading for all young new doctors. No, this is worth reading for ALL doctors. This is what he said.

Ever since it was announced that a non-doctor, in fact an actor, had been invited to give the commencement address at one of the most prestigious medical schools in the country people have been wondering: “Why get someone who only pretends to be a doctor when you could get a real one?” Some people have suggested that this school had done everything it could to show you how to be doctors and in a moment of desperation had brought in someone who could show you how to act like one.

It’s certainly true that I’m not a doctor. I have a long list of non-qualifications. In the first place I’m not a great fan of blood. I don’t mind people’s having it, I just don’t enjoy seeing them wear it. I have yet to see a real operation because the mere smell of a hospital reminds me of a previous appointment. And my knowledge of anatomy resides in the clear understanding that the hip bone is connected to the leg bone. I am not a doctor. But you have asked me, and all in all, I think you made a wonderful choice.

I say that because I probably first came to the attention of this graduating class through a character on television that I’ve played and helped write for the past seven years: a surgeon called Hawkeye Pierce. He’s a remarkable person, this Hawkeye, and if you have chosen somehow to associate his character with your own graduation from medical school, then I find that very heartening because I think it means that you are reaching out toward a very human kind of doctoring. And a very real kind of doctor.

We didn’t make him up. He really lived as several doctors who struggled to preserve life 25 years ago during the Korean war. In fact, it’s because he’s based on real doctors that there is something especially engaging about him. He has a sense of humor and yet he’s serious; he’s impertinent and yet he has feelings; he’s human enough to make mistakes, and yet he hates death enough to push himself past his own limits to save lives. In many ways, he’s the doctor patients want to have and doctors want to be.

But he’s not an idealization. Finding himself in a war, he’s sometimes angry, sometimes cynical, sometimes a little nuts. He’s not a magician who can come up with an instant cure for a rare disease without sweating and ruining his makeup. He knows he might fail. Not a god, he walks gingerly on the edge of disaster – alive to his own mortality.

If this image of that very human, very caring doctor is attractive to you — if it’s ever touched you for a moment as something to reach for in your own life – then I’m here to cheer you on. Do it. Go for it. Be skilled, be learned, be aware of the dignity of your calling…. but please don’t ever lose sight of your own simple humanity. Unfortunately, that may not be so easy.

You’re entering a special place in our society. People will be awed by your expertise. You’ll be placed in a position of privilege. You’ll live well, people will defer to you. Call you by your title – and it may be hard to remember that the word “doctor” is not actually your first name.

I know what this is like to some extent because in some ways you and I are alike. We both study the human being. And we both try to offer relief — you through medicine, and I through laughter — but we both try to reduce suffering. We’ve both learned difficult disciplines that have taken years to master, and we’ve both dedicated ourselves to years of hard work. And we both charge a lot.

We live in a society that has decided to reward my profession and yours, when we succeed in them, very highly. It can sometimes be easy to forget that the cab driver also works 14 or 15 hours a day and is also drained of energy when he’s through. It’s easy to think that because our society grants us privilege that we’re entitled to it. Privilege feels good, but it can be intoxicating. As good doctors. I hope you’ll be able to keep yourselves free of toxins.

It’s no wonder, though, that people will hold you in awe. I know I do. You’ve spent years in a gruelling effort to know the structure and process of human life. I can’t imagine a more difficult task. It has required the understanding of complexities within complexities, and there has been more pressure placed on you in four years than most people would be willing to take in a lifetime. I stand here in utter amazement at what you’ve accomplished. And I congratulate you.

I only ask one thing of you: Possess your skills, but don’t be possessed by them. Certainly your training has encouraged you to see the human side of your work, and you’ve examined the doctor-patient relationship. But still, the enormity of your task has required you to focus to such an extent on technique and data that you may not have had time enough to face your feelings along the way.

You’ve had to toughen yourself to death. From your first autopsy when you may have been sick, or cried or just been numb, you’ve had to inure yourself to death in order to be useful to the living. But I hope in the process you haven’t done too good a job of burying that part of you that hurts and is afraid.

I know what it’s like to be absorbed in technique. When I write for M*A*S*H, I’m always writing about people in crisis with what I hope is compassion and feeling. And yet one day I found myself talking to someone who was in a real crisis and real pain — and I remember thinking, ‘This would make a great story.” Both of these things — becoming set apart and becoming your skill — can make it tough to be a compassionate person.

All right, that’s my diagnosis of the problem. Here’s my prescription: I’d like to suggest to you, just in case you haven’t done it lately, that this would be a very good time to give some thought to just exactly what your values are, and then to figure out how you’re going to live by them. Knowing what you care about and then devoting yourself to it is just about the only way you can pick your way through the minefield of existence and come out in one piece.

It can be a startling experience when you try to rank your values, though. Just ask yourself what’s the most important thing in the world to you. Your work? Your family? Your money? Your country? Getting to heaven? Sex? Dope? Alcohol? What? (I don’t need a show of hands on this). Then when you get the answer to that, ask yourself how much time you actually spend on your number one value — and how much time you spend on what you thought was number five, or number ten. What, in fact, is the thing you value most? It may not be easy to decide.

We live in a time that seems to be split about its values. In fact it seems to be schizophrenic. For instance, if you pick up a magazine like “Psychology Today”, you’re liable to see an article like: “White Collar Crime: It’s More Widespread Than You Think.” Then in the back of th’e magazine they’ll print an advertisement that says. “We’ll write your doctoral thesis for 26 bucks.” You see how values are eroding? I mean, a doctoral thesis ought to go for at least a C-note.

The question is where are their values? What do they value? Unfortunately, the people we look to for leadership seem to be providing it by negative example. All across the country this month commencement speakers are saying to graduating classes, “We look to you for tomorrow’s leaders.” That’s because today’s leaden are all in jail.

Maybe we can afford to let politicians operate in a moral vacuum, but we can’t afford to let doctors operate under those conditions. You know how we’re feeling these days as tin power and fuel monopoly has its way with us. Well, you people graduating today are entering a very select group. You have a monopoly on medical care. Please be careful not to abuse this power that you have over the rest of us.

You need to know what you care about most and what you care about least And you need to know now. You will be making life and death decisions and you will often be making them under stress and with great speed. The time to make your tender choices is not in the heat of the moment.

When you’re making your list, let me urge you to put people first. And I include in that not just people, but that which exists between people. I suggest to you that what makes people know they’re alive – and in some cases keeps them alive – is not merely the interaction of the parts of their bodies, but the interaction of their selves with other selves.

