tag:blogger.com,1999:blog-45814540229887193032024-03-22T11:45:45.213+08:00WebNotes in Emergency MedicineDr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.comBlogger235125tag:blogger.com,1999:blog-4581454022988719303.post-16626585360839486232023-11-06T13:35:00.089+08:002023-11-11T12:22:33.788+08:00A whole entire generation of copycats<span face=""Trebuchet MS",sans-serif" style="font-size: x-normal;"></span><div><br /></div><div>An Open Day. </div><div><br /></div><div>An International Showcase Event. </div><div><br /></div><div>A Launching Ceremony. </div><div><br /></div><div>The major event on the calendar. The one day of the year where the best of everything that one can do, is on show. To the pretty, it is time to show their beauty. To the strong, their muscles. To the intellect, their academic accomplishments. To inventors, their innovations. To artists, their art. But for those with none of the above, the gongs of empty drums and flashes of sparkles cannot hide their lack of prowess. </div><div><br /></div><div>Instead we hide our lack of imagination with a lot of sideshows; speeches from people with important roles from important sounding organisations, panel discussions from so-and-so using words that almost everybody cannot comprehend, but nobody will bother to ask for clarification (what the heck is 'leveraging'), and boy-oh-boy our all time favourite, colouring contest. Yes, that's the way to build out future generation, a colouring contest. (With prizes, you know.)</div><div><br /></div><div>That's where we are today, I think. After having a generation of young only allowed to look at a generation of "acceptable older persons" doing only acceptable things, that's where we are today. Colouring contest.</div><div><br /></div><div>Nothing wrong with copying others, if copying the best was the thing. But only allowing copying what was acceptable, and that which was acceptable was mediocre at best, we are</div>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-68349118844179060802020-04-14T17:01:00.000+08:002020-04-14T17:01:34.200+08:00I just don't know ...<span style="font-family: "trebuchet ms" , sans-serif; font-size: x-normal;"></span><br />
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How does this end ? This COVID thing, how does it end ?</div>
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This is not a usual question. Most people are more keen to know <i><b>when</b></i> it ends, rather than how. But to know <i>when</i>, we must know <i>how</i> first. And to know <i>how</i>, we must look at history, and science. </div>
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Viruses can infect humans who are susceptible to them ie. humans who don't have any immunity to those viruses. After being infected, the body usually develops immunity to that particular virus strain. So, if exposed to the same virus, the human now has immunity and no longer falls sick. On the other hand, viruses have learnt many ways to continue infecting humans. Influenza viruses, for example, are infamous for their ability to mutate, producing different strains every year. Most years, the changes are subtle, so the new virus strain still encounters some parts of the human population who have some immunity to another relatively similar strain from previous years. Therefore, the new strain of influenza viruses that appears each year will encounter some people who are susceptible who will fall ill, whereas others, having some immunity to it, will not. And that's why the seasonal flu very seldom causes pandemics. </div>
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In 1918-1919 in the midst of the cold winters of the First World War, the Spanish flu struck. This was an entirely new strain of influenza virus which meant that nobody had any prior exposure, nor any immunity to it. It spread wildly throughout the entire population, and killed millions by the time it ended in the summer months of 1919. How did it end ? Likely, when a large proportion of the community had already contracted the infection, and developed some immunity to it. As the months drew on during that epidemic, a larger and larger proportion of the community had developed immunity to the virus, making it more and more difficult for the virus to spread to susceptible ones. This is called <i>"herd immunity"</i>. Epidemiologists estimate that about 50% of the population must be immune in order to control the spread of the influenza virus and bring the epidemic to an end. </div>
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In 2009 - 2010, a variant of the swine flu H1N1 emerged and also encountered a population with no inherent immunity to it, spreading rapidly from Mexico to North America and then to the rest of the world, infecting up to 25% of the world's population. This H1N1 virus was not particularly deadly though, causing only about half a million deaths worldwide. Interestingly, the H1N1 virus seemed to spare the elderly, very few over the age of 60 actually fell ill. One possible explanation was the prevailing immunity from the previous flu outbreaks in 1957-58 and 1968 protected those who lived in those years from the H1N1 infection. Adding in the proportion of elderly to the 25% who were infected, a very rough estimate of 50% of the population must be immune, in order to bring the epidemic to an end. </div>
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That brings us back to the COVID-19 pandemic. There are probably 3 main scenarios happening in various parts of the world at the moment. One, where the community spread is widespread or soon to be widespread from lack of any kinds of community controls eg Wuhan, northern Italy, New York. In these places, the infected numbers will spike markedly, healthcare systems will be overwhelmed and many will die. Then the infection rates will drop sharply too, as herd immunity builds up. Two, where the community spread is controlled by some social distancing measures eg most of Europe. Here, the infected numbers will become high, hopefully not enough to overwhelm the healthcare services, but the peak will not be reached for some time, as the rate of climb is slower. After <b>months</b>, maybe, the herd immunity may have reached a level to control the spread further, and the epidemic ends. Three, where the community spread is strictly controlled by lock-downs and movement control orders or whatever you might want to call it, Singapore's CB ∼snicker∼, where the numbers infected will fluctuate due on local and imported clusters, but remain relatively low eg, Msia, Spore, Korea, Japan, China, Tw etc. In this scenario, the total number of patients are controlled well, <b><i>but</i></b>, herd immunity does not build. To the virus, the susceptible community remains exactly as it was, months before the lock-down. Still susceptible. Still vulnerable. Still in hiding.</div>
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So, <i>how</i> does it end ? It ends when the community builds up enough herd immunity to prevent the spread of the virus. Somewhere around 50% of population must have immunity to stop it. <i>How</i> we achieve 50% of population with immunity - this is really the crux of the matter - is either by controlling the number of infections slowly so that it doesn't overwhelm the healthcare services and doesn't kill too many people, or by immunization with a vaccine. The vaccine is not likely to be available soon. Scenario One is intolerable. Scenario Three doesn't build herd immunity at all. Scenario Two, by relaxing movement controls, slightly, or intermittently, or only to targeted groups (eg elderly - high risk, schoolchildren - rapid spread), and allowing infection numbers to rise among lower risk in a more manageable rate, seems to be inevitable. </div>
Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com1tag:blogger.com,1999:blog-4581454022988719303.post-77660819657497673792020-03-21T14:21:00.002+08:002020-04-14T13:23:25.449+08:00COVID-19 Rapid Test Kits - What you should know first<div>
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<i>COVID-19 Infection. A very short pathology lesson in viral infections. </i><br />
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When anyone gets infected with the SARS-COV-2 virus, usually via the respiratory system, they will have no symptoms for the first few days as the virus starts to replicate more and more in the body. This is called the <i>incubation period</i>. You are unlikely to be contagious at this stage. </div>
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After a few days, the body starts developing a fever, in response to the viruses in the body; and cough as the viruses invade the respiratory passages. These are the most common symptoms. At this stage, a person is likely to be contagious, as cough and respiratory secretions may carry viruses to infect others. </div>
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It then takes a few days more after that, for the body's immune system to start producing antibodies to this virus infection; usually the first ones are IgM then followed by IgG immunoglobulins. </div>
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<i>Testing for COVID-19 Infection. A short introduction.</i> </div>
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Testing for COVID infection tests for several different items at different stages of the disease. PCR testing checks for very small quantities for viral DNA in deep swabs of the nose and throat. Simply said, PCR tests for the actual viruses itself. Therefore PCR testing can become positive in 2 - 3 days after the fever and cough starts. This is now the gold standard for diagnosis of COVID infection. </div>
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However, since the PCR technique relies on amplication of those very small quantities of viral proteins, this takes time. So a PCR tests will take hours to do, and often can only be done in special PCR labs. On the whole, between taking of the sample and the return of the results, it will be hours at best, days usually. </div>
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This makes PCR testing not useful for screening of patients with fever and unknown history of contact with a confirmed COVID-19 positive case. And we know, as the COVID-19 spreads in the community, the number of such patients (with unknown contact history) will rise rapidly.</div>
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<i>Rapid Testing for Antibodies to COVID-19 infection. The potential use.</i></div>
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Rapid Testing to confirm the presence of, or to rule out, COVID-19 disease early in the disease is important to help in the control of this disease. After all, if we can identify the disease earlier, we can isolate them quickly. On the other hand, if it was negative, everybody happy and can go eat nasi kandar. No need air suam. <span style="font-family: "trebuchet ms" , sans-serif; font-size: x-normal;"></span></div>
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But, but, but, as much as we want that to happen, let's look at the truth, and dispel the myths. </div>
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IgM and IgG is only produced when the person is infected and has become sick. That means with fever and cough, and whatever other symptoms they may have. Sick. Because sick means got virus. After kena virus, then only immune system kicks in, right ? </div>
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So if a person is not sick, it means no virus, right ? Wrong. That person could also be in their incubation period. Not yet sick. This means that if we test a person who is not sick, the negative test will mean nothing. Can be not infected, can also be infected but still in incubation period and not yet sick. Lesson #1. Don't test those who are not sick !!! Waste money.</div>
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OK, so we test when the person is sick lah. Remember the pathology lesson, immunoglobulins needs a few days after onset of symptoms (after start being sick) to develop. So, for COVID-19, most of the IgM/IgG tests only report data taken more than 5 - 8 days after being sick. Which means to say that most IgM/IgG tests can accurately tell us whether positive or not after 5 - 8 days. Msia fellow says die already laaa after so long. So how ?</div>
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There are some accredited labs that have produced tests that claim to be able to diagnose accurately within 3 - 5 days. There is little data to validate their claims as of today (21st March 2020). So what is needed urgently is to validate the claims of those tests. </div>
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Why didn't China do it already, you may correctly ask ? China outbreak did not have the benefit of these test until late Feb / early March. Until last week, China's use of IgM and IgG testing was to identify recovery - who can go home. IgM titre reducing IgG rising boleh balik rumah. </div>
