Sunday, December 30, 2007

New Year Greetings

As 2007 comes to an end, I look back on a tumultuous yet exciting 12 months, and eagerly anticipate the year ahead.

To cap my last blog entry for '07, here's another photo from the US trip. Taken from our visit to Disneyland in Anaheim, California, it's a nice reminder of my happy childhood.

Enjoy your New Year, everyone! :)

Saturday, December 22, 2007

Time For A Few More Photos

Hoover Dam

The biggest thrill I get from having visited this historic landmark is knowing that Transformers was filmed here. :)

Only found out about it after I returned home and rented the DVD, of course. But you should've seen me when I spotted the dam's unmistakable towers in one pivotal scene: I was post-call but jolted wide awake. Huge adrenaline rush! :D

As you can see, it really is a remarkable structure, with the cream- / grey-coloured buildings contrasting strikingly with the turqoise waters of Lake Mead.

Weather-wise, it's positively cooking out there in typical desert fashion. Dry, dusty and cancer-inducing. I got a major sunburn, but didn't mind it one bit. :)

At least there's an occasional breeze from the lake to alleviate the discomfort.

One rather surprising finding: it's relatively quiet even though the place was packed with tourists and there was quite a bit of road traffic passing through.

A half-day trip is more than sufficient. Rent Transformers for a more complete tour. ( But pay no attention to the kooky storyline, which is totally untrue, though kinda fun :))

The Grand Canyon

... truly lives up to its name.

Again, super-hot and super-dry, but awe-inspiring in so many ways.

We visited the West Rim, where the newly constructed Skywalk is located, with a tour company run by the Shanghainese fellow who helmed the project.

The round trip took about 12 hours, and guess what -- the helicopter ride costs extra!

But it's an experience worth paying for. It's approximately 8 minutes each way, and you get spectacular views for dramatic aerial shots.

This is one such example -- notice the slightly skewed angle.

Here's a picture taken at the bottom of the Canyon. The water was muddy that day, but it's a lot cooler down below, which was nice.

Yet another illustration of God's great hand in this world we inhabit. But I still prefer the grand mountain ranges and vast, crystal clear lakes of New Zealand. :)

Wednesday, December 19, 2007

Reflections 2007

Ahh, another year draws to a close yet again. But 2007 seemed to pass by at a much faster speed compared to most. I attribute this to my post-AST work schedule, which has been insane ( to put it mildly ).

A quick rundown of memorable events:

Best of 2007

1. Jersey Boys on Broadway, NYC

Regular readers know how much I love this musical, so I won't belabour the point any further. :)

For the uninitiated, you can read my review posted October 20th 2007.

I'm just hoping JB will be staged at the Esplanade sometime in the future. We've already had quite a number of hit shows at that venue ( including the upcoming We Will Rock You ), so keep your fingers crossed.

2. Trekking across the USA

I survived 4 weeks of 24/7 contact with my parents, and had a great time along the way ( imagine that! :)).

NYC was obviously the biggest highlight of this holiday, but Las Vegas came a very close second.

I haven't blogged about Seattle or Los Angeles yet, but will do so in the coming weeks.

The weather was fantastic, the sights spectacular, and the people -- surprisingly pleasant! Singaporeans -- especially the men -- have lots to learn.

3. A Few Good Men

Not local, of course. :)

Seattle: Nick, our waiter at a cozy Chinese restaurant ( but populated by Caucasian staff ), looks only 17 or 18 years old but possesses perhaps the best public relations skills we've ever witnessed in one so young.
My mom still talks about how he kept replacing her glass of Coke every 15 minutes. Not refill, mind you. It's "replace". He'd come sweeping over with a brand new glass and take my mom's half-empty vessel away. It was unbelievable!
He also stopped at our table every 5-10 minutes to ask if we were happy with our food or if we needed anything, and kept saying "awesome" ( which my mom found very amusing -- oh well, he's pretty much still a teenager after all :)).
Looks-wise: cute in my book, heh heh. Blonde, blue-eyed, slim and clean-cut.
But ultimately, it's his impeccable manners and terrific personality which won us over. The generous tip I left was well-deserved.