Let me challenge you. With all your study, you can name all the bones in my body. You can read my X-rays like a telegram. But can you read my involuntary muscles? Can you see the fear and uncertainty in my face? If I tell you where it hurts, can you hear in my voice where I ache? I show you my body but I bring you my person. Can you see me through your reading glasses? Will you tell me what you’re doing, and in words I can understand? Will you tell me when you don’t know what to do? Can you face your own fear, your own uncertainty? When in doubt, can you call in help?

These are things to consider even if you don’t deal directly with patients. If you’re in research, administration, if you write — no matter what you do — eventually there is always going to be a patient at the other end of your decisions.

Now, of course, everyone is for this in principle. Who’s against people? But it gets harder when you get specific. Will you be the kind of doctor who cares more about the case than the person? (“Nurse, call the gastric ulcer and have him come in at three .” … “How’s the fractured femur in Room 2087″) You’ll know you’re in trouble if you find yourself wishing they would mail you their liver in a plain brown envelope.

Where does money come on your list? Will it be the sole standard against which you reckon your success? How much will it guide you in relating to your patients? Do patients in a clinic need less of your attention than private patients? Are they, for instance, less in need of having things explained to them?

Where will your family come on your list? How many days and nights, weeks and months, will you separate yourself from them, buried in your work, before you realize that you’ve removed yourself from an important part of your life?

And if you’re a male doctor how will you relate to women? Women as patients, as nurses, as fellow doctors — and later as students. Will you be able to respect your patient’s right to know and make decisions about her own body? Will you see nurses as colleagues — or as handmaidens? And if the day comes when you are teaching, what can young women medical students expect from you? Questionnaires filled out by women at 41 medical schools around the country have revealed a distressing pattern. The women were often either ignored in class or simply not taken seriously as students, They were told that they were only there to find a husband and that they were taking the places of men who would then have to go out and become .chiropractors. (Logic is not the strong point of sexism). They were often told that women just didn’t belong in medicine. And at times they were told this by the very professors who were grading them. They would be shown slides of Playboy nudes during anatomy lectures — to the accompaniment of catcalls and wisecracks from male students. And in place of discussions about their work, they would often hear a discussion of their appearance.

These are reports from 41 different medical schools. I’m dwelling on this because it seems to me that the male-female relationship is still the most personal and intense test of humane behaviour. It is a crucible for decency. I hope you men will work to grant the same dignity to your female colleagues that you yourselves enjoy.

And if you’re a female doctor, I hope you’ll be aware that you didn’t get where you are all by yourself. You’ve had to work hard, of course. But you’re sitting where you are right now in part because way back in 1848 in Seneca Falls women you never knew began insisting you had a right to sit there. Just as they helped a generation they would never see, I urge you to work for the day when your daughters and their daughters will be called not “A woman doctor”, or “My doctor, who’s a woman…” but simply, “My doctor.”

It may seem strange to rank the things you care about, but when you think about it, there isn’t an area of your work that won’t be affected by what you decide to place a high value on and what you decide doesn’t count. Decide now.

Well, that’s my prescription. I’ve given you kind of a big pill to swallow, but I think it’ll make you feel better. And if not — well, look, I’m only human.

I congratulate you, and please let me thank you for taking on the enormous responsibility that you have — and for having the strength to have made it to this day. I don’t know how you’ve managed to learn it all. But there is one more thing you can learn about the body that only a non-doctor would tell you — and I hope you’ll always remember this:

The head bone is connected to the heart bone – and don’t let them come apart.

"I think the only time we were exactly right in knowing why we wanted to be a doctor was when we were 4 years old, when we realized that a bruised knee could be treated well with a sad and sympathetic face, and a hug. And we wanted to do it again."

Dengue Shock

2010-10-02T11:29:00.002+08:00

"There is just much more dengue in the world now"

If anything, dengue has achieved pandemic proportions. What used to be the common mosquito and common disease of the tropics, had become a worldwide problem and a significant cause of preventable death.

The Aedes mosquito is quite "man-made" in that it has evolved with man in mind. It lives in clean stagnant water common in human environments; and the dengue virus affects only man.

Why is it that Dengue has now begun to kill so many people ? More mosquitoes, poor care or just has the disease turned bad ? Maybe all of the above.

Definitely more mosquitoes. Breeding sites for Aedes are increasing markedly; ask any common man about Aedes, and the most common answer returned is "waiting for fogging by the authorities". But fogging is merely a stop-gap measure, killing only those mosquitoes that are in the air at that time, not the larvae. So the seek and destroy method for Aedes breeding sites that the authorities advocate must be done. Do your part laaa. Look for areas around your house for places where water may collect, and drain it. If you have houses that are empty at the moment, cover the toilet bowl, block off the overflow of the water tank and toilet bowl tangki, and cover the wash basin's outlet. Aedes mosquitoes common breed in empty houses' tangki, toilet bowls and water traps of sinks.

Definitely poorer care. We are still missing out many patients with danger signs of dengue, and failing to identify them early.

But is dengue the disease getting badder ?? Is it now capable of killing more ??

This is not clear. We now understand that Dengue has 4 serotypes; and primary infection [first time infection] with any of the serotypes usually does not produce any serious complications. However, secondary infection [subsequent infection with the same serotype] often seems to produce more complications. This leads many to believe secondary infection leads the body's immune system to over-react, releasing mediators that ultimately lead to all the problems of dengue shock syndrome.

Dengue shock is terrible. Sometime between the 5th and 7th day of the onset of fever, the fever subsides. By this time, the patient would probably have some warning signs already; abdominal pain, persistent vomiting, restlessness and severe lethargy and maybe some bleeding from the mucous membranes. The subsiding fever is associated with a sudden worsening of the patient. The blood vessels suddenly become very porous, and the fluid part of the blood starts seeping out of the blood vessels [almost like continuous bleeding, that involves only the plasma] The HCT starts climbing; the platelets start dropping. Patients are now at a much higher risk of severe internal bleeding. Then the organs start failing; the liver function goes haywire, and kidneys start shutting down from all the fluid losses and as a result of direct damage. The blood stops clotting. Shock soon turns to irreversible shock.

The main therapy remains maintaining intravascular blood volume with fluid replacements, sufficient and timely fluid replacements. Often these patients are not able to consume orally, so these fluids must be given IV. Maintaining the intravascular blood volume reverses all the adverse effects of prolonged shock; giving the body the change to self-repair and come out well.

Take home message: at the moment, fever without an obvious source is dengue until proven otherwise. Watch out for warning signs; fluid resuscitate them early and aggressively. And go after the mosquitoes.