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<i>Then in Malaysia's COVID hospitals, why are we not doing it?</i></div>
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Because these tests need validation. We need to test how good those tests perform in the early stages of the disease (within 3 - 5 days of onset of symptoms). If they are good, then the tests should be really useful in identifying the disease early. If not, then we still need to wait for PCR results and all that delay. </div>
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<i>Private centers are offering rapid testing. Apa macam ?</i></div>
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Ahhhhh. This is really the Malaysia-boleh moment. If you see the criteria listed by these centers, most of them say <i>for asymptomatic patients only</i>. We already explained why testing persons without symptoms is pointless. So why would someone pay RM 650 to RM 990 for a test that ultimately will tell them nothing ? </div>
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I really cannot be sure. Most likely they all didn't read the fine print about these tests. They thought in simple terms that tests are positive and negative. I hope that is the case. Honest mistake. I really hope it was not to cash in on fears. </div>
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Or better yet, why not test those who are sick, symptomatic ? Makes good sense, right ?</div>
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Maybe what we are seeing here is decisions made out of human failings. Many ppl are scared of sick ppl. Scared to be infected. Don't come near. Go somewhere else. If not sick, got money, come come. If sick, no money, go go. I really hope this is not the case. But it sure looks like that to me. </div>
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Stay Safe. Stay at Home.</div>
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Come to COVID Screening Hospitals only when </div>
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<li>You have a fever for more than 3 days</li>
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<li>You have been in contact with anyone from the tabligh cluster of confirmed cases, who are sick</li>
<li>You are sick and those around you are sick too. </li>
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Otherwise, stay home, monitor your fever.</div>
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com3tag:blogger.com,1999:blog-4581454022988719303.post-23178022499136292992018-05-08T23:41:00.001+08:002018-05-13T15:51:41.740+08:00At the edge of the cliff, <span style="font-family: "trebuchet ms" , sans-serif; font-size: x-normal;"></span><br />
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<span style="font-size: small;">8th May 2018. Tuesday. Nearly midnight. At the edge of the cliff, the view becomes clear. Malaysia - one country, one people - well, almost ...</span></div>
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<span style="font-size: small;">More than 2 years have passed since we all started looking forward to this election. It's been a long journey, bruising and testing, often calling on us to examine our principles, our moral compass, our relationship with our fellow Malaysians. And as we now stand together at the end of this journey, and at the edge of the cliff, one thing is certain - regardless of outcomes tomorrow, we are all much much more similar than we thought. </span></div>
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<span style="font-size: small;">We all have common aims in life, ways of thought and behaviour that are very alike,</span><span style="font-size: small;"> similar hopes and aspirations for our kids and their future, and in many ways, a fairly indistinguishable misunderstanding and mistrust of each other. This has been used by the ruling government to divide us for decades, so that we would never, could never agree on changing a govt, regardless of circumstances. </span></div>
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<span style="font-size: small;">But somehow, the unerring wheels of karma have aligned the moons, and we now stand on this very edge, watching history being made. We must never forget this lesson, that every Malaysian share so much more in common, only the smallest quirks setting us apart. And we must never again let anyone misuse those minor differences to set us against each other again. </span></div>
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<span style="font-size: small;">This lesson has been 14 years in the learning, for it was in 2004 that Pak Lah won an overwhelming victory by promising rule of law, no corruption, helping the common man achieve all that he can be and respecting each and every one from every race and walk of life. He never delivered. That's what we wanted then, and remains what we want now. Tomorrow, we can start rebuilding that future. </span></div>
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<span style="font-size: small;">Tomorrow too, we shalt need to deal with the crooks and their enablers, the saboteurs and instigators, the haters and liars. Let the rule of law take back its honour and strength by dealing with them, fairly and justly. But let's start off with compassion, not revenge. Love not anger. Tolerance not hatred. Let's build, not tear down.</span></div>
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<span style="font-size: small;">So, at the edge of the cliff, do we jump, or do we fly ?</span></div>
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<span style="font-size: small;">Vote. Rebuild. Save our country. </span></div>
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-48998410785976589042018-05-02T17:38:00.000+08:002018-05-02T17:38:00.242+08:00Ayer Hitam, Ayer Hitam .... Air Itam calling!<span style="font-family: "trebuchet ms" , sans-serif; font-size: x-normal;"></span><br />
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Ayer Hitam - Parliamentary constituency in Johor; total voters approx 45,000; incumbent - MCA-BN</div>
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Air Itam - State constituency in Penang; total voters approximately 19,000; incumbent - DAP-PR</div>
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In GE-14, it is interesting for the constituents of Ayer Hitam to take a closer look at their smaller (and maybe wiser) namesake in Penang. </div>
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Consider the management of government-controlled funds, and where those funds ended up; consider those who kept quiet, enablers who ignored or distracted from it.</div>
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Consider the passing of questionable laws in double-quick time, and the disdain shown to fairness and natural justice.</div>
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Consider where we are now, and where we are heading; and think of what burden we leave behind for our children to bear.</div>
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Consider your voice, and wonder if you still have one; for who stifles voices calling for justice, fairness and doing right.</div>
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Considering all this, even if he is the most friendly fellow, who does his best with the roads, and lights and drains, and the friendly nod and pat on the back; he is not worthy of our vote - our lost voice, lost riches, lost dignity, lost pride, lost peace is not replaceable. </div>
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Vote ! For Malaysia's sake, vote!<br />
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-79362698343120645212018-04-06T12:50:00.001+08:002018-04-06T16:06:50.852+08:00I trust these to be self-evident and true ...<span style="font-family: "trebuchet ms" , sans-serif; font-size: x-normal;"></span><br />
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... that in these trying times, </div>
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<li>we as a people of this country, will build in a common future together; </li>
<li>believe in each others common strengths, shared ideals and similar intent; </li>
<li>look at each other with patience, tolerance and understanding; </li>
<li>discard that which is diseased, </li>
<li>overcome those who sow hate and discord, and</li>
<li>uphold what is fair, upright and just.</li>
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... that in recent times,</div>
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<li>we, the people of this country, have NOT had a govt for the people,</li>
<li>but thieves, crooks, liars and swindlers,</li>
<li>who made us suffer, taught our children injustice, made us fight each other, </li>
<li>made us poorer - in culture, in decency, in respect, in money</li>
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... that when it comes time to #Vote,</div>
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<li>we Malaysians, who already share so much history, and must share the future together,</li>
<li>we, who have our fears, preconceived prejudices, stoked by ugly politicians,</li>
<li>we, must believe that we are better than the ugliness, repulsive arrogance shown to us,</li>
<li>we trust in us, you and me,</li>
<li>we turn away from the path leading to more of the same, and worse to come,</li>
<li>to that path of hope for a better future.</li>
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... that when our children ask us, sometime in the future,</div>
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<li>what did you do then, at the turning of the tides,</li>
<li>you can say I moved and we became a tsunami of hope</li>
<li>that swept out all that was decrepit and rotten, </li>
<li>and we built again, better, fairer, a government for the people.</li>
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-6408811244379574452018-02-02T16:53:00.000+08:002018-02-03T11:01:57.978+08:00Errors vs Crimes<span style="font-family: "trebuchet ms" , sans-serif; font-size: x-normal;"></span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><i>"I don't wish to be a doctor anymore. I used to do it to help relieve somebody else of their suffering. Now, all I do is to achieve some system's role or performance target, or fulfill some documentary requirement, or avoid some complaint, or guide the next generation in joining into this abyss. The suffering continues unabated. The sick and needy and injured keep coming. On my back, their care, and their satisfaction. On my back, the hospital - administration, ancillary, supporting services, and the others - insurers, payers, financiers, earn money. But on my back alone, I carry the burden when things go wrong"</i></span></div>
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<i style="font-family: 'Trebuchet MS', sans-serif;">Anonymous Doctor</i></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Medical errors have received much attention. Doctors in administration and management have attempted to address it like doctors would - as a disease. Find out what happened, investigate to identify causes, and correct the problem with interventions. Like antibiotics for an infection. Initiate preventive measures to avoid the similar error happening again. Like vaccination. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">But the problem is that the two main parts of the equation, doctor and patient, are human. And humans aren't exact like science. That inexactness of humans will result in <b>inaccuracies with communication</b> - listening, speaking, understanding, interpreting; <b>variability of actions</b> - due to awareness, urgency, concurrent situations, prevailing environment; and <b>acceptance of outcomes</b>. It is this inexactness that gives intuition, gestalt, clinical acumen; and it is this inexactness that contributes often to errors. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">So medical errors will continue to be, as long as the parties involved continue to be human. System measures may place safeguards, usually to avoid simple mistakes; but often cannot address errors of interpretation. As medicine becomes ever more complex, and the body of knowledge expands to (almost) beyond capability, the number of errors are unlikely to be ever much less. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">But when did we ever promise that Medicine was free of errors ? Some may argue that it was at the very beginning with Hippocrates' <i>"first do no harm"</i>. Surely I cannot argue with Hippocrates, but it is hard to think of any medical therapy which doesn't at least carry the risk of some adverse effect. Hippocrates' had he lived today maybe have said <i>"first try to do more good than harm" </i>reflecting the risk-benefit analysis which we do all the time. But then again, Hippocrates had he lived today, would probably have quit Medicine altogether. Especially if he had known about lawyers.