are we tidak apa?
I've always regard myself as a laid back, easy going kind of guy. Even 'close one eye' on a lot of the so called regulations. But when it comes to patient safety, there is no way I'm going to tolerate 'tidak apa' attitute.
Last saturday when I was oncall, the 1st case in the morning was an exploration and repair of a tendon cut on the forearm due to a deep laceration wound.
I explained brachial plexus block to the patient but he refused a regional anaesthesia and ask for a general anaesthesia. Since patient refuse is a contra-indication for regional block, and he was fasted with no airway difficulty, I agree for General Anaesthesia without much ado.
However, when I go through the routine check, these were the photo I took from the medical gasses alarm panel:
One of the main panel was totally offline.
All gases were in alarm status except the 4 bar air and vaccum.
Asked the staff nurse incharge to called up the support service to call up the support service to get it sorted out. Guess what she told me
? It's ok, u can carry on, last night also like that and they switch off one of the panel becoz it keeps alarming... Mind u this is from a senior staff who is almost going to retired, not those rookie
NST was complaining about!
Huh? WTF? Last night already like that and they just switch off the alarm panel and we suppose to continue gas down our patient in this condition??? I was benggang... Called the support service hotline myself, 5 minutes later a technician came to OT and told us his colleagues were at the gas plant checking the system... We got everything back to normal in 20 minutes time.
Waking up cost has a story about OT nursing manager (sister in our local system) messing with his oxygen system while a case is going on...
So what I'm trying to say is, those new nurses probably needs more tutoring but some senior one are bad examples for them!
p/s: dun get me wrong, I do hold high regards on those good nurses that I've work with over the years.
US Marine Corps Rules for Gun Fighting Vs Anaesthsia Rules for Engagement
I have a good laugh on this, I'm sure other anes buddy will too... Read this from
4F Rant. It's a good one!
Marine Corps Rules for Gun Fighting:
1.Bring a gun. Preferably, bring at least two guns. Bring all of your friends who have guns.
2. Anything worth shooting is worth shooting twice. Ammo is cheap. Life is expensive
3. Only hits count. The only thing worse than a miss is a slow miss.
4. If your shooting stance is good, you're probably not moving fast enough nor using cover correctly.
5. Move away from your attacker. Distance is your friend. (Lateral and diagonal movement are preferred.)
6. If you can choose what to bring to a gunfight, bring a long gun and a friend with a long gun.
7. In ten years nobody will remember the details of caliber, stance, or tactics. They will only remember who lived.
8. If you are not shooting, you should be communicating, reloading, and running.
9. Accuracy is relative: most combat shooting standards will be more dependent on "pucker factor" than the inherent accuracy of the gun.
10. Someday someone may kill you with your own gun, but they should have to beat you to death with it because it is empty.
11. Always cheat; always win. The only unfair fight is the one you lose.
12. Have a plan.
13. Have a back-up plan, because the first one won't work.
14. Use cover or concealment as much as possible.
15. Flank your adversary when possible. Protect yours.
16. Don't drop your guard.
17. Always tactical load and threat scan 360 degrees.
18. Watch their hands. Hands kill. In God we trust. Everyone else, keep your hands where I can see them.
19. Decide to be aggressive ENOUGH, quickly ENOUGH.
20. The faster you finish the fight, the less shot you will get.
21. Be polite. Be professional. But, have a plan to kill everyone you meet.
22. Be courteous to everyone, friendly to no one.
23. Your number one option for personal security is a lifelong commitment to avoidance, deterrence, and de-escalation.
24. Do not attend a gunfight with a handgun, the caliber of which does not start with a "4."
Anes Rules for Engagement:
1. Bring an IV. Preferably, bring at least two IVs. Bring all of your friends who have IVs.
2. Anything worth a liter of fluid is worth two. Crystalloid is cheap. Life is expensive
3. Only working IV’s count. The only thing worse than a miss is a slow miss.
4. If your sterile technique is good, you're probably not moving fast enough.
5. Move away from bodily fluids. Latex is your friend. Follow Universal substance precautions
6. If you can choose what to bring to a trauma call, bring a big IV and a friend with an ETT.
7. In ten years nobody will remember the details of IV gauge, location, or tactics. They will only remember who lived.
8. If you are not managing fluids or airway, you should be communicating, restocking, and running.
9. Accuracy is relative: most drug dosing standards will be more dependent on "pucker factor" than the inherent factors of the drug.
