What

  hospitals dont save lives, people save lives.  2008-05-02, 07:48:57

  
(Obviously getting me on the ground was the goal. Only then could the other three morons waiting patiently on the corner start their head kicking.)

You got a fucking problem? Do you mean, like, apart from the fact that you just punched me?

I ran to the centre of the road: standing on the tram tracks - two lanes of traffic between my secret admirers and I - it felt like the perfect place from which to yell abuse. Fuck you. At this point fuckwit and his morons seemed to be sorting through my souvlaki debris, looking for something valuable amongst the yoghurt and pita bread. Fucking morons. My provocation was enough to enrage fuckwit and get him running towards me.

Although seemingly awkward, giraffes can run extremely fast when pursued. Even faster when escaping tabloid scenarios (alcohol fueled violence on the rise in Melbourne's streets, duh...).
">Giraffe  2008-04-21, 13:10:00

  Urchin Sampler  2008-04-25, 06:08:00

  Bluebird of Happiness  2008-05-01, 03:06:00

  What is Stage 0 Colon Cancer?  2008-04-23, 09:16:30

  Recurrent Cheilitis in a 37 yo Woman  2008-04-02, 17:11:00

  
Questions:
1) What has been learned about this entity since 1982?
2) Should he be rechallenged with penicillin and kept on long-term antibiotic prophylaxis.
3) What role does "hypersensitivity" to bacterial exotoxins play in the dermatitis.
4) Does anyone have magic for cases such as this?
5) Allergic contact dermatitis will be ruled out by patch testing.

Comment: My plan at the moment is to "clean up" any residual infection, consider prophylactic antibiotics and work on the dermatitis. I will refer him to a lymphedema center, if possible, for evaluation. Aggressive management of his leg swelling will help. He was told not to bathe the leg and I think this sets him up for infection. Your thoughts will be greatly appreciated. This man's life revolves around his leg. He is a keen student, a political scientist and in his later years he must focus exclusively on a leg. Let's give him "a leg to stand on!"

Reference:
Recurrent cellulitis after saphenous venectomy for coronary bypass surgery.
Baddour LM, Bisno AL.
Ann Intern Med. 1982 Oct;97(4):493-6.

We describe a previously unreported complication of coronary artery bypass
grafting, recurrent cellulitis. Five patients had 20 episodes of acute
cellulitis, each occurring in the lower extremity in which saphenous venectomy
had been done. The cases were striking because the patients presented with high
fever and considerable systemic toxicity. The appearance of the lesions, presence
in one case of obvious associated lymphangitis, and prompt response in three
instances to therapy with penicillin alone all suggest group A streptococcal
infection. In one case, a beta-hemolytic, bacitracin-susceptible Streptococcus
strain was isolated from the lesion. The pathogenesis of this syndrome remains
obscure but, based on our understanding of postsurgical erysipelas, this
cellulitis likely results from the interplay of several factors, including local
compromise of lymphatic drainage, direct bacterial invasion, and acquired
hypersensitivity to streptococcal exotoxins.">A Leg to Stand On  2008-04-04, 00:46:00

  
Diagnosis: Non-healing erosions etiology unclear. One always considers factitial disease in health care professionals with atypical skin lesions and this man also has free access to needles as a diabetic. In a year, the scalp lesion has shown no tendency to improve.

Further Treatment: He was treated with topical corticosteroids in case this was erosive pustular dermatitis of the scalp (no response) and imiquimod in case erosion might have been hypergranulation tissue. (no response) We ordered Duoderm dressings, but they were too expensive for the patient.

Questions: Where would you go from here? Diagnostic and therapeutic suggestions.">Stumped...  2008-04-16, 12:14:00

  Aquaria  2008-04-11, 18:39:00

  Am I dreaming?  2008-04-12, 18:36:00

  Ridiculous  2008-04-16, 15:38:00

  
These are the many medications I give out to patient with Psoriasis.

I usually diagnosed this disease in a glance. Most part of my consultation is to explain to the patient regarding the disease, as well as various types of medications the patient need to apply, including the various detail steps on how the medications are applied and their various expected side effects.

Am I in no better qualified position to do the explanation and counseling in regards to the medications used and their various side effects?

How much one be sure that the pharmacists could explain how exactly I want the patients to use the way I want them to use?