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">You see medical errors are the lawyers windfall. Negligence, they claim in their letters of demand; Negligence they claim from their side of the aisle. The error was the worst they had seen, and had directly contributed to the injury, or death. The doctor did it. Inexcusable. Strike him off the register. Unforgiveable .... but some money will alleviate the suffering of the family; and 40% for the "suffering" of the lawyers. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">It has gotten worse. In some countries, and some situations, medical errors have gone onto criminal proceedings. Crimes. Acts against the written law that may lead to jail. I cannot understand this. If I kill somebody, steal something, assault someone, cheat people, rape, maim, torture or even fake documents, I can understand jail-time because I did something. I committed a crime. BUT if I missed a diagnosis, when treating someone, I may end up in jail, professional career forever destroyed ? Is it a crime of commission, or of omission ? Are they the same ? Or is it, an eye for an eye type of justice ??</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">The crime of omission is a failure to act, often in medicine, a failure to recognize and therefore to act. This is considered in law, very different than crimes of commission, and therefore attracts different legal consequences. It give rise to liability only when <i>the law imposes a duty to act. </i>Yes, doctors often have that duty to act; but does the law impose a duty to be correct ? Furthermore, although the act of omission is considered actus reus ("the guilty act") criminal liability is considered only if proven in combination with mens rea ("the guilty mind"). So I really cannot understand criminal proceedings against doctors who are treating their patients. It is, to me, an eye-for-an-eye type of justice. Except that lawyers get paid for exacting the eye. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Most professional organizations say that such actions are necessary to protect the integrity of the profession and its standards. Judge yourself from the article in the 1st paragraph if you think this is still the case. I think by allowing this to happen, the medical fraternity is tearing at itself, a suicidal down-spiral to its ultimate doom. A future of doctors behaving as pseudo-lawyers, patients as potential adversaries, eyes all the time on the money earned versus the legal risk incurred.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">The medical fraternity is already the only one that looks at itself with the most critical eye. Mortality Morbidity meetings, inquiries, clinical conferences, quality monitoring, sentinel events, compulsory reporting, audits etc etc. This doesn't happen to any other professions. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Imagine the gallery where a legal case in on-going involving medical negligence. Two spectators are there. One a doctor, the other a lawyer. The doctor is watching the doctors testimony and is thinking, that's wrong, i wouldn't have done this, or I may have done that in a similar situation. The lawyer is watching the defense lawyers tactics and line of questioning, and is thinking, that's not good, I wouldn't have used that tactic, he should have done this or that. And yet, only the doctor is on trial. </span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;">#Bawa-Graba</span></div>
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-14202655595969404222018-01-29T19:16:00.000+08:002018-01-29T19:16:18.223+08:00You wanna do what ?? #UndiRosak<span style="font-family: "trebuchet ms" , sans-serif; font-size: x-normal;"></span><br />
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<span style="font-family: Trebuchet MS, sans-serif; font-size: x-small;"><i>#UndiRosak - a movement predominantly amongst the young, spread via social media; aiming at registering a protest vote by intentionally spoiling their votes during elections</i></span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">When I was younger, Malaysia was a country with hope. A middle-class that was growing, confident, capable, with a 'bring-it-on' attitude. We were regarded favourably by others both in our abilities and our reputation. We were attracting "talent" from outside from labourers to skilled experts. Children from surrounding nations came here to study. Yes, we lost many to the stars that shone even brighter then ie Singapore and Australia, but most left not because they could not do well here, rather because they knew their options as better elsewhere. We had ooomphh !</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Today's Malaysia seems much more lost. The positivity of before has dissipated, our reputation now more of infamy, and people are leaving just to survive. We are pummeled by a constant onslaught of extremism, unfairness, one-sided views and marked polarity. The news of corruption and the stealing came in waves, until many couldn't stomach the local news anymore. The voices of reason, moderation, of consideration, and the voices on the ground, was either shouted down or stifled by censorship, and the drone of those in power kept the voice of the common man at bay. Middle-ground common-man Malaysia seems to have crept into the shadows, beaten into a disbelieving submission.</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">And in those corners, we are forced to confront ourselves with some difficult questions. Did I contribute to this state of affairs ? Could I have done something to prevent it ? Did I somehow just sit by and watch it happen ? Did my generation wreck Malaysia ?</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">I cannot believe that in the matter of 20-odd years we have lost all the good that Malaysia was. Yes we are a diseased tree. We probably need to lop off that rotten branch that is making us all sick. Remove those roots that is absorbing all that poison. Get rid of all those ants, bugs, rot and blights. The tree will still stand. Then it will repair itself, and it will start growing again. </span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">But things need to be DONE. Change requires action, work needs doing.</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">That's why I cannot understand #UndiRosak. Yes, I can understand a protest vote. Sure I can accept that both sides are far from perfect. We can hardly expect to vote between good and bad. More like between better or worse. Or at least some varying degrees of bad. If a protest vote was the aim, then get a candidate and run. Use the election to argue your point. Tell your plans. Describe your hopes and dreams for Malaysia, and I'm sure many many Malaysians will support that cause. We can surely use some hope and sunshine in that dark corner where we all are. Don't just say everybody's bad and SULK. That's what it is. Sulking, because your choice of menu was not on the table. You have a choice. Add to the menu. Say what you want. Inspire us. For all you know, for some sunshine, we may just bite.</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">So please let me share this after-thought with you. In another 20 years, when your youngest asks what you did then, when Malaysia was at the edge, how would you say that you #UndiRosak ?</span></div>
Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-2265303743055605532015-08-26T01:00:00.000+08:002015-08-26T12:57:37.169+08:00On our behalf<span style="font-family: Trebuchet MS, sans-serif;">In life, many times, things are done on our behalf. Our parents did most things on our behalf, and probably made important decisions for us through our early years (and sometimes even beyond our early years). That's okay, for parents always have our good outcome in mind. Along the way, elder siblings, the kind aunt or kay-poh uncle and your Mum's best friend neighbor probably weighed in a bit too. That too was probably okay. </span><span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">We would think that as we grew up, much fewer things would be done, on our behalf; that we would instead do more on our own, in our own way, to meet our own needs and desires, intentions and outcomes. But it may not be so.</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">And sometimes, we must think if these "on our behalf" actions is really to our own good. Or is it actually serving another. </span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">One of the biggest worries of actions done on our behalf is in politics. </span><span style="font-family: 'Trebuchet MS', sans-serif;">As a democratic nation, we pick people to represent us to formulate government actions. In the early years of democracy, politicians did represent the people. Their actions was guided by what the people wanted, individually, or at least for the greater good. But today unfortunately this is no longer the case - politicians represent themselves most of the time, their political party some of the time, and you almost none of the time.</span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">They fight, quarrel, sometimes even create riots and fear purportedly in our name. They then govern as they wish because they claim to have been given the mandate to rule. (really? I thought they were given the mandate to represent us. Represent us is quite different from Rule us!) </span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">So, no more I say. We must at least take back some of our rights. At least, the right to decide. Then definitely the right for due process. The right for justice, fairness and transparency. The right to tell our politicians to bugger off when we want them to. </span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">We must take back ownership of our schools, our courts, our newspapers, our institutions, our nation. We must take back our minds ability to think for itself, our voices ability to speak for itself, and our hearts ability to love our fellow Malaysian for who they are, varied, different and yet similar. </span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">And we must never, ever again, ever allow bloody politicians to get away with so much, on our behalf.</span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">#Bersih4.0</span></div>
Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com3tag:blogger.com,1999:blog-4581454022988719303.post-81918186539952677772015-08-01T22:16:00.000+08:002015-08-07T22:17:00.359+08:00The Horror Movie that was July 2015I think we as Malaysians will remember this month July 2015.<br />
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If not for its momentous events, then maybe as the month we as Malaysians lost pride as a people and a nation.<br />
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If not for its breaking news, then maybe as the period when we explored how far can we bend our values, and beliefs, before breaking ourselves.<br />
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If not for its many unanswered questions, then maybe a month we will remember, for after it, we will never be able to look our children it their eyes and explain without some creeping disbelief and trepidation in our hearts that there is God's value to being good, and decent and kind, and truthful.<br />
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At several stages during the month, it was entertaining for a while. A little bit like seeing JR Ewing in Dallas squirm and connive. But it quickly turned into a full-scale horror movie, with blood galore, senseless brutalities with some quite atrocious lines. What was obvious, though politics tries its best to appear clean and acceptable, power itself stinks of the sewers.<br />
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And though we hoped, and hoped, that the horror movie would end, and some glimmer of movie-like ending would come eventually, we were left with …. a continuing sequel, and worse, an almost JR-like snigger at the end.<br />
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I think the question is this. Do we just bend, until we break ?<br />