10. Someday someone may kill your patient with an IV, but they should have to beat him to death with it, not cause an air embolism because the IV is empty.
11. Always cheat; always win. The only unfair fight is the one you lose.
12. Have a plan.
13. Have a back-up plan, because the first one won't work.
14. Use cover or concealment as much as possible. Always wear gloves, mask, & glasses.
15. If one approach to an IV or drug doesn’t work, try another.
16. Don't drop your guard.
17. Always check IVs, drugs and scan monitors 360 degrees.
18. Watch the surgeon’s hands. Hands kill. In God we trust. Everyone else, keep your hands where I can see them.
19. Decide to be aggressive ENOUGH, quickly ENOUGH.
20. The faster you finish the code, the more sleep you will get.
21. Be polite. Be professional. But, have a plan to resuscitate everyone you meet.
22. Be courteous to everyone, friendly to no one.
23. Your number one option for personal security is a lifelong commitment to avoidance, deterrence, and de-escalation.
24. Do not attend a trauma code with a IV, the caliber of which does not start with a "14."
There u go, never rush down to A&E to help resus a bad trauma without few 14G IV!
Full load of the Kangoo
Went to Melaka for
MSAASM 2006 in March. Those of u who follows GASMAN's blog may know that we went down together. Both Gasman and I presented a paper there.
On our way back, there are 5 of us in the Kangoo. These were the photos taken on our way back after stopping over at Tapah R&R for some fruits...
Luckily our boss decided not to follows...
House keeping
Did some house keeping tonight.
1) Due to reason unknown to me and many others, MyKangooClub had been shut down by it's founder and there a new forum setting up by some of the exmembers in MyKangoo Club which the calle it
Kangoo Club Malaysia. The forum link at the side bar had been changed accordingly to
Kangoo Club Malaysia Community.
2) Added <
Spinosum Diary> to my link.
3) Added <
PACES MRCP UK> to my link.
4) Added <
The heart of the matter> to the link.
Thak you.
DrugDoses (Frank Shann) Update
I blogged about
PDA version of Drug Doses by Frank Shann back in May 2005. They have updated the PDA database recently. This is the email I received the other day:
Dear Colleague,
We are proud to announce that we have updated our database. You'll find lots of
new drugs, corrections, and new informations. All these changes will only appear
in the next booklet, that will not be published for at least two more years...
Therefore, thanks to DrugDoses, you'll be the only one with this new database!
I'd say it's very handy indeed. I still keep a printed copy in my locker but with the PDA version in my Palm, It's definitely better for those young patients occationally lodger in our adult ICU.
It comes with searchable drugs database, cardiology database, resuscitation drugs where u can just enter the weight of the patient and the programme tells you the correct doses of those common resus drugs; also feature the normal lab values of different age groups.
Go to http://www.drugdoses.net/ to download.
A near miss encounter
Cases of near miss happens on and off in both public and private hospitals. Resently I met one, this time my wife is the 'victim'.
My wife when to a foreign own private hospital in penang for delivery of our
new born kid. Our 1st and 2nd was delivered in public hospital, very good obs care but the nursing care as usual is NOT desirable at all. That is another story, lets go back to this encounter.
Her os was 6cm when we admitted to the labour suit, supprised to find out that they don't routinely insert a IV line patient in labour. I felt uneasy but still ok with that coz I'm confident with my IV setting skill and I know that my wife had 'good vein' easy to set a line anytime.