I can tell you, they have no ideas and that is why I kept a full range of medications on my table to show and teach the patients how to use them.

Here's some comment from one reader:

"My point is that if dispensing separation were to take place, a check and balance system will be in place. The doctors wins, the pharmacists win, the patients win. Win-win for all. Isn't that good?"

My question now is, how are we really be sure that what the doctor prescribes, is what the patient should get?


This was the third time I encountered this on the same day.

I wrote a prescription for the amount of 200 gm, and the patient only received 60 gm. Did the pharmacists understand how much 200 gm is? Did they see the patient and estimate how much the patient need it? NO, and I am so tired of writing new prescriptions again and again just to get the exact amount of cream I wanted the patient to get. I am just so fed up.
Here was another prescription I wrote for a patient.

I wanted to give out the 'cream' form and for 30 gm amount.
This was what the patient received, 'ointment' and only for 15gm.

When I called back to confirm, they admitted it was their mistake.

Therefore, if pharmacists are to check on the doctors' prescriptions, who are there to check if the pharmacists dispense the correct medications and amount or not?

So, does the separate dispensing system really work with the 'check and balance' concept that benefit patients.

I hope doctors would not get new role, that is, to check back on pharmacists.

Read more about my posting over Storyformydoctor 1.0.

">This dispensing stuff again  2008-04-20, 06:59:00

  But for me, so so only lah.

So, what exactly so special about this bowl of bihun?

RM 7.00
">Water fish  2008-04-21, 17:30:00

  remembrance. (for mr wimps)  2008-04-19, 14:41:46

  could meditation lead to deep vein thrombosis?  2008-04-22, 03:02:39

  supression of public health information.  2008-04-26, 05:47:07

  Lizards and Harlequins  2008-03-11, 11:30:00

  On the Train  2008-03-16, 07:11:00

  Really?  2008-03-30, 12:56:00

  What Soap Does to Your Skin  2008-03-23, 23:10:14

  2008: Recent lesion biopsy report was short and sweet-recurrent melanoma

Diagnosis: Acrolentigious Melanoma

Questions:
1. How would you classify this patient?
2. What would you recommend for this patient?
3. The patient initially refused amputation. Is there a lesser procedure that might help her now?

Your answers and comments are welcome.">Acrolentiginous Melanoma from Malaysia  2008-03-11, 01:05:00

  
So, what happen if someone owns a gun but doesn't have bullets?

Here are some questions and answers related to my posting:

What is the hottest topic among health care providers these few days until even LKS and Malaysia Today blog about it?
The dispensing rights between the doctors and pharmacists.

What is dispensing (medicine)?
To give out or to distribute (medicine).

Who has the rights to dispense in Malaysia currently?
1) Doctors. 2) Pharmacists.

What has the pharmacists been demanding for the past 20 years and now?
The exclusive rights to dispense medicine, no one else.

Why is the rights so important?
Pharmaceutical industry is an extremely profitable business. There is a huge market out there. One can become rich (like doctors?) with such rights. This can be equate to automobile companies with APs (exclusive rights to import certain cars).

Who are practicing separate dispensing currently?
1) All the government hospitals and clinics in Malaysia (Actually not entirely true as many of the dispensing role are done by "dispensers" because there are shortage of pharmacists in the country).
2) All the private hospitals in Malaysia.

Who are not practicing separate dispensing?
All private General Practitioner clinics and most of the individual Specialist Clinics.

Why are they not practicing it?
1) There are not enough pharmacists.
2) Smaller clinics could not afford to hire pharmacists to dispense.

Why are pharmacists unhappy about it?
They are losing income or business for not been able to get enough prescriptions for them to dispense. That is why they are resorting to selling all sort of stuffs (like supermarket), such as health supplements, milk powder, self-grooming stuffs and even food stuffs like mineral water.

Why are doctors refuse to give away their rights?
Primary care or General Practice in the private sector is very profitable (one can not denied) and very competitive as well. Many GPs resort to lower their consultation fees in order to get the patient volumes and gain from dispensing medicines. Take for example, many GPs lower the cost to charge per patient (in a package of consultation plus medications) in order to get accepted as "panel" for many companies. This lowers the cost of health care.