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<span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-12657433888715015922013-05-01T11:58:00.002+08:002013-05-01T14:23:07.967+08:00The Silent Majority or the Silenced Majority ?<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;">It is a favourite excuse of the powers-that-be in Malaysia, to say that voices of <span style="font-size: small;">opposition<span style="font-size: small;">, </span>discontent and dissatisfaction are <span style="font-size: small;">coming just from a small group of dissidents, of trouble-makers and 'pengacau<span style="font-size: small;">'<span style="font-size: small;">. They often c<span style="font-size: small;">laim that the "silent majority" of Malaysians are very <span style="font-size: small;">happy and sati<span style="font-size: small;">sfied, and that is why they keep silent. <span style="font-size: small;">Of course, those who support them will often parrot this argument<span style="font-size: small;">. Even w<span style="font-size: small;">hen the opposition won almost half of all votes in 2008, they <span style="font-size: small;">still insisted that the "silent majority" was with them.</span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">But let me ask you, <span style="font-size: small;">t<span style="font-size: small;">he common man<span style="font-size: small;">, the average Malaysian on<span style="font-size: small;"> the street. <span style="font-size: small;">Are you happy with the <span style="font-size: small;">way things are going ? Have you tried to voice out your dissatisfaction, only to realize that you can't ? <span style="font-size: small;">Have you written in complaints to the Press, only to see only "favourable<span style="font-size: small;">" letters praising the government of the day being printed ? Have you felt helpless as your leaders brought the country along a direction you don't want to go ? Have you felt that you are not heard, and your point of view<span style="font-size: small;"> not considered ?</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">Well, you are not wrong. Malaysia <span style="font-size: small;">has built a large gap in the last few decades; a gap not between the races, not between common Malaysians. T<span style="font-size: small;">hat <span style="font-size: small;">gap i<span style="font-size: small;">s the gap between the people and its leaders. We<span style="font-size: small;">, in fact, TOP the world<span style="font-size: small;">, in that we have the largest <span style="font-size: small;">gap between the common man, and their leaders. Our common Malaysians cannot communicate with <span style="font-size: small;">our leaders; they cannot hear us (or maybe they <span style="font-size: small;">just don't<span style="font-size: small;"> want to hear us). For this, of all things, Malaysia<span style="font-size: small;"> BOLEH<span style="font-size: small;">!!!</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">So then, are we now the silent majority, happy s<span style="font-size: small;">atis<span style="font-size: small;">fied con<span style="font-size: small;">tent and silent because we have just nothing to say; or are we the "silen<span style="font-size: small;">ced majo<span style="font-size: small;">rity", who shout out <span style="font-size: small;">but are not heard, who tell but are ignored, who suggest but are laughed at, <span style="font-size: small;">who resist an<span style="font-size: small;">d are labelled trouble-makers ?</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">I REFU<span style="font-size: small;">SE to be sile<span style="font-size: small;">nced anymore<span style="font-size: small;">. I will shout out for me, for my family, for my f<span style="font-size: small;">riends (even those who continue to support <span style="font-size: small;">BN), for my neighb<span style="font-size: small;">ours and my fellow Malaysians; fo<span style="font-size: small;">r our future, and our common path toward that better tomorrow.</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYRK4-qLiEdOC38Cg8WDBahh_es6AklXsppZbzLD3DbPoJ2wIADd8FPrck78rhzwGV4zD4jpXJ8zN5Uv1926GH9mdoC_QiQqwsTxDrT5OEOyx2FF8SxJJTlKKEwnP2Y8oa5U6Gu6k97tg/s1600/dap-rally-penang.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="426" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYRK4-qLiEdOC38Cg8WDBahh_es6AklXsppZbzLD3DbPoJ2wIADd8FPrck78rhzwGV4zD4jpXJ8zN5Uv1926GH9mdoC_QiQqwsTxDrT5OEOyx2FF8SxJJTlKKEwnP2Y8oa5U6Gu6k97tg/s640/dap-rally-penang.jpg" width="640" /></a></span></span></span></span></div>
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">Han Chiang college 28 april 2013 - I was there, so were 80,000 others; and I, we, will <span style="font-size: small;">not be silenced anymore</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">Les M<span style="font-size: small;">iserables "Do you he<span style="font-size: small;">ar the <span style="font-size: small;">people sing?"</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">So shut up about the silent majority already ....</span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">whewww ! </span></span></span> </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span> <br />
<span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-1762615649686385642013-04-25T13:38:00.000+08:002013-04-25T13:38:00.701+08:00You mean there was all that MONEY in the other pocket ?<span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">This election has seen government spending on an unprecedented scale. From free concerts by Psy and Taiwan artists, to big-name events like Michelle Yeoh and Alan Tam. From handouts to all and sunder, to free makan, free beer and free T-shirts. From spending on flags and banners (with enough cloth to clothe all the poor in Malaysia for 5 years at least), to online ads on every social media webpage that you may be on.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In any other democracy, this would have constituted vote-buying, an election offence. It is an election offence here in Malaysia too, but as always, there are two sets of rules; one for the governing, where "we'll close both eyes" is the guiding principle; and the other for the rest of us, the governed, where we learn quickly "do as I say, not do as I do".</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The amount of money spent is staggering. Where did all this money come from ? Where is this other pocket, where we had all this extra money to spend ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">I wish we had known about this other pocket full of cash when -</span></div>
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<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">we were short of money for specialized medicines</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">we had to treat patients 4 to a room</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">we had not enough beds and had to treat patients on wheelchairs, until ...</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">we ran out of wheelchairs</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">we have not enough ambulances</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">we asked for an allocation of just RM 5 per person in the community to provide additional ambulance services</span></li>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">I wish we had known about this other pocket full of cash when - </span></div>
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<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">we treated that retired school teacher who was getting RM 350 in pension to survive on</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">our staff was so much in debt that his six children were just taking one meal per day; the church group came in to support this Muslim family with daily rations</span></li>
<li><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">the whole family structure disintegrated when the sole breadwinner suffered a stroke; and they are now all relying to donations from fellow villagers</span></li>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Free beers and free makan ? I really find it distasteful.</span></div>
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-66800948319526292902013-04-24T16:50:00.000+08:002013-04-24T16:50:02.184+08:00Absolutely ..... !!<span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Rabies is not endemic in Malaysia ie we don't have this. If you have been bitten by a dog in Penang for example (unless there were incredibly suggestive features eg drooling crazy dog who bit you and then died) I would really not think about rabies. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">But rabies is endemic in Thailand. And Westerners, being Westerners, like dogs, and like to pet dogs who don't belong to them. Invariably, some of them get bitten. So, rabies, being endemic in Thailand, it makes sense for them to get an anti-rabies vaccine. This is almost always started in Thailand. But this vaccine requires multiple doses over many days. So this Western tourist decides that they can continue their travels to, Penang !!</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Now, when in Penang, they now want to continue their anti-rabies vaccine. Which we don't have. It is not unreasonable for us not to have it, since rabies is not endemic in Malaysia, it is very expensive, and really, should we carry vaccines for something that uncommon ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Generally, these Western tourists are usually diverted to private hospitals, where apparently they are charged about RM 500 per dose. "What ?? RM 500 ?? Are you trying to rip us off ??" becomes the standard reply because they think we are cheap. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Bring your sick dog to the vet in UK, and it would easily cost you 100 pounds. Ditto the US. Ditto everywhere in the Western world. But because we are "cheap", these tourists make noise. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">If you make noise at the private hospital, they have one standard option. They tell you to go to the government hospital. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So, now the already upset tourists appear at your doorstep, expecting something more, and ready to make even more noise. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Are we wrong not to store anti-rabies vaccine ? </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Remember we are spending the rakyat's money. Each dose costs a couple of hundred bucks; you don't know when you will use it, and it expires in under 2 years. Will you decide to stock up this vaccine ? What say you ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">What next, you may ask ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Well, let me tell you. We have no King Cobras in Penang. Cobras, yes; vipers, yes. Kraits, probably yes. No King Cobras. So we keep anti-venom for Cobras, Vipers and Kraits. Being good people, we also keep some anti-venom for sea snake just in case, considering that we are an island, and a sea-snake bite is rather deadly. A few thousand RM per vial. We did not keep any antivenom for King Cobra.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Last year, a zoo in Kuantan imported and kept King Cobras without informing anyone. One of their staff got bitten, and of course, everybody was in chaos. A King Cobra anti-venom was sourced finally after many hours, and administered. The blame game then started. Easy to blame. Why no anti-venom stock ? Why govt hospital so lousy ? Interestingly nobody blamed the zoo.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">But similarly to rabies, would you stock an anti-venom which costs a thousand RM, and lasts less than 2 years, if you have no King Cobras in your expected area ? Would you ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">I wouldn't. And we didn't. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Until a couple of weeks ago, and I nearly fainted when I found out; that the Snake temple people have imported King Cobras and are conducting snake shows, where the handler will kiss the head of the snake. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">And now we are hearing the some people like to keep exotic pets including rattlesnakes.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So really, what can I say; I am absolutely ..... !! [speechless!]</span></div>
Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-31434686867545469732013-03-26T20:51:00.000+08:002013-04-25T13:41:20.489+08:00How Doctors Die<span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">A magnificent article by Ken Murray. Original link <a href="http://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/" target="_blank">here</a>. Worth reading to the very end.</span></div>
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Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.</div>
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It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.</div>
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Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).</div>
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Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.</div>
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To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.</div>
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How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.</div>
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To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.</div>
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The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.</div>
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But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.</div>