When the os is 8-9cm, the nurse called the obstetrician for delivery. When she came, after she assessed the cervix, it was almost full and she ask the nurse to set an IV branula. The sister oncall was there and she know me since I do locum in their A&E too, so she ask if I'd like to set the line myself. I did that, they gave me a pink (20G) branula - it has an estimated flow rate of clear fluid 61ml/min as compaired to green (18G) which allows 96ml/min in best condition.
IV line in-situ but no plan for running a drip. They proceed with delivery when the os is full and Tina has bearing down sensation. After about 50min, when the baby finally crowning, gush of fresh blood came out from the vagina, luckily with a good push and a liberal episiotomy, my baby was delivered in just a few seconds after blood started to gush out from within. Apgar 9, crying spontaneously. Thank God.
At this moment, I can feel my wife's pulse became tachy (about 150bpm), I asked if we can start a drip, the obsterician then ask the nurse to run Hartmen solution. Took a BP and it was 54/33mmHg, PR 146bpm. She ask the nurse to take another BP, still the same. I noted my wife became very pale and she complaint of dyspnea. I ask the sister to give me another branula, and put up another drip, at this time the 'good veins' already almost collapsed.
My hand abit shaky when I inserted another branula into my wife's wrist. The largest IV branula they have in Labour suit is a grenn (18G), I'm sure they dun have a 14G, ask for a 16G they don't have. The obstetrician noted the severity, ask for to put up a Haemacele and ask to draw blood for cross match.
Lowest BP recorded was 48/28mmHg. BP and pulse rate improved as we flood her with fluid to meet the looses. BP and pulse became stable after running in 2L of crystaloid and colloid when the 3rd Little going in, she is already comming back from the shock. And the placenta was delivered and episiotomy wound repaired. Uterus well contracted.
Thank God she is ok. Clinically looks like Hb 4-6g% to me. Transfused 1 pack of blood. Still dizzy when standing erect early this morning. But she is all well later in the afternoon. Can even walk to the neonates unit without support for breast feeding.
IRB's e-Filing
The Star running a story claimed success of the IRB's e-filing system. I welcome the move but had story to tell regarding its implementation.
Back in Feb 2006 when the IRB announce to the public the launching of e-filing, they said public can register for the digital cert in their brunch. It is also stated so on IRB's website.
I when to the IRB brunch in Bandar Perda, Seberang Prai in Feb twice to register for e-filing. The 1st time, I was told by the counter staff that they still don't know what to do and after a few weeks on my 2nd visit, I was told there are only a few public relation officers who are in-charge of this issue and they are having meeting.
My 3rd encounter was in March, I get the digital slip from IRB's moblie counter in Giant Bayan Baru, Penang. It was a Saturday, the officer told me to try register online after tuesday. Knowing their effectiveness, 2 working days seems 'reasonable'. However, when I tried on the following tuesday, the server tells me there are no such information in the system. Tried many times over the weeks. Get the same message my friend GASMAN get: "Pemegang No KP ini Belum Cukup Umur 18 Tahun!" (The new IC holder not yet attain 18years old) [I later realised it's because of firefox, using IE there is no under 18yr old problem, they do mention we need Windows and IE].
Went to IRB office again mid April and finally get it registered in the office itself. Must admit it is very fast (the punch line is u have to be there and watch them doing the work.) My guess is the officer in-charge didn't enter my information into their server after I got the earlier slip from the IRB mobile counter. (same old story, we have to watch them doing their work, without our present, they will not bother to do their work)
Well, after 2 months of trying, I finally manage to upload and sent my tax return on the 27th April. So my verdict is: The system is ok, it's the people! Again, another story of 1st class infrastructure, 3rd class mentality...
ps: A 5th year in service malaysian government doctor (married with kids)
doesn't have to pay tax as we don't earn enough to be taxed... am I supposed to be happy or sad??
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