What happen if doctors loose the rights?
Many will close shops due to competition as they will never get enough from consultation alone in view of so many private GP clinics out there.

While it is really not of my concern about who gets to dispense, because I work in the government hospital, what curious me is, why is the MOH so eager to bring up the issue and to go ahead of such implementation (of separate dispensing)?

Indirectly, this may have to do with stopping more outflux of doctors to the private sector as it may not be profitable anymore to earn a living as GPs in future.

In few years to come, with so many medical graduates coming from every corner of the country and overseas, there will be a time where the market is saturated and doctors would need to start begging to get employed in MOH.

While John Chang and Dr. Khoo Kah Lin can go and debate who and why pharmacists should be or not given the exclusive rights, I am more concern if implementation would be successful if ever the pharmacists won the rights.

This patient has been buying the above three medications from the pharmacy for the past two years without a doctor's consultation and prescription for frequent joint pains.

My few concerns:
1) Will patients ever understand the danger of not consulting the doctors for their problems and to buy medicine from the pharmacies because they are cheaper?
2) Will enough enforcement be there to make sure pharmacists only dispense medicine with only prescription from doctors?
3) Will patients willing to spend more on separate prescription and dispensing (higher cost of health care)?

Meanwhile, few possibilities I could imagine if doctors and pharmacists want to cooperate to share the pie:
1) Doctors to hire pharmacists and pay them accordingly to dispense in the clinics.
2) Doctors and pharmacists to open joint venture and share the profit accordingly.

Related links:
MMR
">Gun without bullets  2008-03-31, 14:29:00

  fixing statistics, not patients.  2008-03-24, 03:45:47

  the well interdigitated penis.  2008-03-25, 08:31:07

  cricoid pressure. friend or foe?  2008-03-27, 12:00:19

  doctors and nurses and guns.  2008-03-28, 09:00:11

  Aftermath of a Tsunami  2008-03-09, 08:09:00

  Postcard from the Suburbs  2008-03-09, 03:17:00

  Blockages  2008-03-06, 11:37:00

  W@Anjung  2008-03-02, 18:20:00

  Big joke  2008-03-05, 17:48:00

  
Here was some interesting quotes I read in the ">Back home  2008-03-07, 10:03:00

  
So, we headed to our old hang out place, Taman Free School, where the food stores open till past midnight.
Curry Mee, RM 3.00 (Large).
Wan Than Mee, RM 2.50 (Small).

Myuho lamented about the smaller portion this time, but then where can one still find hawker food at such a price?
">Back to vote  2008-03-07, 20:34:00

  
So, after the voting, I went looking for the "claim" counter. I asked the EC officers, one guy shyly whispered that I need to go to certain "booth" set up by certain "people". I then walked out from the school compound, and I saw many men in blue, absolutely no other colors seen!.

I was been referred from one man to another, and finally one guy brought me in his motorbike to a camp set up some 200 meters away. According to him, that was the MSeeA camp. So, I asked the two Chinese guys sitting there about the said claim. I was told, "No, there is no such claim. You need to go back to your original work place to enquire". "Huh? Go back to my work place to ask? Ask who?" Obviously, these MSeeA guys did not understand what I asked them, or were they just pretending?
Backed to the school, one chap then offered to bring me to another camp belonged to @MNO, which was a bigger one. I was asked to go into the office, and there I saw few others were already lining up.

So coincidently and embarrassedly, I bumped into a nurse who actually recognized me, but I didn't know who she was. And, she had such a thick face to ask me who I voted for.

Didn't my appearance show it all?

Anyway, least to say, my trip back this time was worth it.
">Men in blue  2008-03-08, 07:07:00

  Weighted Down  2008-02-27, 11:32:00

  Leap Day  2008-02-29, 17:07:00

  Breakfast Quinoa, Canyons, and Bears, Oh My!  2008-02-25, 03:43:00

  New False Starts  2008-02-18, 14:10:00

  
Certain things are hard to articulate, hard to swallow.

The people that tell you these certain things are usually the ones you need to know.
">Pig and Monkey  2008-02-19, 10:12:00

  
It's a bit off: Neither or. Either nor.