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Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.</div>
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Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.</div>
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It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.</div>
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Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.</div>
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Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.</div>
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But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.</div>
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Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.</div>
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We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.</div>
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Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.</div>
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<em style="border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-family: inherit; font-size: 13px; font-style: italic; font-weight: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><strong style="border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-family: inherit; font-size: 13px; font-style: inherit; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Ken Murray</strong>, MD, is Clinical Assistant Professor of Family Medicine at USC.</em></div>
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com2tag:blogger.com,1999:blog-4581454022988719303.post-63522086960790621702012-10-01T15:07:00.000+08:002012-10-01T15:07:12.226+08:00The Perfect Evidence Based Emergency Doc<span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Let's just say that there is this PERFECT emergency doctor. Just perfect. Evidence-based references, guidelines, NNTs and all that. We all wish that we worked with someone like that, right ? Or even better, we all wished sometimes we were as good as that, eh ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Now, one day, whilst managing a patient, he applied a guideline correctly. Performed a score, applied a guideline and made a decision based on that guideline. Something goes wrong. A diagnosis is missed and an adverse outcome occurs.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Until now, everything has been done as would have been done in usual practice. Even more, the guideline applied is well accepted both locally and internationally. But looking deeper at guidelines and evidence, nothing is ever 100%. It is always in the high 90's percentage points but never 100%.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So the real question is, what do you say to the patient or family members, who have suffered the adverse outcome ? Those who were unfortunately in the small percentage points not covered within the guideline ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">How do we answer the allegation that the guideline is not good enough, or that the doctor who we all think is perfect, was negligent and incapable ? Can we actually say that the guideline was good enough, when it had failed in that particular rare occasion ? </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">And how do we counter-argue when (invariably) some Googles and finds some loophole or some other obscure guideline which would have picked up this patient ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Is there a way to win the scientific argument, legal argument, moral argument and at the same time, reconcile that with what the heart says ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Help. I don't know this one.</span></div>
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com2tag:blogger.com,1999:blog-4581454022988719303.post-63973822114487302822012-09-06T13:54:00.000+08:002012-09-06T13:54:29.022+08:00EMS Asia 2012 - Welcome Address<div>
<span class="Apple-style-span" style="background-color: white;"><span class="Apple-style-span" style="color: #073763;"><br /></span></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif;"><span class="Apple-style-span" style="color: #073763;">On behalf of the Organising Committee, I am most honoured to welcome all of you to the inaugural EMS Asia 2012 Conference, to the island of Penang and the country of Malaysia. We are most honoured to be able to present this conference to all of you and to share in an experience which we hope you will find most memorable. If you look around this hall, you will see more than 500 participants - all of them EMS leaders, experts, trainers and providers, from 20 represented countries in Asia and beyond. What an opportunity to make friends or renew friendships, seek collaborators and exchange ideas.</span></span></span></span></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif;"><span class="Apple-style-span" style="color: #073763;"><br /></span></span></span></span></span></div>
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<span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="background-color: white;"><span class="Apple-style-span" style="color: #073763;">The EMS Asia 2012 Conference was built on this very foundation - To bring together experts; and to learn from best practices in the region. </span></span></span><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="background-color: white;"><span class="Apple-style-span" style="color: #073763;">To develop models of good care and to raise the standards of prehospital care. </span></span></span><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="background-color: white;"><span class="Apple-style-span" style="color: #073763;">To conjointly develop standards and safety specifications for ambulances. And t</span></span></span><span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="color: #073763;">o develop a road map for the further collaboration between EMS systems in Asia.</span></span><br />
<span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="color: #073763;"><br /></span></span>
<span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="color: #073763;">This inaugural conference is co-organised by the Asian EMS Council, St John Ambulance of Malaysia in Penang, and the Penang General Hospital. The theme of "Safety and Quality in Pre-Hospital Care" highlights the conjoint effort of us all to develop better safety standards and specifications for our ambulances and to provide better care in our ambulances as we all move toward developing our EMS systems in Asia.</span></span></span><br />
<span class="Apple-style-span" style="font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><span class="Apple-style-span" style="color: #073763;"><br /></span></span></span>
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;">I must thank Assoc Prof Marcus Ong and the Asian EMS Council for giving us the honour of hosting the Inaugural EMS Asia Conference, and for believing our assertion that an EMS Conference here would be able to attract participation from around the region. I would like to thank Dr Sarah Shaik Abd Karim, our Scientific Chair, and her team for her tireless work in bringing together our faculty of more than 60 Malaysian and International experts. I must also thank the team from the Penang General Hospital for their very admirable effort in coordinating and supporting the entire conference. I would also like to express our gratitude to our partners and sponsors from around the world, who have worked with us to make this event a success. </span></span><br />
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><br /></span></span>
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;">I must especially thank the St John Ambulance of Malaysia team in Penang, who have yet again, taken up the challenge of working towards improving EMS in Malaysia in bringing together this international congregation. The many months of shared work have resulted in this magnificent conference and this unique opportunity to share and learn. I am very proud of this team.</span></span><br />
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><br /></span></span>
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;">Do take some time to enjoy the beaches of Batu Ferringhi, the food and shopping that Penang has to offer. Take some time to explore some of the heritage tours or hiking trails. Soak in the sun or try the fun-filled beach activities that are just outside that door. </span></span><br />
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><br /></span></span>
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;">We are most happy to welcome you all, and we look forward to an enjoyable conference and a memorable time.</span></span><br />
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;"><br /></span></span>
<span class="Apple-style-span" style="color: #073763; font-family: 'lucida grande', tahoma, verdana, arial, sans-serif; font-size: small;"><span class="Apple-style-span" style="font-size: 13px; line-height: 18px;">Thank you.</span></span><br />
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-28974094129971017822012-08-29T17:04:00.002+08:002012-08-30T09:35:05.569+08:00Statutory Rape for Dungooos<span style="font-family: "Trebuchet MS",sans-serif; font-size: x-normal;"></span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><i>Dungoo - Dungu = 'village idiot'</i></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Statutory rape - sex with a minor under the age of maturity to provide consent for the act; in Malaysia, girls under the age of 16 years. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">The law assumes that girls under the age of 16 years are too young to understand the act and consequences of the sexual act; so it is considered as RAPE even if it would seem that the girl had consented to the act.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In many countries, due to the higher incidence of teenage sex, and I suppose the earlier exposure of our teenagers to sex, boyfriend and girlfriend sexual activity takes place before the ages of 16. </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">But this needs to be differentiated from SEXUAL PREDATORY behaviour ie sex between a 22 year old man and a 12 year old girl; or between a 19 year old and a 14 year old girl. In these situations, the larger age gaps between both the man and the girl provides ground to believe the the older man should know that sex with a young girl is illegal and she is not old enough to make a reasonable decision.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So, in many countries, an age gap of more than 3 years is considered in convicting of statutory rape to try to differentiate between early teenage sex and predatory sexual behaviour.</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Malaysia, as usual, must be different. Read <a href="http://www.malaysiakini.com/news/207380" rel="nofollow" target="_blank">here</a>.</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">In Malaysia, our courts apparently determine that "first time offenders", people who are "not highly educated", are "young and have a bright future" can be bound over for good behaviour without going to jail !! </span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So if you are a bloody young DUNGOO, our courts have said that you can have your way with young girls because your DUNGOO-ness really spells a bright future.</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">I am sure there are extenuating circumstances, but the law was made to protect our young girls. Have our system let down this 12 year old ? Are we at the doorstep of making 12 year olds girls marry their 22 year old boyfriend- rapists ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Not sure who is the DUNGOO in this whole matter. Sigh !</span><br />
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Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-85635795543613688362012-08-10T20:34:00.000+08:002012-08-10T20:35:08.811+08:00EMS Asia 2012 Conference in Penang<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirGYabmw1_3Eyznk0BwZVhqOrECEvZYT_uuQJEw_fKJH_JPji16GQwtxxTD0umh1AsWsG-bci5rz80T1BeC-8M57zvo_jpBX1t7iQoxHrNp1v9rtGsxFObaHgecLrvA00WwFdexcHgU0w/s1600/Picture+1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="259" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEirGYabmw1_3Eyznk0BwZVhqOrECEvZYT_uuQJEw_fKJH_JPji16GQwtxxTD0umh1AsWsG-bci5rz80T1BeC-8M57zvo_jpBX1t7iQoxHrNp1v9rtGsxFObaHgecLrvA00WwFdexcHgU0w/s640/Picture+1.png" width="640" /></a></div>
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<span style="font-size: small;"><span style="font-family: "Trebuchet MS", sans-serif;">Penang beckons. </span></span><br />
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<span style="font-size: small;"><span style="font-family: "Trebuchet MS", sans-serif;">More info at <a href="http://www.emsasia.org/">www.emsasia.org </a></span></span><br />