To all my friends, who now live somewhere else

2010-09-30T13:40:00.003+08:00

I have many friends who now live in other countries. They are all Malaysians; some I grew up with, others were my schoolmates, friends from medical school, colleagues, mates, brethren. Many, I would consider as best friends.

They left Malaysia at different times, for various reasons and under trying circumstances. Many have made a good life in another country, and will probably not return. They still love Malaysia for it is the land of their birth and infant nurture, and the land of their friends and family. They love Malaysia partly for its unique way of life, partly for its familiarities and peculiarities. The way you would love that ugly smelly shirt that is discoloured and mishapen, just because it is yours and it comfortably smells of you !

All of them left with a heavy heart, knowing that their future and the future of their young ones in Malaysia was not bright; and elsewhere, in another country, where they were not citizens, they would be able to make a better future. Elsewhere was better than home. That is the sad truth. And that, we must condemn as the disastrous legacy of government policy then and now.

Those that are left behind have a heavy heart too. Not merely because we are "not wanted" elsewhere, but the burden of making our future in this country seems heavier with fewer hands. But we try. What else can we do.

But Malaysia is not a lost cause, not a foregone dismal conclusion. It remains a place with hope, not just for us, but for our next generation. We just have to work at it. We need to work to make significant changes, make right where we were so wrong before. Give hope where we had given up. Try when all seems beyond us.

Let us start by making that small but significant step. Let us vote for the government that we want, that we deserve. Let us work at making this new government accountable to us, the people. Let us X for change.

To all my friends, who now live somewhere else, we need you too. Our future could very much depend on you, and the price of that flight ticket back home, to vote. Surely, this is not beyond you. Let us make that X for change together. When that fight is done, we can have our teh tarik under the tree, and talk about the good old days, and the time we came together to make Malaysia right again.

The Utter Insignificance of Here and Now

2010-09-27T06:59:00.001+08:00

We live in this great country of ours, in this great world of ours. Great we think it is, for it accords us life and living. And living is what we do, here and now. But maybe, we should spend some time to reflect about here, and about now.

I watched Stephen Hawking's "The Story of Everything" a few hours ago. In the context of the universe, our world is a minute fraction of a speck of dust, existing in a minutest nano-second of the existence of the universe and of time itself. There are billions of galaxies, containing billions and billions of stars, that have existed over billions of years. I was most struck by the size and scope of the universe; and the utter insignificance of our world. By chance, we are here, alive. By chance, we have the opportunity to live. By chance, we are what we are.

Seen in this context, we can only accept our insignificance. And at the same time, accept the insignificance of here and now. So, no need to fight; no need to argue about rights and power and political voice.

What is probably worth doing, is what affects tomorrow, what affects our next generation, our future country. And that is why we struggle on.

The future of Malaysia just cannot be a future of a small handful of people with political power that has everything and can get anything; where the rest of us are told to make do and be grateful. It cannot. Malaysia cannot survive like that. The future of Malaysia has to be one where each and every Malaysian, different, varied, active and tolerant, works towards a better Malaysia. A Malaysia for all, not for one.

That may be the only contribution that we have for the future; the only thing that we can do here and now. So we must.

Are you paying for your health ?

2010-09-20T06:48:00.002+08:00

The discussion about the National Health Financing Scheme is getting heated up again. Or should I say, getting stirred up again, a bit like Char Kuey Teow, with everyone adding a bit more oil, or chilli, and some just trying to fan the fire.

Everyone at the decision table seems gung-ho about forcing the public to pay more for health, most likely by buying insurance.

The people who are talking don't seem to make much sense; and those who aren't, are probably smugly "organizing" their piece of the pie. Very sad laa, after all that heat and stirring, I think we, the people, are just going to get another burnt up plate of crap for us to swallow.

"Are you paying for health?"

It is an interesting question, don't you think ? Most young people would probably scratch their heads at this, thinking "Should I be?" After all, we have grown up in an environment where healthcare was everywhere, and free. From the village nurse who would take blood pressure, check urine, give jabs and examine pregnant mothers, to the grouchy government doctors in clinics and hospitals who somehow seemed just too busy writing to care. Healthcare was available. Easily. And free. Or you could just drop by any of the clinics that would charge a bit more, and essentially get what you want.

Why then would we want it to change ? Why would we want healthcare that was available and affordable, something that other countries wished they had, to change and then have to pay for it? Is it really going to be better, and is it going to be worth the money?

Or is the government just trying to shirk their responsibility and pass on the costs of healthcare to us all?

Let us examine this.

Whilst our healthcare system is widely regarded as available and accessible, it is only true for basic primary healthcare. This is very good, and highly regarded internationally; but this is not the only part of healthcare.

Specialized care is must more difficult to access and is often available only in large towns and cities. There is a discrepancy between the number of specialists in government hospitals compared to that in private hospitals. So if specialized care was what we wanted, healthcare is now no longer easily available, nor is it affordable for most of us.

What about drugs? Again, newer drugs tend to be better drugs; but they are much more expensive, and often only available in limited supplies. Or else, purchase your own. We must realize that the affordable drugs dished out in government facilities are older drugs, not the best that medicine can offer at the moment.

What about procedures, operations and tests? Only in larger hospitals with specialists. Most of the time, basic and emergency procedures are done very quickly, but specialized procedures will mean joining the queue; which can extend to many many months of waiting. Not the best news for the person with a failing heart, nor the patient with possible cancer invading with each passing hour.

So why is it that our healthcare system is in this state? Aren't we always told that we have one of the best systems in the world?

It is, believe it or not, all about money. Doctors want more money. Many doctors want the better money that they can get in private practice. Who doesn't? After all, it now costs a bomb to study medicine. A lifetime worth of work and savings, gone in 5 short years of medical school. To follow that up with long hours of work, postings into undesirable places, and dealing with all the crap that government services throw at you, is just too much for many. The private practice entices and we leave. For more money, greener pastures, fewer patients; it all seems good.

It is also about money, or at least the lack of it, that the government puts into healthcare. We spend 3.8% of our GDP of healthcare. That's miserable. Many countries spend 7 - 12% of their GDP on healthcare [and their GDP is more than ours!] We spend 8% of our annual budget on healthcare. African countries spend 15% of their annual budget on healthcare!. To make it worse, a large chunk of that 8% annual budget is swallowed up by government concessionaires from the single agent providing drugs to the government, to the single agent providing support services, to the single agent providing ..... yes there are more money gobbling monopolies. So we spend too little money, and that little that we spend, we do it poorly.

So how? Should we pay for our health? Yes we should.