Not a word, not a thought:
Boundless love will surge through my soul,
And I will wander far away, a vagabond
In Nature--as happily as with a woman.
">Black Ghedalia  2008-02-22, 12:21:00

  Human factors in anaesthetic practice: insights from a task  2008-02-14, 00:00:00

  What can you do in 12 weeks as a house officer in anaesthesi  2008-02-14, 00:00:00

  What is a Drug?  2008-02-13, 08:23:03

  Ginger-y Cranberry Walnut Scones (No Elephants were Harmed f  2008-02-14, 20:50:00

  Scientists Able to See What Happens in the Brain When We Scr  2008-02-13, 09:15:22

  Asymptomatic annular lesions on face and hands  2008-02-11, 00:24:00

  
The career luck experiences fluctuations, business dealings are with many setbacks. Working persons should continue to be adaptable to environment, and performance is also continued to be good lights of superior. The young tiger persons lack the drive to study, coupled with confused moods. There may be mouth and stomach illness, so take note of daily meal consumption. Beware of muggers when outdoors. Take greater care of the elderly at home. Take precaution against fire hazards.

Wealth luck is low, proper income is stable, with no sign of windfalls, so control your spending to prevent cash flow problem. There may be loss of monetary funds, so manage your finance prudently. This is not a good year for relationship matters, where there are communication issues with family, and lovers; be more tolerant and caring."

For those born in 1974 [Wood (Den Tiger)]: Lucky number is 4296.
Noble persons: Symbols of Ox and Goat.
Noble Person direction: North East or South West.
">Very Fat t Fat t  2008-02-11, 17:19:00

  I am just old fashion but yet a simple person. Close friends will know that my meal consists of rice plus hard boiled egg everyday.

That's enough for me to call celebration.


Powered by eSnips.com ">Double celebrations  2008-02-14, 17:09:00

  picture a nurse.  2008-02-10, 07:40:41

  Living Well Without Chemo  2008-02-04, 08:14:08

  Umbilical Erosions  2008-02-08, 23:58:00

  quick tip: keep air out of your IV line.  2008-02-07, 08:39:44

  Queensland fluoridates water  1970-01-01, 02:00:00

  Resolve to be better in 2008  1970-01-01, 02:00:00

  Pets Need Dental Care Just Like People  1970-01-01, 02:00:00

  Check Out the "What is the Rectum" Song  2008-01-14, 08:14:19

  Fungal Nail Infections  2007-12-28, 00:10:01

  What are the causes of pompholyx (dyshidrosis)?  2008-01-02, 00:26:20

  Palmar Lichen Planus?  2007-12-06, 15:23:00

  
Exam: 1/3/08: There were 40 - 60 6 - 8 mm in diameter erythematous papules on torso, upper and lower extremities and to a lesser extent face. No lesions on doubly covered areas. After treatment with topical steroids this improved, but then flared around a week later.
1/10/08: Many new papules, neck, torso, extremities. No longer "breakfast, lunch and dinner" distribution.





Lab: CBC pending

Pathology: Consistent with arthropod bites or drug reaction. Will add photos later. Specimen shows parakeratosis, epidermal hyperplasia with focal eosinophilic exocytosis and a moderately dense superficial and mid perivascular interstitial lymphocytic infiltrate with scatterred eosinophils.

Diagnosis: Papular Urticaria (PU)

Questions: This woman is a competitive athlete. She does not want to take prednisone while racing. The lesions are very widespread and potent corticosteroid creams do not give much relief. Hydroxizine, too, will blunt her competitive edge. What would you recommend.

Reference: There was a good review of PU by Hernandez and Cohen in Pediatrics in 2006. "Insect bite-induced hypersensitivity and the SCRATCH principles: a new approach to papular urticaria." It is available in full-text: Hernandez/Cohen

Your thoughts and suggestions are welcome.">Papular Unticaria  2008-01-11, 12:44:00

  Eyelid Tumors  2008-01-21, 13:11:00

   My work station.

As I am new to this 'hi-tech' thing, I am still not get used to the system. Can you imagine, I took 15 minutes to finish seeing one patient (plus all the data entry) for a case that usually take me 5 minutes? I am quite dislike been a 'robot' as all our clinical notes are entered with many clicks. One step missed, we would not be able to proceed. That slows down everything if one is not familiar with it.

   What more interesting was, the stay came with a complemen