Seattle: Again! This time, there're 2 guys whose names I don't even know.
One's a fellow who was about to walk into a shopping mall as my parents and I were exiting. He opened the door for my dad, but continued to stand there for 5 whole seconds, patiently waiting for my mom and I to walk towards him, smiling broadly the entire time. He graciously acknowledged our effusive thanks, before entering the complex after we'd emerged. Young man, maybe in his late 20s or early 30s.
Since returning to Singapore, we've had no such luck with local guys, who make it a habit to slam doors in other people's faces, rush in front of you to get ahead, or just act like you're invisible in case they're expected to behave a certain way.

The 2nd chap, I suspect, is a fellow emergency physician. I met him at a souvenir store within the Convention Centre where the ACEP Scientific Assembly was being held. I accidentally dropped something but caught it before it hit the ground, and suddenly heard a male voice exclaim, "Great catch!" just behind me. He looked like he's about my age, with brown hair and glasses, slinging the same conference bag as I was. He had a huge grin on his face, so I laughed and said, "Thanks!"
Unfortunately, the story ends abruptly, because even though he clearly appeared eager to strike up a conversation with me, for some strange reason I didn't take the bait ( damn! ). Still kicking myself over it.

By the way, the people of Seattle are the nicest I've met so far in my travels.
Coming in a close second are the Japanese, followed in third place by the New Zealanders.

Las Vegas: Gorgeous young man at the front desk who checked us in at Caesars Palace, and upgraded us to a Deluxe Suite for free, just because he "can tell that you really want it". He means my mom, since I was the one who kept telling her NOT to get it.

Las Vegas: Juan DeAngelo. Enough said. :)

Manhattan: An African-American fellow who runs a stall selling branded perfumes at wholesale prices ( at least I think that's why they're going so cheap, 'cos they definitely smell genuine ). We went back a 2nd time to pick up more bottles, and for some funny reason, he decided to throw in an extra one for free. We didn't see him do this for any of the other customers crowding his stall, and as we walked away, he came running over to whisper, "Now I don't do this for anyone, so don't tell anybody okay?"
We just stood there stunned for a moment until it finally sank in. Our lucky day indeed. :)

4. Favourites of the Year

Movie: Transformers -- just rented the DVD, and am already watching it for the 2nd time! I'm a long-time fan of Michael Bay's work, and couldn't be happier with this film. It's chock full of Bay's trademark dramatic, vivid-coloured shots and creative camera angles. There's enough migraine-inducing action to earn every cent of whatever money you put into the experience ( movie ticket or DVD rental ). But best of all, this might be the only movie of his that actually shows real heart and soul. From the geeky protagonist to the macho military and yes, even the hot chick -- every character is likeable and memorable despite being somewhat stereotypical and/or psychotic ( e.g. John Turturro's over-the-top Sector 7 agent, who had me in stitches :)).
Really hope Bay's future projects will stay true to this winning formula.
Plus, Bay's pretty hot himself. ;-)

Of worthy mention: Hairspray, which I watched on the plane back to Singapore -- twice. I'm such a sucker for musicals :) -- and Ratatouille, an absolutely perfect piece of animation and storytelling.

Actor: It's official. My latest list of Top 3 Favourite Actors include Kevin Spacey ( #1 ), John Cusack ( #2) and, new at #3 -- Shia LaBeouf.
I've already seen him in Constantine, The Greatest Game Every Played and I, Robot. But last week, I rented Disturbia and Transformers, which put him dead centre in the lead role. How I adore him. :)
LaBeouf reminds me of John Cusack in many ways -- the same limpid brown eyes, similar speech patterns and nervous tics, a laid-back everyman quality yet also sexy in a non-threatening way.
Cusack kinda missed the blockbuster mark with his career choices, but LaBeouf has the great and powerful Steven Spielberg behind him, so it's going to take a meteorite to annihilate the entire human race in order for this young talent to fade into obscurity.
Mark your calendars: Indiana Jones 4 ( where LaBeouf plays Indy's son ) is due for release on May 22nd 2008.

Album: Maroon 5's It Won't Be Soon Before Long is galaxies away from their debut effort Songs About Jane, but they've experimented successfully and are up for a few Grammys -- for Pop Vocal Album and Pop Vocal Performance by a Duo / Group.
Of worthy mention: The Jersey Boys original cast recording, which features covers that far exceed the original Four Seasons' versions, and East Of Angel Town, Peter Cincotti's 3rd studio release which features more pop, but still stays quite close to his jazz roots ( a full review to follow in a subsequent entry ).