For one, paying for it means we are taking more responsibility for our own health. It also means that we have a greater say in what we want in our healthcare system. Furthermore, it will help reduce the great discrepancy now between the healthcare that we can afford, and the healthcare that we want.

We can get so much better healthcare by paying a bit more than we are now, coupled with demanding more for our money.

So how do we do this? How do we "pay for better healthcare" ?

NOT by buying insurance, which is what the insurance companies, private sector, government and just about everyone else with a finger in the pie wants us all to do. NO. That would just escalate the costs of healthcare on the whole, putting money is a few pockets and not making a dent in the growing need for better care for everyone. The ONLY support the insurance industry should get out of this is to allow tax breaks for those who buy medical insurance, especially if done for families, work groups and as part of employment benefits.

Instead we should pay more in taxes. Yes. Agree to pay more in taxes; on the sole condition that the increased revenue be dedicated toward a greater budget for healthcare. We need to the government to spend more, and they can only do that with higher taxes.

At the same time, demand absolutely for a review of common medications, common tests, common screening protocols, common practices in hospitals. We may not want the newest drugs, but we want drugs that are cost effective and people friendly. We want better materials used in our hospitals, no more reusable stuff, no more old outdated stuff. We want better tests, better diagnostic screening done. We want better options in procedures. We want specialists in smaller towns. We need a review of everything done in all hospitals; bringing it in line with evidence based medicine, current best practices and priorities for the people of Malaysia.

Write to our Minister of Health, write to your MP or ADUN. Write and demand. Now. Do it now. Waiting around and hoping for the best, is a sure way of getting buggered in this issue.

Priceless moments

2010-09-17T00:05:00.006+08:00

Spending time with young children is refreshing. Sometimes, eye-opening. Almost always worth your time [although it is hard to remember this]

Today, showing daughter how to use a measuring tape, we measured length of hands and legs, size of tummies [hers too small, mine wayyyy too big]. Decided to measure her height, which was 37 inches. Happily I informed her that she was now three feet tall. Her response ?

"Noooo. I have only 2 feet. See? One, Two! And two eyes, two ears, two hands, one nose and one mouth"

Later, reading to her before bedtime, a story about a tiger, that was sleepy, after a long day of jumping and playing and snarling, she decided to show me, how tigers slept.

... which according to her, was how all animals with four legs slept!

Priceless.

"Lepas makan, mai pi hospital"

2010-09-14T21:42:00.003+08:00

Translated as "After dinner, let's drop by the hospital"

Unfortunately, this is the way we Malaysians regard healthcare that is provided to us. Outpatient care is not only free, and close by, it is just so convenient that it is often regarded as a "by-the-way" after-thought.

Just look at what is available for us, after dinner in a typical day. GP clinics are open. Private hospital A&E units are open. 1Malaysia clinics open. Government hospitals off-hours outpatient clinics open. Free community clinics run by volunteers open. Even bomohs and "theet-thar" sinsehs are open.

With RM 50 in your pocket, you could almost pick and choose your doctor. With no money in your pocket apart from your IC, you are still not short of options. We are lucky indeed. But are we spoilt ?

Imagine yourself in any of the developed world countries. Fever and cough ? Treat yourself. Go to the pharmacy [which are often closed after hours] and buy your own medicines for fever and cough. You want to see your own GP ? Sure. Let's make an appointment. Can squeeze you in next Tuesday. Don't even think about going to the Emergency Department unless you want to pay quite a sum of money or you have a few hours to spend waiting. Or both.

But here in Malaysia, it is just soooo different. No difficulty at all. Open late after hours. It is so convenient that we can take our time to finish dinner first, and have a shower, and dress the kids, before going to the doctors.

"Bang, the little one has been sniffing since the afternoon laa. Shall we drop by the hospital?" or "By the way, can you bring me to the doctors afterwards, I have a headache." Healthcare has become a "by-the-way" after-thought.

Why am I complaining about this ? Isn't this a good thing ? Available accessible healthcare for everyone ?

No, it is NOT a good thing. And I will tell you why.

Firstly, it is NOT what you would want from a healthcare system. Your tax money is going to pay for doctors and nurses and other staff working after hours and at added costs, so that people with headaches and fevers and running noses can get symptomatic relief; something which they could very well do for themselves. Take Panadol and apply Vicks, as my grandmother did and her grandmother did before that. It works. Don't argue with grandmothers.

What you want your healthcare system to provide is more important stuff. Screening for cancers and other diseases. Better, newer, more accessible and reliable diagnostics tests. Better drugs. Single use items not reusable stuff. Better wards, better infection control, better facility environment. More money for Emergency Departments. [heh heh had to include that, laaa] That is where your tax dollar should go to. Where it makes a difference.

Secondly, having healthcare that is free and accessible makes us irresponsible. Spoilt. No need to lead a healthy lifestyle because there are always doctors to take care of me, cheaply. No need to take care with our medications because we can always get more, at any time. Hypertension? No problem. Can just drop-by any clinic and get some medicines. Diabetes? No worries; will just go when I have some spare time. Most Malaysians don't even know what drugs they take, commonly describing them as the yellow one, or oval shaped one, or the white one with the KK on it [which to old-timers was the best thing we ever gave out, the KK Paracetamol tablet]. It is amazing how little responsibility we each take on our own health.

But the real reason why I am bitching away is this. Malaysians, in greater and greater numbers, are seeing their doctors after hours. After their work. After their dinner and shower. After they get ready. By the time they reach the clinic, it may have closed for the night. 1Malaysia clinics close at 9:30 pm. Hospital off-hours outpatient clinics close about the same time. Many GPs also close about that time. So what happens to the family, with the headache, with the sniffles, with the tummy pain, with the tired-lah-need-MC problem? They end up at the Emergency Department. Waiting and waiting as the heart attacks and strokes and accident victims and heart failures get seen first. Complaining and complaining and complaining when they don't get seen in time.

That's what gets to me.

Footnote Fact: Three years ago, anyone coming with non-emergency symptoms after the outpatient department was closed, would be told to come the next day. The off-hours outpatient clinic was opened from 5 pm to 10 pm on normal days and from 10 am to 10 pm on weekends, to cater for families who may have difficulty seeking care during normal working hours. It was meant to provide assistance and relieve the non-emergency workload on the Emergency Departments. We now see more than 5000 patients each month in that one clinic. And even though it opens early, most patients still come after 9 pm. Most do not make it in time before the clinic closes. And they still do come to the ED.

So help me God, keep me steadfast..

2010-09-06T22:38:00.003+08:00

Religion is NOT a sensitive topic.