<br />Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-45992749551668857912012-07-02T23:37:00.000+08:002012-07-02T23:50:52.752+08:00Dear Julia<span style="font-family: "Trebuchet MS",sans-serif;">Dear Julia,</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Forgive the lack of honorifics; at least for the length of this blog, I would like to speak to you as a friend, instead of a Prime Minister of a country. I am after all, a nobody in a voiceless country, one where it would seem we have got our priorities totally wrong. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Our countries are quite similar in many ways; we have about the same population size, our countries flourished at around the same time mainly from large-scale immigration, yours mainly from Western nations, mine from China, India and the surrounding Malay archipelago. And for many many years, our countries have had close ties. Both in good times and in war. Generations of Malaysian have gained from the high standards of university education in your country; in many ways, the entire life earnings of millions of Malaysian families have gone to your country to pay for that education. Many Malaysian having found the way of life there to their liking, have stayed on. Many more Malaysians, having found life in Malaysia lacking fair prospects and opportunities, have left for your shores. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">So in many ways, your country have gained somewhat from this relationship with us. We have worked away so that we can pay for our children's education in your country; our best and brightest have left us for your greener pastures, and now contribute to your country, instead of the land of their birth and early education. As I said, our priorities, totally wrong, was never to retain our Malaysians, nor to create an environment for them to flourish. But that, Julia, is our mistake.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Your mistake, if you should decide to do so, would be to continue to support the <a href="http://savemalaysia-stoplynas.blogspot.com/2011/06/about-lynas.html">Lynas Advanced Materials Plant</a> in Gebeng Malaysia. This project is just wrong. </span><span style="font-family: "Trebuchet MS",sans-serif;">Malaysia has no need for rare earth. We have no special skills, no special environment, no special resources that make us THE ideal place in the world to process rare earth. The only special thing that we may have is a government that is willing to spend our money to make the infrastructure for this plant, offer a 12-year tax holiday for its earnings; a government that is willing to believe that Lynas would like to ship unprocessed materials, a few thousand miles to Gebeng for processing, just because it likes Malaysia. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">This plant, in Gebeng, will produce <a href="http://savemalaysia-stoplynas.blogspot.com/2011/06/solid-waste-material-3-types-of-waste.html">radioactive byproducts</a>. There are half a million people who live within 30 km of this Gebeng plant. That is 150,000 more people that the entire population of Canberra. Look around you. Imagine. What would you think, if Lynas decided to build one in Kambah, one of your most popular suburbs, about 30 km from the Canberra CBD ? Well, you don't have to worry really, because Australian regulations insist that such plants must be at least 300 km away from the nearest human community. But just imagine one in Kambah, and you may actually understand a bit more about Gebeng.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">So the truth of the matter is this. We don't want it. We don't need it. And we definitely do not appreciate being <a href="http://www.malaysia-chronicle.com/index.php?option=com_k2&view=item&id=35815:now-lynas-ceo-blames-alternative-media-in-msia-for-rare-earth-woes&Itemid=2">lectured</a> about the adverse impact on businesses and foreign investments. We don't want it because it does not make any sense to us. We are simple people, of simple ways. Our simple minds just tell us that it is wrong. Despite what the powerful people say. Despite all our government says, and what your government may say.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">We don't want it because it has happened to us before. Bukit Merah, near Taiping, was also a rare earth plant. It is now abandoned, contaminated and desperately never mentioned in our news. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">This Lynas issue never really hit me until very recently, when a fellow doctor was lamenting the high numbers of leukemia and cancer patients in Taiping Hospital. I wonder if the ones who approved and supported the Bukit Merah plant can sleep well at night.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Julia, we have over the years, given to your country, our best. We even thanked you for it. Must you, and your country, really, give us your worst ?</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-44527408608992660972012-06-05T21:28:00.003+08:002012-06-05T21:29:06.639+08:00The Physiology of Bleeding to Death<span style="font-family: "Trebuchet MS",sans-serif;">Young man, on his bike. Side-swiped by another vehicle going in the opposite direction. Crash, dragged, rolled and left almost lifeless by the road. Passers-by spot him, load him up into their car, drop him off at the nearest Emergency Department and leave.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">The ED doctor on duty there identifies a patient with multiple injuries; very restless, not obeying commands, hypotensive (80/40) and tachycardic (130) with an SpO2 of 80%. Automatic mode kicks in - oxygen is given via non-rebreather high-flow mask at 15 L/min, Normal Saline is started at full flow, bloods are taken for inx, and documentation of injuries ensues. Repeat BP comes back at 130/60, HR 135, SpO2 94% and doctor sighs relief. Would you do the same ? Same sigh of relief as well ?</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Patient gets sent to X-ray; spends an hour there with X-rays of just about everything unimportant, when the accompanying staff notices that the patient was gasping and rushed him back to the ED; in time for them to note asystole and commence CPR. The patient succumbs to his injuries (and the doctor's failure to understand physiology of bleeding to death) about 45 minutes later.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">What was the doctor thinking about ? I thought I would ask some of the new doctors who were posted to our ED. Scenario presented; and this reply was their COMMON thought process. Initially restless and then obtunded (must be head injury - must do CT scan as priority). Initially hypotensive (must be bleeding - need to look for source of bleeding - but since BP improved with fluids, should be getting better). Very tachycardic (must be due to pain, anxiety). Low SpO2 (something wrong with the breathing - better look for pneumo- or haemothorax - but since improved with oxygen, must be getting better - let's do x-rays to find out more). Yup, that's right. This was their COMMON reply. So it is not merely that particular doctor's failure to understand the physiology of bleeding to death, it is ALL our YOUNGER DOCTORS FAILURE to do so as well.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">This is what happened to that patient, in physiological simple speak. This patient did suffer many many injuries; abrasions, lacerations, a few fractures of the limbs. These injuries bled quite a bit, but they were not killers. Nope. He had, instead, suffered a high force impact onto his left torso which broke multiple ribs, resulted in a severely lacerated spleen and severe pulmonary contusions. Which was not recognized, and which continued to bleed until he bled to death. That was the killer.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">The reason why he came in very restless was because of hypoxia and hypotension, NOT because of head injury. Being very short of oxygen and deprived of blood supply to the vital organs would make every single one of us become highly agitated and distressed. This is the reason why GCS is not a useful tool for estimation of head injury until the ABCs have been stabilized.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">In severe bleeding, the body compensates to try to maintain the blood pressure. The pressure is maintained to try to preserve blood flow to the most vital of organs; the brain, heart and lungs. But this pressure is maintained mainly by squeezing all the main blood vessels (vasoconstriction). Blood is now shunted away from the skin, limbs and intestines to the brain, heart and lungs. The limbs become cold and bluish from the lack of fresh oxygenated blood, and the SpO2 reading drops. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">This entire compensation mechanism maintains pressure, but the total amount of blood flow and oxygen supplied decreases, to the rest of the body. Cells in the body, deprived of enough oxygen, are now forced use their fuel without oxygen; in an inefficient manner that starts producing huge amounts of acids, mainly lactic acid. This leads to worsening acidosis.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">So this patient has severe bleeding from his lacerated spleen, and had lost so much blood that his compensation mechanisms were beginning to fail; that was why he came in hypotensive. He was definitely restless from all that lack of oxygen and blood to his brain.</span><span style="font-family: "Trebuchet MS",sans-serif;"> His peripheries were cold as no blood was reaching his fingers and toes; his SpO2 was obviously going to be low.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Let's look at what happened next. He was given oxygen, a good thing. What it did, was filled the little blood that was still available with oxygen. Which made the saturation SpO2 of the little blood that was available, 95%. Although 95%, it was still too little blood to really carry the oxygen needs of the patient. NO, the SpO2 of 95% did not mean he was any better.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">And he was given fluids. So all those fluids would have rushed into the "squeezed" blood vessels and immediately raised the pressure within those blood vessels. This gave the impression of "improvement" to the doctor. In fact, it probably made things worse. There are two main down-sides to this. Firstly, the sudden increase in the pressure has the tendency to suddenly burst some of the newly formed clots, causing bleeding to resume. Secondly, the fluid now dilutes the clotting factors in the blood making it more inefficient at formed a clot to stem the bleeding. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">So, none of the initial therapy really helped much. What was worse, was the assumption that he was now "better" and could be sent to the X-rays Dept for further xrays. What happened there was this. The bleeding continued, and the compensations were not able to maintain his blood pressure anymore. The decreased blood supply to the brain made the patient obtunded (accompanying staff may have just thought that the patient was now more quiet and easier to handle). He would also have lost his airway control reflexes, and regurgitation of food may have partially blocked his airway, further worsening his overall hypoxia. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">By now, the amount of blood circulating would have been minimal, and acid levels would have skyrocketed. This acidosis would be the final nail. Reaching a particular dangerous level, it would essentially have prevented the heart from working properly. The heart essentially stops and the quick spiral to death ensues.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">What was reversible, and when was it reversible ? Could things done right made a difference ? What things, done differently in what ways ?</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Firstly, any person in trauma, with tachycardia, is in SHOCK until proven otherwise. SHOCK in a patient presents with various degrees of anxiety and restlessness, tachycardia, cool peripheries, rapid breathing and signs of poor organ perfusion (low urine output, acidosis and altered mental states). SHOCK is almost always due to bleeding from trauma (significant alternatives include only tension pneumothorax, cardiac tamponade and airway obstruction; but always think of bleeding as well). So, the first right thing to do is to <u>recognize the SHOCK state</u>.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Next, look very carefully for the source of bleeding. Search carefully for spilled blood, either on-the-floor (external bleeding) or in only 4 other areas of significant internal bleeding. Massive haemothorax (diagnosed clinically and with the bedside ultrasound), bleeding into the pelvis and retroperitoneal space (almost always related to pelvic fractures, lower spinal injuries and associated vascular injuries), bleeding into the peritoneal space (mainly due to liver and splenic lacerations, as in this case; and diagnosed with a FAST ultrasound scan) and the tissue spaces of the thighs (which are easily seen, and associated with fractures and vascular injuries). That's it. No X-rays other than the bedside trauma X-ray of the chest and pelvis. No other x-rays needed. <u>Search carefully for bleeding</u>, and once you find it, get the surgeon. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">And lastly, this patient needed blood. Lots of blood. Preferably <u>fresh whole blood</u>. If not, packed cells and the freshest plasma you can get. What needs to be done is to replace the lost blood with actual blood. And with it, hopefully some additional coagulation factors to help stop the bleeding. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">The physiological derangements needed to be reversed. To do that, young doctors must must simply must understand the physiology first. That was the only way to save this patients life.</span><br />