TV Shows: None to speak of this year. Lost interest in Heroes after all that Sylar mumbo-jumbo kicked in. But I do love Milo Ventimiglia ( Peter Petrelli ), who will always be "Jesse from Gilmore Girls" to me.
Most of the TV fare hasn't lived up to my expectations. Managed to catch a lot of fall season premieres in the US, including CSI and CSI: New York ( both rather dull and unchallenging ), Grey's Anatomy, The Closer and Private Practice ( a Grey's spinoff which is so childish it's painful ).
The only one that didn't disappoint is Law & Order: Special Victims Unit, guest-starring Sex And The City's Cynthia Nixon as the scariest psychopath since Glenn Close in Fatal Attraction.

Books: Read minimally this year. But Raymond Tallis' Hippocratic Oaths and Mohamad Khadra's Making The Cut are quite excellent.

Upcoming in 2008

At least 3 to look forward to:

The Rise and Fall of Little Voice -- Jubilee Hall, January

The Police in concert -- I'm seeing Sting again in February, woohoo! :)

Maroon 5 -- their 1st gig in Singapore come March. Am REALLY excited about this one.

Now all I need is a Michael Buble performance, and I'll be happy for the rest of the year. :D

Here's wishing everyone a Merry X'mas in advance. Please don't get too drunk over the New Year. Or if you do, don't come to my ER ( oh wait, I won't be on call that day, so who cares haha ). :P

Sunday, December 09, 2007

ZoukOut, aka PukeOut

Forgive me for ranting yet again. ( Relaxing photos will be posted another time. )

I didn't realize my night shift coincided with the above event until it was too late.

Thought my December requests had covered all the bases ( i.e. X'mas and New Year ), but alas! the dreaded ZoukOut passed below my radar, and now I suffer the consequences.

Big bunch of young people brought in by ambulance -- intoxicated, vomiting, hyperventilating, shouting.

Mostly in their early 20s.

Typical history:

Dr: What happened to you?

Patient: I drank too much, doc.

Dr: What did you drink?

Pt: Vodka ( or some other hard liquor ).

Dr: How much?

Pt: A big bottle ( or "I don't remember", or "A lot lah, dunno how much exactly" )

Dr: And then you started vomiting?

Pt: Uh-huh.

One guy puked altered blood -- likely alcoholic gastritis vs Mallory-Weiss vs acute PUD, who knows which? Admitted to General Surgery.

Another girl is still pretty out of it. Able to sit up on her own but speaking gibberish intermittently. I gave her an empty vomit bag and she proceeded to try to drink from it like she was guzzling beer.

I suppose these youths think it's cool to drink themselves into a stupor, all in the name of partying.

And I guess the Singapore government believes that supporting such events makes our country appear hip and happening, raising its profile as a fun travel destination for tourists.

I'm just disgusted by our young people's behaviour. It isn't just during ZoukOut and festive seasons anymore. We now get similar cases at the ER most days of the week, often with concomitant injuries sustained in falls and fights.

Of course, we do see patients from the older age groups presenting with the same problems from time to time, especially old chaps with alcohol dependence who come to us almost daily for overnight TLC till they're sober.

But for such huge glitzy events, shouldn't the authorities think about setting up a few first aid stations on-site for these people, instead of stretching ERs which are already working on minimal manpower during night shifts?

In between the drunks, we had to attend to other legitimate patients, including one STEMI who went for PTCA and a collapse case who needed resuscitation.

Plus, our computer system was down for a couple of hours while undergoing maintenance. Thank goodness it was up and running way before the stipulated time, or things would've slowed down even further.

I'm just gearing up for the next wave, likely to begin in 2009 once the Integrated Resort is completed. This will comprise even more drunks converging on Marina Bay from every corner of the island, as well as gamblers both local and foreign. There're sure to be many coming in for chest pain, breathlessness, giddiness and what-not, probably induced by winning / losing, or just sitting down at the poker table / slot machine the whole day without eating or drinking anything.

I just find it all so sad really.

Note to self: do NOT do night shift during ZoukOut next year.

Tuesday, December 04, 2007

Dousing The Fire - Sort Of

Regular readers are no doubt aware of my intermittent burnouts ( I count at least 3 major ones since 2003 -- SARS being the start of it all ).