How can it be a sensitive topic? In the history of every religion, there has always been a push to spread the word; to tell others, to share in this new knowledge, this new belief, this new way of life. Believers set forth to let others know about their religion, to tell about the beauty of their beliefs and show the strength of their faith. So, it naturally follows that every religion is meant to be told, to be talked about, to be convincing. How can this be done, if it was sensitive, if the slightest inappropriate word, or inopportune gesture, risked repercussions, and provoked anger and fights? That is not what religion was meant to be. Surely not.

All religions share huge similarities. Each and every one teaches us faith in something greater than ourselves; to do good, to trust in fairness and justice, to treat our fellow man with respect so that the deed would be returned in kind. Every religion teaches us to call onto our God in times of need, to pay heed to his teachings and to show our young and others about the beauty of our faith. Every religion emphasizes truth, understanding and tolerance. Every religion teaches us to sacrifice for something higher in life. Every religion helps us with death. Every religion teaches us to be better than what we already are.

But somehow, religion, in the hands of man, has been "corrupted". Its reputation tainted. Its beauty lost behind gross injustices carried out in its name. Religion became sensitive. We only learnt of the differences between religions, not their common teachings. We only learnt of one God, and loudly proclaimed ourselves as right, others as misguided. We only practiced what crumbs of religion that we picked up from our peers and other pretenders of holy men; not as it is taught in books and written words. We became fakes ourselves, practicing that which other fakes practice; treating that which is within our comprehension as correct and holy, and that which is beyond it, as wrong. The few crumbs of our knowledge could not stand up to argument or challenge, so we made religion sensitive, so that we would not be questioned; and we would not be shown as ignorants and fools.

This cannot be right; and we must act upon this.

So help me God, keep me steadfast .... for i wish to say again, aloud and loud, that religion is not meant to be sensitive, not meant to be kept within oneself. It is meant to be shared and appreciated by many. Despite all that the powers-that-be say.

So help me God, keep me steadfast ... for i wish to suggest to my fellow man, that the best that they can do to a fellow man, is to assist him in his practice of his beliefs, his religion and his faith. Despite all that the fake teachers of faith preach.

So help me God, keep me steadfast ... for i wish to proclaim that to truly know and appreciate the beauty of ones own faith, is to learn and understand the wisdom of other religions.

So help me God, keep me steadfast .....

The search for .. cyanide antidote!!

2010-09-02T19:25:00.007+08:00

We had a patient who accidentally drank a solution of sodium cyanide. Thought it was water. [I wouldn't be surprised if it was kept in a mineral water bottle]. He was working in the jewelery industry, and solutions of sodium cyanide are regularly made from tablets of the soluble salt, and then used to clean gold and silver.

It was interesting because we quickly realized that we did not have any antidote for cyanide toxicity. Neither did any of the other hospitals nearby, government and private. Neither did the Pusat Racun Negara. Neither did the Bomba or the Hazmat teams. Called a good friend who works as a EHS manager at one of the multinationals. He said that he tried getting the antidote sometime back; but failed because the company that was supplying it, ceased doing so. Waaaa, we were running out of straws. Even resorted to asking if anyone had "underground friends" who could supply us with 'poppers', which essentially is Amyl Nitrite, a favourite with the underground party scene. But that turned out to be a dead end too. [it would have been good, if it came through. Sometimes good to have naughty friends!!!]

Cyanide is toxic in many forms; as a gas, commonly as Hydrogen Cyanide, it was used in the Nazi gas chambers. This gaseous form is also produced as a by-product of thermal combustion of plastics and rubber substances. [so, always remember cyanide toxicity in a patient exposed to smoke and fumes related to burning plastics] As a soluble salt, eg sodium cyanide, it is often used in gold and silver processing, metallurgy, electroplating and reprocessing of x-ray films. And insoluble salts of copper, lead and silver are commonly used in many industries. In medicine, cyanide toxicity is a possibility to be considered whenever patients are treated with Sodium Nitroprusside for hypertensive emergencies.

The cyanide anion, when released from these salts, bind to the cytochrome c oxidase pathway, and blocks the electron transport chain in the mitochondria. Essentially, it blocks our cells from using oxygen to produce ATP, which is energy all our cells need to continue living. Exposed to cyanide, the energy production machine grinds to a halt and the cells die. The first cells [and therefore organs] to die are those with high levels of activity and high oxygen requirement, mainly the heart and brain.

The patient would appear to be suffocating despite additional oxygen given. [the bright red skin colour and lack of cyanosis is not a common clinical finding]; the rapid onset of clinical findings soon after exposure is characteristic of significant exposure. Death come very quickly indeed. And the only way out was an antidote.

This patient came after accidentally drinking some sodium cyanide solution; most likely, he managed to spit out most of it, because he was relatively stable. But we were very worried, so the search for the antidote went on.

Then a stroke of good luck. A Bomba Hazmat officer remembered a company that used to stock antidotes, as a precaution since they used cyanide in their industrial process. I called back my EHS friend, and by then, he has found a company that had the antidote. I was truly amazed [and very very very grateful] at the speed and willingness of that company to share their antidote with us. They are the true heroes of the day.

So we had our hands on an antidote. It was the recently approved [2006] Cyanokit ® which contained Hydroxocobalamine.

Previously antidotes for cyanide toxicity mainly consisted of using Nitrites (often either Amyl Nitrite or Sodium Nitrite). The Nitrites will bind with Haemoglobin to form Methaemoglobin, which will compete with the cytochrome oxidase for the cyanide anion. This will form Cyan-Methaemoglobin and release cytochrome oxidase from the cyanide anion, allowing it to function again. The cyanide anion in Cyan-Methaemoglobin will then be enzymatically converted to a non-toxic thiocyanate which is excreted in the urine. Sodium Thiosulphate accelerates this process by being a sulphur donor for the process.

Hydroxocobalamine works in a different way, by directly reacting with the cyanide anion to form a non-toxic cyanocobalamine, which is excreted in the urine. It is highly effective, and nowadays the preferred antidote for cyanide toxicity in hospital management protocols. But it is not cheap, costing a few thousand RM per patient.

So what happened to our fellow ? After our fairly intensive search and ultimately successful search for the antidote, we hear that he wants to take an AOR (at-own-risk) discharge from the medical ward. Aiyohhhhhhh ! Now, don't you wonder why we scold patients sometimes ?

Anyways, all ended well. I think episodes like this one wakes us up a bit, some excitement from the monotony of routine living, some appreciation of hidden heroes around us, and an opportunity to learn something about a very very lucky escape from death.

The stunted trees of Putrajaya

2010-08-23T23:37:00.005+08:00

I was on the KLIA express today, on my way to KL Sentral. There was a particular point during that journey, when the train was passing through Putrajaya, there was a stark contrast between the trees on both sides of the train track.