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<br />Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com4tag:blogger.com,1999:blog-4581454022988719303.post-5568909161946955362012-04-01T17:32:00.001+08:002012-04-01T17:32:28.892+08:00What happens to bad habits ?<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">What happens to bad habits ? <i>Well, the nuns just change them for better ones ...</i></span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Really, what happens to bad habits ? You know, common ones like</span><br />
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<li><span style="font-family: "Trebuchet MS",sans-serif;"><i>the motorcyclist who likes to take a shortcut through pedestrian walkways and park illegally there</i></span></li>
<li><span style="font-family: "Trebuchet MS",sans-serif;"><i>the motorcyclist who goes the wrong way down a one-way lane </i></span></li>
<li><span style="font-family: "Trebuchet MS",sans-serif;"><i>the motorist who habitually cuts the queue on the left; using the emergency lanes</i></span></li>
<li><span style="font-family: "Trebuchet MS",sans-serif;"><i>the motorist who double parks and leaves</i></span></li>
<li><span style="font-family: "Trebuchet MS",sans-serif;"><i>the public toilet user who just cannot aim right, both in the bowl and in the rubbish bin</i></span></li>
</ul>
<span style="font-family: "Trebuchet MS",sans-serif;">When do those bad habits ever end ? </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><i> </i></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">How do they end ? Will there come a day, when that motorist / motorcyclist just come to his senses and realize his bad ways ? I just don't see that happening. Or will someone have to die, or get injured as a result of a crash first before they see the folly of their bad habits ? </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Or can someone else, maybe, help change their ways before that something bad happens. Who is that someone ? The police ? When was the last time you saw our police handing out summonses for shortcuts, wrong way motorcyclists, queue-cutting maniacs and double parkers ? No ? Well I haven't. I think our Police are busy hiding in bushes trying to catch you when you go a few km above the speed limits. Easier job for them. That right. The Police isn't all that interested in correcting dangerous bad habits; they are probably more interested in meeting their monthly saman targets. So much easier to sit in bushes and hide.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Or maybe, just maybe, that someone special is you. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">All you need to do is <u>speak up</u>. Say something, to that motorcyclist / motorist with the bad and dangerous habits. Try to avoid profanity, like most of us mere mortals will resort to. Tell them to stop before they kill someone; or someone kills them. Please don't believe that Malaysians are just too polite to say something bad or critical to another. Just speak up, it may save a life.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">And if you have that skill to help someone aim right, wowww, that will really help too.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com1tag:blogger.com,1999:blog-4581454022988719303.post-7904363961149262302012-03-28T21:42:00.000+08:002012-03-28T21:42:00.571+08:00Leptospirosis<br />
<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><i>a.k.a. Weil's Disease, Icterohaemorrhagic Fever (haemorrhagic jaundice), Swamp fever</i></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Zoonotic disease ie spread from animals to man; probably the most widespread zoonotic disease in the world at the moment. Humans get infected by coming in contact with urine of infected animals esp rodents, cows, pigs and dogs. </span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"><i>Leptospira sp.</i> is a spirochaete which can enter the body through micro-breaks in the skin or intact mucous membranes. Unlike the other infamous spirochaete (<i>Treponema pallidum </i>causing syphilis), Leptospirosis does not spread from human to human.</span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Essentially the disease has two forms, a mild disease of fever, headache, chills, rigors and muscle pain lasting for a few days, accounting for more than 90% of all cases; or a severe disease which often starts off in the same way, improves then deteriorates again with severe jaundice, red eyes, abdominal pain, diarrhoea and a rash. This may often deteriorate to Multi-Organ Failure and death; believed mainly due to the severe vasculitis caused by the organism's spread in small vessels of most organs.</span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Difficult to diagnose in the early stages; the presentation is quite varied, difficult to differentiate from any other infections, and a history of exposure to rivers, streams, swamps and ponds is rarely obtainable. I personally don't think this is a major source of the problem; all the rats running around our sewers could easily be the culprits as well. </span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">The problem is that infected animals don't die. They often live asymptomatically, shedding the Leptospira with every pee, throughout their lives. Trying to trace these rats would be quite impossible. It is also believed that the global warming phenomenon is playing a huge role in the re-emergence of leptospirosis in tropical areas; especially as a result of floods and contamination of drinking water sources. </span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">Not worried yet ? There has been recorded in history, instances of epidemics of what is now believed to be leptospirosis, in wars especially. (Napoleon's infectious jaundice, American Civil War's swamp fever) But it is not only in ancient times, that these epidemics occur; it swept through the Andaman islands in the late 80's, Philippines in 2009, Ireland in 2010 with high mortality rates.</span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">It could easily have been us; it still can. </span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">How to treat ? fairly easily really with the right antibiotics. They are still sensitive to Penicillin group drugs and to the old favourite Doxycycline. Erythromycin if pregnant. Amoxicillin is another alternative. Only 3rd gen cephalosporins have any effect on the Leptospira spirochaete.</span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">To my simple mind, we are losing the fight with Leptospirosis; the battle cannot be won if we keep on thinking that it is due to isolated exposure to contaminated water in the wild. Many of the patients we see do not have that history. I think the problem is much closer to home; the infected animals, probably rodents in our urban and sub-urban areas, especially in our longkangs (sewers). </span></span></span><br />
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<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;">That rat hiding there may just kill us one day.</span></span></span><br />
<span style="font-size: x-small;"><span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: small;"> </span></span></span>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com0tag:blogger.com,1999:blog-4581454022988719303.post-67428325997742832882012-03-23T22:00:00.002+08:002012-03-23T22:00:56.788+08:00Ahhhh, so that is why ....<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"></span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Question 1 - Malaysia has huge resources of Rare Earth that will bring economic wealth to the country and its people. True or False ? </span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Question 2 - Malaysia has vast acres of available land suitable to make some Rare Earth refinery and loads of space where the waste materials can be thrown away, stored or buried. True or False ?</span></div>
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Question 3 - Malaysia has a high expertise workforce, the only ones in the world capable of running a Rare Earth plant as it should be run. True or False ?</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Question 4 - Malaysia needs to products of Rare Earth processing to further develop our economy, our wealth and our people's well-being. True or False ?</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Question 5 - Malaysia has something RARE, and that is why the Rare Earth plant needs to be here. True or False ?</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">We unfortunately have nothing rare in our earth, not in Gebeng, nor anywhere near Malaysia. That rare earth that will need processing and refining will be imported from China on rail or from the US on ships to reach our shores; be processed and then sent out again all over the world especially to Australia. What they will leave behind is the rare waste products and rare waste water; rare mainly because it will be radioactive and will potentially lead to contamination of our land, water and exposure to our people. Question 1 False.</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">China and the US has Rare Earth, but no processing plants for it. Both these countries have land way way way more than we have in Malaysia. Australia, which is probably a zillion times the size of Malaysia, has existing processing plants for rare earth, hundreds of miles from the nearest human population. Gebeng has 700,000 people living within 35 km of the Rare Earth plant !!! Question 2 bites the dust with a resounding False !</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">They are employing 400 people. </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Just find me 400 radiation and rare earth specialists in Gebeng. </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">High expertise ? or administrative staff ? human resource henchmen ? or just employ anyone, who doesn't understand radiation, </span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">to handle the dangerous stuff ? The "lucky" chap would probably not</span><span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"> live the 10 years to see his hair fall off and his balls wrinkle up. Question 3 just cannot be true. False !</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Pahang needs the FDI ? We need the jobs ? Our economy needs this ? Well, so does the US economy, the Euro economy, the African economy. Let's just do it in Portugal or Spain. Or let's just do it in Obama's backyard; surely the FDI and jobs will boost his chances of winning another term. WTF ? Question 4 False.</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">So then why why why is Gebeng the damn lucky place to be picked as the next Rare Earth plant ? That, my friends, lies in the answer to Question 5. For Malaysia, yes, our Malaysia, is a unique place. We have something rare that nobody else has. RARE ! NOBODY else !! BOLEHHHHHH ! </span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">We have a parliament, the highest authority in the land, duly elected by its people to take care of the country, that will accept being snubbed and humiliated, by a foreign company. How else can you explain, that when the Parliament summoned the top management of Lynas to answer questions on the project, they duly sent their HR Manager with 2 lawyers, whose only answer to our Parliament, is that they were not authorized to answer any questions !!!! And our towering Parliamentarians in effect said, errrr, okay lah ! Now, that is truly RARE. No where else in the world, will this happen. We BOLEHHHH !!</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Our parliament is also the only one where parliamentarians are not allowed to ask questions or raise issues, when cases are still under the courts deliberation. No discussion on NFC allowed because scared the courts will find the parliament in contempt !! Another unique one in the world. Because we BOLEHHHH !!</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Our Malaysia, yes, our Malaysia, is also the only place, where we can get Malaysian hooligans, rempits and samsengs, to fight, abuse, assault and intimidate their fellow Malaysians, on behalf of a foreign company. Yes, our towering Malaysians. Damn proud of these fellows laaa.</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Ahhhh, so that is why .... we are so lucky to be picked. We are just so rare, so unique, so truly Malaysian to support this cause just because someone says so. So taat, so setia. </span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">Ahhhhh ....</span><br />