I still get minor attacks on and off, but have learnt to accept that it comes with the job.

Each individual episode, however, has its own unique trigger. The SARS period took its toll on me physically ( I couldn't get sick when I desperately needed medical leave to rest! ) and of course emotionally ( helping to write Ong Hock Soo's obituary for the SMA News remains one of the most difficult things I've ever had to do ). Subsequent burnouts occurred for various reasons, be it insane patient loads, intolerable ER overcrowding ( not a problem anymore, thanks to a friend's marvelous initiative and some administrative pushing ), or most recently, a traumatic event which revealed someone's terrifying ability to camouflage pure evil with a sweet, innocent smile.

Don't worry, I've been able to recover successfully so far. But each bout inevitably eats away at one's soul, sapping energy and blotting out what little optimism one has left in a fast-emptying arsenal of defences.

Wow, that was a mouthful. :/

So lately, I've been asking myself: Why did I choose emergency medicine? Why do any of us emergency physicians do it, when it pays less than most specialties, is no less demanding in terms of hours and workloads, isn't exempt from angry complaints and adverse events, and rarely gets the recognition it deserves -- from fellow colleagues who treat the ER like a dumpster, and patients who never give us credit for saving their lives, choosing instead to bestow their appreciation and gifts on those upstairs who take over from us once the case has been resuscitated and stabilized?

We battle forces from all directions -- intubated patients who get rejected by every specialist we call, ward nurses who give us hell when we want to send cases up, patients who make unfounded accusations, administrators who scrutinize the numbers and don't bother to solve the underlying problems.

Contrary to what some people would like to believe, no, emergency physicians aren't losers who chose this specialty after unsuccessfully applying for other traineeships. Many of us have been encouraged to train in surgery, paediatrics or medicine during our MO postings, but had either already set our hearts on the ER, or subsequently picked the emergency medicine route, after considering our options.

Having spent many years in the ER, I've seen emergency physicians trump other specialists in making the right diagnosis ( without the need for scans or numerous blood tests ). They override decisions that are deemed incorrect, saving lives, improving outcomes and reducing costs ( lawsuits included ). They take their roles as patient advocates seriously, have some of the thickest skins in existence ( try talking to certain disciplines when you need a HD / ICU bed ), and have no opportunity to sit down or answer nature's call during most shifts.

You know I love what I do. But honestly speaking, it's a bloody thankless job, and there're times when I want to tear my hair out, slap people, or say, "To hell with you, I'm sending my patient up whether you say yes or not."

But of course, the real world is nothing quite like that.

A few hours earlier, my registrar described a complaint from the ward concerning a case where the diagnosis relied primarily on the history given by the patient. The team upstairs was unhappy about the admission, and some harsh words were used.
The registrar's side of the story made good sense to me, and it was clear that an underlying condition needed to be excluded. I don't know if the patient was entirely truthful or lucid while he was in the ER ( additional consideration should be given to the fact that an interpreter was needed ), but apparently he said something different once he got to the ward, hence the impression that the emergency physician made a huge mistake.

I know the author of the complaint -- a senior consultant who isn't famous for whacking others just for the fun of it, unlike some nutcases strolling along the hospital corridors. Still, the harshness of the correspondence had a significant negative effect on my registrar's psyche, and his tone was a mixture of sadness and frustration.

What we all need to realize is that nobody's perfect. But IMHO, the ER deserves special consideration because we pretty much function like the control tower at our Changi International Airport, juggling hundreds of patients a day, making snap decisions and hoping no-one dies in the process.

We don't have the luxury of ordering 20 different tests to evaluate a single complaint. On the contrary, we almost always decide whether to admit or discharge within the first 3-5 minutes of consultation. There're efficient management algorithms in place to expedite disposition and treatment. We don't believe in doing urgent CT abdomens for no good reason.

I suppose the main difficulty in getting other specialties to understand our limitations stems from the fact that most doctors don't have experience working in the ER. Back in 2001, when I did my first ER posting, I worked alongside trainees from surgery and medicine, as ER rotations were still considered a compulsory component of their training at the time.

Since then, this has been abolished in favour of more specialty-specific training -- surgeons do only surgical postings, and vice versa. Those who desire a more well-rounded CV may opt to work with us for 6 months, but of course, it's no surprise that most prefer to stick to what they know and like rather than set plugs, do manual evacs and treat our regular drunks and PSY cases.