On one side, the landscape of Putrajaya; on the other, nature left to its own devices in abandoned land.

On the Putrajaya side, specially planted trees, arranged in order, nicely separated in patterns, far from each other, landscaped, watered and weeded. And looking SICKLY. The trees had few leaves and those that were there looked brown and unhealthy. These were trees that were planted at great cost to us taxpayers, who probably cost quite a sum to maintain as well, but were just not doing well. Despite getting the most sun, despite getting watered artificially if there was insufficient rain, despite having any near trees and weeds [potential competition for sun, water and nutrients] removed. These were trees that were stunted, despite getting the very best of everything.

On the abandoned land side of the tracks, it was a vastly different story. Separated by a mere rail track, sharing the same climate, same rain, same soil, the trees here were healthy, green, bursting with life. Sure, there were many trees in a small area, there was no artificial separation, there were weeds and brush everywhere. Sure there was huge competition. But trees there were healthy, and doing well, despite getting nothing special.

Why then, the stunted trees of Putrajaya ? Why the failure to grow, to prosper despite getting the best environment to do so ? Maybe trees need competition to grow. Maybe without competition, those few sickly leaves is enough; to sustain that sickly branch, of that sickly trunk and its sickly root. For that tree, it is enough to survive. And the trees of Putrajaya are stunted because it had done just enough to survive. Nothing more was needed from it, and nothing more did it do. Just survive.

But until when? It will survive, until some challenge comes along. Then it will die; unable to cope with any challenge.

The stunted trees of Putrajaya reflect a wider picture in Malaysia today. We have all been in a watered, weeded and catered for environment; some of us much more than others. We have all created an artificial environment that is not making us any better. We are all on the wrong side of the track.

It is not possible to continue this. Firstly, it is too high a price to pay, for sickly stunted growth. More than that, we now put ourselves in a position where we just cannot meet any challenges. The longer we wait, the more calamitous the drop.

It is time for change.

The solution is not to jump the tracks. We cannot [and should not] do that. We should not remove that sickly trees either. We should however, remove the barriers to competition. Let weeds grow, let other trees grow. Reduce the weeding, watering, landscaping. Allow open, even-ground competition begin. Let the trees grown as they should, competing with each other; each making the other try harder, reach higher, grow faster.

It is time for change.

The solution may be painful for a while; but it will be a short while. Soon, Putrajaya will be green again. Healthily green. And growing. And we would have paid nothing for it. We would have sacrificed nothing; other that the artificial delusions of having rights to water, sun and being on the right side of the track.

It is time for change.

I work for the rights of ...

2010-08-20T13:53:00.000+08:00

Dr Pornthip Rojanasunand, testifying at the Teoh Beng Hock inquest, when badgered about her intention and purported agenda, said "I work for the rights of the dead". That was brilliant. That was inspiration, if not to you, at least to me.

This is a person, willing to stand up and give an opinion, stating the reasons and arguments behind it, despite quite substantial hindrances. A person, seemingly without a personal agenda, standing up for her opinion, without compromise and without equivocation, is a person worth listening to. This is a rare breed of person indeed.

It is actually not difficult to have a clear stand on any issue; as long as we understand it well, and we leave our personal beliefs and biases behind us. Without an agenda, without a cause to defend, without the distractions of power, money and position, it is not difficult to say what we think, and why we think so.

It is only when we have fear in our hearts and minds, when our argument cannot be held to be logical, when our thoughts are so distorted that they cannot withstand the light of reason, when our beliefs are swayed by the distractions of greed, that we are not able to speak up, that we are not able to answer to scrutiny, that we cannot say in earnest "I work for the rights of ..."

I wish we had many more people like Dr Pornthip.

But we don't.

We have a whole bunch of people who work for their own rights only. Chinese rights, Malay rights, Mamak rights, Indian rights, Muslim rights and so on. This is nothing to shout about. In fact, I would even say that all of them are not worth listening to. If you are fighting for the rights of a group, of which you are a part of, forget it. Not worth listening to you. You are just contributing to the noise of every other group fighting for their own small cause.

But if you are fighting for the rights of others, ahhhh, maybe you deserve our ears. And our support. Community service groups are in this group. Charity groups, volunteer organizations, support groups etc. All of them do good work, much of it behind the scene. They deserve our ears and support.

Above all, the one who fights for those who cannot fight for themselves; those who give voice to the silenced, strength to the dispossessed, attention to the neglected, justice for the dead, and hope for those who have give up; they are the ones that command not merely our ears and our support, they command a following. Such is the strength of those few words from Dr Pornthip.

Imagine if ...

... our judicial system is filled with luminaries who can say out loud, "I work for the rights of the just in seeking justice and fairness",

... our police officers can rightly claim, "I work for the rights of the common man to have a safer society"

... our teachers who can say, "I work for the rights of all our young to have a better future"

... our leaders say, "I work for the rights of our rakyat; not for political parties or political leaders"

... our newspapers say, "I work for the rights of our people to know"

... and you and me, who must now say, "I work for the rights of the right, upholding that which is right as taught by God, my parents and my teachers"

Those few words of Dr Pornthip's testimony are powerful, indeed.

Why I teach

2010-08-16T21:24:00.003+08:00

My mother was a teacher. She taught Mathematics, English and Chinese, retiring after a 30 year career as a Chinese Primary School Headmistress. I don't know if that is the main reason [I suspect it is] but teaching is in my blood. I love teaching; I enjoy it, I like the sharing of knowledge, the creating of thought and understanding, and the ahhhhh! that comes with finally understanding something or getting something through.

I have always felt the learning process to be much more important than the teaching process. The idealism of striving to learn, working for experience, hunger for knowledge, searching for new developments strikes a key deep within me. In this regard, the good teachers could always get their students to go that extra mile to learn, without teaching them that extra mile.

But, this may be why I just cannot be a full-time teacher. Knowing that learning is just as important, if not more, than teaching, I just cannot accept it when my students don't want to learn.

Why does anyone want to learn anyway ? Why does anyone want to teach, for that matter ? Are the reasons the same ?

I teach because I know some skills and knowledge, which when applied at the correct time and circumstances, may significantly help another person. I hope that these skills and knowledge, if shared around with more people, may lead to more opportunities and help more people. I hope that by teaching these skills and knowledge, I may, by proxy, help more persons. So, in the same vein, if those that I teach, proceed to teach others, my impact would be even more.

There. That is why I teach. For personal fulfillment. A bit of self-satisfying personal glory. A very selfish reason indeed.