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<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;">P.S. I really do wonder how many cancers there are, reported and linked to the Bukit Merah area. To the people of Gebeng and the 700,000 people of Kuantan and its surrounding areas, you are not alone. Vote TAK NAK !!</span><br />
<span class="Apple-style-span" style="font-family: 'Trebuchet MS', sans-serif;"><br /></span></div>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com1tag:blogger.com,1999:blog-4581454022988719303.post-45197039035784693392012-03-04T15:10:00.000+08:002012-03-04T21:11:50.525+08:00Irrigating Deserts<br />
<span style="font-family: "Trebuchet MS",sans-serif;">It has been a while since I blogged. I’ve been busy, true; distracted and undisciplined all too likely; and maybe I had nothing to write about because I had too much to write about. You know, when no work gets done just because there is too much work to do.<br /><br />No EM topic unfortunately; Geography will be the flavour for this post. I expect this to be a long rambling post of not much importance, just showing how minds can wander on long flights; just as mine is on this 3 hour flight to Tawau. So you may want to just skip over to the last paragraph. Heh heh heh.<br /><br />Looking out of the plane, interestingly I noticed rather thick clouds over land; which for some reason suddenly disappeared at the shore line. Weird I thought. Why should the clouds only appear over land, and not over sea ? Trying to dig back to those few memory cells that may still contain info about physical geography learnt at school, I thought of an explanation.<br /><br />During day, the land heats up much more than the sea. The land of Malaysia, with its high humidity and relatively wet conditions, has high levels of water; which then evaporates and forms those clouds. Which ultimately will condense forming rain bringing all that water back to the land again. The convection rains that we get on many afternoons and evenings is formed in this way. Nice cycle, right ?<br /><br />The sea however, although it has much more water than land, heats up much less than land; and thus does not form those dense clouds, but rather lighter clouds which need more monsoonal winds to bring them together and inland for them to condense and form rain. Our seasonal monsoon rains are probably formed this way.<br /><br />Being rather pleased with myself, [any Form 4 kid learning Geography will probably just say Bahhh!! at this] I thought that was why deserts always remain deserts. For even though they do receive lots and lots of sun, there is precious little water for the sun to evaporate and form rain. And the common direction of the monsoon winds do not favour deserts, that’s why they are deserts.<br /><br />Trying to act smart and think out of the box, I thought, wouldn’t it help if we were to irrigate the deserts with huge amounts of sea water; just to increase the humidity levels of land ? Then maybe, just maybe if we can cross some magical humidity level, that cycle of convection rain may actually start, and continue its perpetuating cycle. <br /><br />Why sea water ? For one, fresh water is super valuable in desert lands. Sea water often is in huge amounts, although the logistics of it may be difficult. Maybe we should try some “irrigating the desert” experiment in a desert that is small, narrow and above all, near the coast. Something like the Kalahari, or that desert in Chile which is supposed to be the driest one of them all. <br /><br />Waaaaaa imagining Nobel prize for Geography given to some unknown Emergency doc ... waaaaaa !!!!<br /><br />Okay, okay, okay .... you can stop all that laughing and rolling on the floor.<br /><br />But anyways, since I am an Emergency doc, and this is an EM blog, maybe I can bring this slightly toward Emergency Medicine.<br /><br />Honestly I have always felt very very [extremely] strongly that EM should be taught in Medical Schools. I have always felt that doctors should be learning EM content, and EM way of thinking, and EM prioritization and sense of urgency in medical school. After all, almost every single priority situation that a doctor will ever face, in which he or she will make an impact of the patients’ outcome, either positively or adversely, is related to their ability to analyze the situation and act rapidly and accurately. This unfortunately is not something learnt in any way in medical schools today. <br /><br />Instead, our medical students are learning Medicine by rote, emphasizing stuff that used to be important decades ago, or things that are easy to teach and convenient to test. Then, when they are released, totally wet behind the ears on our patients, we struggle to teach them good EM; unfortunately, often too little and just too late.<br /><br />Surely surely EM is as important to the young doctor that Ophthalmology or ENT or Forensic Medicine or Anaesthesia. Surely like the proverbial desert, it is much better to water our medical students with the EM way of life, so that they do not become deserts, but instead will flourish and continually produce good rain with the nurturing sun. Think about it, and see if you can argue this point with me.<br /><br />How ? When ? You tell me, in your comments.</span>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com3tag:blogger.com,1999:blog-4581454022988719303.post-83175529080010630592012-01-28T20:25:00.001+08:002012-01-28T20:35:03.038+08:00ED Management of Pneumonia in Malaysia<br />
<span style="font-family: "Trebuchet MS",sans-serif;">Huge topic. Brief notes on few important points only. Information pertinent for ED practice in Malaysia.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">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.</span><br />
<br /><span style="font-family: "Trebuchet MS",sans-serif;">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.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">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.</span><br />
<br /><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Strep Pneumoniae</i> 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.</span><br />
<br /><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Staph Aureus</i> 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.</span><br />
<br /><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Klebsiella sp.</i> 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 </span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Klebsiella</i> infection.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Klebsiella </i></span><span style="font-family: "Trebuchet MS",sans-serif;">Bulging Fissue Sign </span></div>
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<span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Pseudomonas aeruginosa</i> 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 </span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Klebsiella sp </i></span><span style="font-family: "Trebuchet MS",sans-serif;">and </span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Strep Pneumoniae </i></span><span style="font-family: "Trebuchet MS",sans-serif;">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.</span><br />
<br /><span style="font-family: "Trebuchet MS",sans-serif;">The "Atypical Pneumonias" were so named because they seemed so different from the </span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Strep Pneumoniae </i></span><span style="font-family: "Trebuchet MS",sans-serif;">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 </span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Mycoplasma sp., Chlamydophilia pneumonieae, Hemophilus Influenza</i> and <i>Moraxella Catarrhalis.</i></span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Hemophilus Influenza</i> and <i>Moraxella Catarrhalis</i></span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"> </i></span><span style="font-family: "Trebuchet MS",sans-serif;">infections<i> </i></span><span style="font-family: "Trebuchet MS",sans-serif;">are</span><span style="font-family: "Trebuchet MS",sans-serif;"> more common in the elderly, and in those patients with underlying lung disease eg COPD and smokers.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Chlamydophilia pneumonieae</i></span><span style="font-family: "Trebuchet MS",sans-serif;"> 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.<i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"> </i></span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Mycoplasma sp.</i></span><span style="font-family: "Trebuchet MS",sans-serif;"> 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).</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Mycoplasma sp.</i></span><span style="font-family: "Trebuchet MS",sans-serif;"> do cause outbreaks especially in army camps and college hostels; but sudden outbreaks should bring to mind <i>Legionella</i></span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"> sp.</i></span><span style="font-family: "Trebuchet MS",sans-serif;"> 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.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Infection from <i>Mycobacterium tuberculosis</i></span><span style="font-family: "Trebuchet MS",sans-serif;"><i style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"> </i></span><span style="font-family: "Trebuchet MS",sans-serif;">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, <i>Burkholderia pseudomallei</i></span><span style="font-family: "Trebuchet MS",sans-serif;"> must also be considered especially if the patient also has DM.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">How should the ED doc treat ? Luckily, it is not nearly as complex.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">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.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">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 <a href="http://www.e-mjm.org/2005/v60n2/Community_Acquired_Pneumonia.pdf">[click here for the actual paper.] </a></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEGK2d8hKJ5AYyicnODpmyE3H-FHn4VskGskmNtz5ln9_ac9NfBU-1NH46V3sXUE3qMZlRAbO6FEGnKtEUdOL2WCU0KR9XSfNcqyPFD2wEMvF8llY33iqDfSfKXDP3Wgy6B-cVw7mAb6s/s1600/Picture+1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="317" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEGK2d8hKJ5AYyicnODpmyE3H-FHn4VskGskmNtz5ln9_ac9NfBU-1NH46V3sXUE3qMZlRAbO6FEGnKtEUdOL2WCU0KR9XSfNcqyPFD2wEMvF8llY33iqDfSfKXDP3Wgy6B-cVw7mAb6s/s400/Picture+1.png" width="400" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj71l8dS-6J_TlHhPY_rn7B6cfYuoCYiSzXJN8mldyRoKgsc_R_unrm8_EoBXJDV8gufHfuGVyFYg4Z0QHDUsXW3xuINb8dO5ZZg0mzS_he2IKC40iZEM6hnPcU-vnHgrdTZqQ_6kuYWmU/s1600/Picture+2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj71l8dS-6J_TlHhPY_rn7B6cfYuoCYiSzXJN8mldyRoKgsc_R_unrm8_EoBXJDV8gufHfuGVyFYg4Z0QHDUsXW3xuINb8dO5ZZg0mzS_he2IKC40iZEM6hnPcU-vnHgrdTZqQ_6kuYWmU/s400/Picture+2.png" width="385" /></a></div>
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<span style="font-family: "Trebuchet MS",sans-serif;">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 !</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Hope this "brief" post has been helpful. Whewwwwww !</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif; font-size: xx-small;">Credit to Mel Herbert and the EM-RAP team. And the Prof CK Liam.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqvBx3vcsnXUiAXJcs62uWL40zJ_kDHk_SA7pbd4-YXaYVSvJSNHXVD8CpOiW_j-PwnYQSQ8cM0VKkkiIzxmpmHYULBauqIAG2AOY45wnOPrRr3VOxACsZBAKd-Dbj8gMBC3lUW3fjCjU/s1600/Bulging_fissure_002.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqvBx3vcsnXUiAXJcs62uWL40zJ_kDHk_SA7pbd4-YXaYVSvJSNHXVD8CpOiW_j-PwnYQSQ8cM0VKkkiIzxmpmHYULBauqIAG2AOY45wnOPrRr3VOxACsZBAKd-Dbj8gMBC3lUW3fjCjU/s1600/Bulging_fissure_002.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqvBx3vcsnXUiAXJcs62uWL40zJ_kDHk_SA7pbd4-YXaYVSvJSNHXVD8CpOiW_j-PwnYQSQ8cM0VKkkiIzxmpmHYULBauqIAG2AOY45wnOPrRr3VOxACsZBAKd-Dbj8gMBC3lUW3fjCjU/s1600/Bulging_fissure_002.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjqvBx3vcsnXUiAXJcs62uWL40zJ_kDHk_SA7pbd4-YXaYVSvJSNHXVD8CpOiW_j-PwnYQSQ8cM0VKkkiIzxmpmHYULBauqIAG2AOY45wnOPrRr3VOxACsZBAKd-Dbj8gMBC3lUW3fjCjU/s1600/Bulging_fissure_002.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a>Dr Teo Aik Howehttp://www.blogger.com/profile/09923378286007184844noreply@blogger.com1