Many of the trainees I worked with are now consultants in their own fields. I speak to them from time to time when I need to override their juniors' strange decisions, and am always glad to hear that they haven't forgotten what it's like for us down in the trenches, often taking us at our word and accepting the admissions without any argument.

Contrary to what many people would like to assume, I derive no pleasure from overriding other disciplines. I don't do it out of sadistic glee, or as part of some power play. In fact, none of us is happy to do it, because it means there's been some disagreement between medical colleagues, and the patient is caught in the middle. If our decision turns out to be correct, the patient benefits ( although s/he is totally oblivious to the preceding shoving match ). If we're proven wrong, then it's a lesson worth learning ( +/- a complaint letter from the ward ).

I'm sure some specialists have their own store of ER boo-boo's. But like I said earlier, NOBODY'S PERFECT. If you can't get past the childish assumption that emergency physicians exist only to make your life miserable, then government hospital practice may not be the right place for you ( private ERs, on the other hand, operate on a completely different set of rules ).

The other gripe I have is how the younger generation of ward doctors treat their more senior colleagues from the ER these days. When I was a house / medical officer, I spoke to my seniors with respect and never dared to answer back.
In recent years, however, I've had registrars and MOs irritate me with their sarcastic remarks and stubbornness. Some of them even yell at me over the phone like rabid animals, cutting me off in mid-sentence and telling me what to do before I can even finish my story. Does any of this help the patient?!

Occasionally, I pull rank on the bugger by announcing my status firmly, or threatening to speak to his/her senior-on-call ( or get the ER consultant on shift to do a bit of arm-twisting on my behalf ). This works in most cases, but one particular female registrar was a real piece of work. She had the gall to reprimand me ( her senior by rank ) and attack my fellow colleagues for being "incompetent", then bullied another discipline's reg-on-call to take over a case in the middle of the night, despite what we thought was an obvious diagnosis.

I followed up on this case who, after a long list of invasive and costly procedures, turned out to have the condition we diagnosed the night she presented at the ER. Suffice to say, my entire department was informed of the incident, and the registrar's chief was alerted to her antics.

Such incidents are becoming more common nowadays, necessitating the the need to track cases on the computer after they've been admitted, to determine whether my assessment was correct. Problematic encounters with other disciplines are flagged out, and nasty comments received are diligently documented under the confidential remarks section, WORD FOR WORD.

So back to the original question about why I chose to work in the ER.

It takes a special type of person to endure such an environment. We may not be experts in new-fangled surgical techniques or know the 50 tests to order for some rare disease. What we're good at is resuscitation in its many forms, rapid assessment and decision-making using the minimum number of investigations, and sifting through some patients' lists of 10 different complaints in order to determine which symptom needs the most urgent evaluation, and hence which admission discipline is most appropriate.

Emergency physicians aren't in it for the money. We're not doing this for the easy lifestyle ( I work most weekends and public holidays -- though by choice, haha :)) or the recognition ( still sorely lacking, despite everything I've said in the above paragraphs ). Getting any present or thank-you card from a patient is like striking the lottery, and the petty nitpicking never ends, so being appreciated isn't on our list of priorities either.

I left for America feeling pretty dejected ( after all, it was only a few weeks after that encounter with The Evil One ). But interacting with thousands of fellow colleagues at the American College of Emergency Physicians Scientific Assembly in Seattle changed all that.

Many of the lectures I attended discussed the same problems I experience here in Singapore. The professors, attendings and residents I chatted with voiced frustrations which echoed my own. But their passion for emergency medicine never abated in spite of all these trials and tribulations. They just kept on fighting.

Then I realized that we actually have some advantage over our American counterparts, since Singaporeans haven't quite developed a thirst for medical litigation just yet ( whew! ). This makes it easier to avoid the practice of defensive medicine, which poses a significant problem considering the ER's limited resources and the healthcare funding policies in our country ( Americans rely wholly on personal insurance coverage ).

I left the conference completely rejuvenated and tremendously inspired. Truth be told, some of those effects have worn off since my return to the warzone, but the underlying lesson will never be forgotten.

Why did I choose emergency medicine? Because I just wouldn't be happy doing anything else. :)