But I've come to realize that people learn these skills and knowledge that I want to share for different reasons. Sometimes just for the sake of learning something new. Sometimes for the sake of doing; providing assistance to others if called upon. Sometimes, for the sake of teaching others, helping to spread the information.

Sometimes people learn the skills and knowledge that I want to share just to show others that they know. That I, I, I know more than you, you, you.

This is not at all uncommon. After all, every single professional in the world calls himself or herself a professional because they have some special knowledge or unique skill. They can then charge professional fees for using this knowledge and skill. They can then reap the rewards and due recognition from that skill. So, learning something so that we can tell others that we are better, and different is not wrong.

Is that true ? Can this is correct ? This cannot be correct; at least not for those that I have taught. I teach because I want to share; and by proxy, help others. This must mean that what I teach is meant to be shared; to help others; not meant to be used to differentiate or discriminate.

But surely, any of my students can argue that they only learn the tiniest percentage of their knowledge from me. Surely I cannot reasonably demand that they must share all the current skills and knowledge with others unless they so desire. They are correct in their argument.

Here, the chasm that lies before me. I cannot now justify why I teach. Why I teach is not the same as why they learn. I am lost.

Until my teacher sets me right. My teacher says this. Teaching of skills and knowledge is NOT the main objective. It must only be considered the by-product. The emulation of good characteristics of the teacher must instead be the main objective. The learning of the good parts of each and every teacher; highlighting the bad in order to avoid its pitfall; so that they student will come up much much better than the teacher ever was, is the final aim.

In short, whilst I teach the skills and knowledge to help others at their time of need, the student that learns my desire to share, a passion to continually learn and improve, and then teach others, doing so in a manner that encourages mutual respect; would have learnt the greatest lesson that I can ever hope to impart.

How do I tell the guy next to me ... Part II

2010-08-11T19:16:00.005+08:00

Taken without permission; but not modified in any way, from SakMongkol [this was a comment from blogger Walla, responding to Sakmongkol's post] It is so reflective of how many of us feel today; but don't know how to say it.

The challenge is how to represent one's race and yet not end up being racialist.

It's a thin line. Too many times that line was crossed. And it was crossed mainly by those inside Umno which then attracted similar response by others. Umno first, others only in response.

The rakyat have become tired of that. They are tired of being forced to be racialist. They are tired of the politics and the lies and the denials, they are tired of the commissions and the omissions, they are tired of waking up to find yet another package of spin at their doorsteps, another bill in their mailbox, another scandal on the front page, another theft in the corridor of power that overwhelms in size and severity those on the streets that they walk in trepidation of their lives while the government under Umno plants more cctv's paid with taxpayers money in its over-priced and under-populated federal administrative enclave than in the places where the real rakyat live.

The rakyat are tired and angry that the end of their days will be bleak. They are equally tired and angry that the beginning of the days of their young will be even bleaker.

Meanwhile, to greet them with such bad prospects, they have been asked to change their lifestyle when costs have gone up but incomes have gone down in an economy that has shrunk in its ability to remain relevant to the world.

They are asked to be more productive by using their knowledge and skills but none of it can be applied because political leaders and little napoleons have wrought havoc with the education system from the way and things taught to the way and things issued.

The very people whose mindsets must first change are trying to change the minds of those who are telling them to change their mindsets. How corny can one get?

It must therefore be to the credit of the rakyat that although tired of politics, they have bounced back on their own to their natural selves. They have on their own said no to extremism and chauvinism. They have gone back to the core values and behavior that had defined the original spirit of this country. The centre that defines what being a Malaysian truly means.

Pas and DAP have moved to the centre. And ever since they have moved towards moderation, they have discovered that they are more comfortable with the new position - because it reflects the inner nature of Malaysians - to be practical and to be fair. They have found that they have lost nothing. By some magic, they have found that their own manifesto's have instead been enhanced.

And the rakyat who are Malays have found again their good nature and sense of fairness. They have found that they really don't lose anything by being accommodative to others, by not playing the zero-sum game, by caring for others as they want others to care for them.

After all, what rights and privileges have they lost in the Opposition states that they had gained, if any, in the Proposition states? Except for the cronies and the elites of Umno, how can one lose what one never had?

And because the Malays themselves have pierced the veil that sought to cover-up the sandiwara's and the ponzi schemes, likewise the others.

It's a tectonic shift by the masses away from trying to defend their rights along racial grounds to trying to defend their rights by muhibbah. Incidentally, that's a term coined by Barisan but lost in the wilderness of its own political machinations.

And the rakyat have found that when they defend their rights by muhibbah, all rights automatically fall into the domain of being pragmatic about things which in turn sustains more capability to benefit from better policies and actions which in turn serves the enterprise to in turn serve the dispossessed and the needy - in this country which fifty years of so-called nation-building under Barisan had only ended up creating the biggest income disparity in the whole of Asia.

The future belong to our young. But what have we bequeathed them under Barisan?

Thirty-four percent of the rakyat earn less than seven hundred ringgit, below the poverty line of seven hundred and twenty ringgit. But how can even RM720 be considered a reasonable sum today to define livable standard? If the poverty line is more realistically raised to RM1,200, then even more rakyat will fall into the poverty group. The official situation is thus spin and nothing but an artful artificial construct to try and pull wool over the eyes of the rakyat. As if that can ever be of any real comfort.

You know that's true because the insolvency department says one hundred and ninety six thousand Malaysians are insolvent. A small number on percentage basis? What about those thousands who are insolvent and running from private financiers, the ones who smear red paint on their doors?

When people say Umno, who do they think of? They think of Toyo, hero of the anti-sand theft. Is he doing it to cover-up his own past or to guarantee there be enough sand to build the extension to his mansion? What has he done when he was MB in the tradition of the past Umno MBs of Selangor? Win a hundred thousand ringgit wristwatch? Go to Florida to study canal management? Denude another hill? Launder money? Screw a relative? May 13, perhaps?

When people say Umno, who do they think of? They think of Taib. How will he explain his wealth overseas on the salary he gets as CM of Sarawak? From the japanese timber buyers who had to pay to the timber cronies whose staff defiled the Penans whose development has to be associated with his plans or else they will suffer him calling them orang-utans?

When people say Umno, who do they think of? They think of Thamby Chik, exonerated by the court over and above a DAP politician who went to jail for bringing up the matter in defense of an underaged Malay girl who finally had to be rescued by the grandmother.

When people say Umno, who do they think of? Megat Junid of Project M infamy? Adam Adib of Mindef procurements? Harun Idris, Umno Youth's Suhaimi, Ahmad Ismail, Ibrahim Ali the mouth, Rahman Yaacob MOE DG who unilaterally changed main medium of instruction to sole medium of instruction? The Ezam's and others who kiss the prince of storyland and perhaps the Umno treasurer? Or could it possibly be our own Placido Domingo himself, patron to Shahrizat for the two hundred and fifty million cow farm project for her husband, and tenderizer of Desaru investors? Or perhaps it’s really the twenty two Umno branches who filed police reports against the Opposition for suggesting that the seven percent discount be canceled for properties that would be only afforded by those already rich enough to buy Porsche SUVs so that the discounts can instead be given to poor Malays, and weren't they prodded on by two Umno leaders, one using the word 'rights' in addition to 'privileges', as if doing so would make it more legal tender than what the Constitution assigns if in the first place that instrument even stoops to mention a discount? What is this country built on? A help-you-help-me with your money jomheboh?

This comment box is too small for all of them.

Name one, single, unitary, identifiable, thing, that Umno has done for the nation which doesn't have debatable positive result.

Felda? Sued by the settlers themselves. Sime? Underbidded until twice bitten but still not shy. Taking Perak against the better judgment of the rakyat? Bakun Dam? Angkasawan and Petronas Sauber? Buying F18’s that can’t fire? Losing islands despite large arbitration fees? Crooked bridges? Collapsing roofs and arches? Phallic symbols of progress? Overpriced DIY and parliamentary hardware? Or a three hundred million ringgit dam in a place without water?

Are there more? This comment box is too small for all of them.

Read Shafee Yahya's book to get an insight of how it really has been by those who had used the name of Umno to immortalize themselves only to deal Malaysia a mortal blow.

People have repeated that under Umno, a hundred billion had been blown. It's not a hundred billion ringgit. The analysts concerned had written it was a hundred billion US dollars.

Now with Malaysia to be a net oil importer by next year and a net gas importer in five years time, where is the Government under Umno to find the money to satisfy the horny callings of Ibrahim Ali of Perkasa and Mahathir Mohamad of The Loaf in order to deliver the 'rights and privileges' so guaranteed by Umno to the Malays when if you go to PJTC's JHDN, you will only find one race as customers at the counter paying taxes and that's the race those leaders are lambasting to make innocent Malay folks think it's still alright to pretend that the other races are the cause of their miseries? Would that also explain why Umno youths still fly to London to rah-rah the Malay scholars that they must always remember the special position of the Malays - despite the 1Malaysia calling of the seventy five million ringgit PR program by the President of Umno? Is it now where Biro Tatacara fails, Umno Youth must succeed in the interest of 1Malaysia to give way to 2Malay?

So, is Malaysia a failed democracy? Only half-right, here. Failed, yes. Democracy? What does anyone think anymore? Isn't this country the only one where one has to bring torch lights to a polling station because, sure enough, there will be an officialized power failure during vote counting? You know that has a ring of truth to it for how else can one explain why the Barisan Sibu candidate declined a recount on such a close call - because he saw the same method applied as in Hulu Selangor? You know that ring grows to a bellow when all of a sudden there is an anti-ISA group. Since when do the rakyat suddenly believe so strongly for imprisonment without trial that our blues can turn an eye from them but nab people who hold candle virgils? Because they know power failures are fakes?

So, is Malaysia even a democracy when there is a fatal MO in its political governance where a political party can assume supremacy over the operational interpretation of constitutional clauses in such a way as to reinforce its own position through divisive policies, by which method it can spice up its airs with shitx3 juxtaposed with racistx8? So how is it that under Umno, we have to ask whether Malaysia is a failed democracy? Because we have reason to doubt the integrity of our judiciary and enforcement institutions? Because corporate and public governance shaped by Umno is a benchmark of excellence? Because this nation still has plenty of time and resources to print money to avert financial collapse, failing which to gerrymander the election system to win yet another five years of political triumph? Because politicians can look themselves in the mirror at the end of every day and grin their grins instead of grimace their grimaces, for the tingling sensation from hearing their retirement cash registers ringing?

Shall we all have to ask our AG for answers?

Perhaps then the rakyat can finally understand how is it that the fate of this nation is now gloriously dependent on whether a college dropout has been anally assaulted.

Update: Sakmongkol has answered here.

And maybe that is why ....

2010-08-09T06:28:00.002+08:00

What would you do, if you could not sleep?

I would watch ASTRO (thank God for 24-hour TV) or make myself a Maggi Mee with warm milk and Milo kaw. I would surf the net. I would read. I might even take a shower. What I would NOT do, is to wake up another member of the family. Nor would I call anyone, because not being able to sleep is misery that is not meant to be shared.

If you were in a hotel, and could not sleep, I suppose that is even easier. Leave the room, go merayau-rayau. Stop by the mamak stall (thank God for 24-hour Mamaks). Or take some alcohol. It works.

But no need to go to the hospital laaa. Surely, not being able to sleep is not an emergency. And it is no where near the kind of misery the other patients are going through, in the ED.

Would we treat you, if you came to the Emergency Department in the middle of the night, because you could not sleep? Yes, I have to say we would. When it comes to your turn. After all the critically-ill patients have been resuscitated, the injured treated, the ill soothed, the ones in pain relieved, the ones in distress calmed down. Then it is the turn of the ones who cannot sleep. [And the ones who want MC.]

What would we give you, to help ? Hmmmm would a sedative-hypnotic anti-histamine be good for you ? Not really, cos it would make you groggy the next day. Maybe a benzodiazepine, except that these are controlled drugs and are not prescribed on an emergency basis, especially at odd hours, for obvious reasons. We really don't want these drugs to end up being abused to date-rape someone. Maybe an anti-psychotic would do; except that would you really like it written on your medical record that you are on anti-psychotics ?

So how laa? Back to the warm milk with Milo kaw. Surely that is not too difficult to prepare, right ?

Really not necessary to call for help, right ? No need to kacau anyone else, right ? Hmmmmm ...

Had a after-midnight call sometime back; from some doctor somewhere, who was called by some Minister in his hotel room, because he (the Minister) could not sleep. The discussion that followed was vaguely the same as above. Why that Minister felt it befitting to stay in his hotel room, and disturb two other persons that late at night, is beyond me.

And maybe that is why .... we should change the Government; having Ministers that cannot solve a minor personal problem, like cannot sleep in the middle of the night, without asking for help, is troubling. Having a Minister who thinks that he can, by virtue of his position, call on others to suit his own whim and fancy, is disgusting. Having a Minister who cannot go to the Mamaks in the middle of the night, is just not Malaysian!!!