The SICU story continues.... from Ero Sennin

Last time, I was telling about our 50plus year old lady with a prosthetic metallic mitral valve who came in breathlessness & later on pulmonary haemorrhage. Check the link: http://doctorsbrunei.blogspot.com/2008/05/interesting-chest-x-ray.html

Her pulmonary haemorrhage settled, whilst on heparin & her ventilation requirements did seem to improve. We did a battery of blood tests on her, autoimmune screen turned out negative, and yes, sputum AFBs and PCR AFB turned out negative too. We even did tumour markers, yes a shot in the dark and debated about the relevance of a high CEA. We did however notice her going into obstructive jaundice.

Eventually, she became stable enough for a CT chest, abdomen & pelvis. We were expecting to find lung metastasis. The only thing that was reported from our radiologist was that she had a dilated common bile duct and some narrowing near the ampulla. (I'm recalling this from memory sorry)

After the CT, she proceeded to have a tracheostomy as she had been intubated all this time and we felt it would improve her chances of being weaned off ventilation.

Our friendly gastroenterologist reviewed the CT film and suggested an ERCP, which unfortunately, she was not fit for. She actually deterioated post tracheostomy (acute lung injury) & required a higher ventilation requirement. I thought she wouldn't make here at that time, but she weathered round.

Surprise

It was time to tell the family what we found & what the options were. When we discussed with her husband regarding the CT Abdomen findings, he asked if the 'stricture' in the billary tract was a result of her previous radiotherapy or chemotherapy ! This completely knocked us off our feet, coz' this was not mentioned before and there was nothing in the medical notes to say that she had cervical carcinoma a few years ago !!

We traced the Obs&Gynae notes, which were completely separate to her normal medical notes, to find the cervical carcinoma with NO mets diagnosed in 2006, this was however treated 'conservatively', to summarise a complicated story, at family request. She did however go to KL for chemotherapy and radiotherapy.
Later on, she had a cervical lymph node biopsy which confirmed metastasis, but it is unclear on whether her or her family were informed about this as they refused follow up from then onwards.

With that in mind, we formed a definitive treatment plan with the family, to continue her on artificial ventilation, but not for aggressive cardiopulmonary resuscitation in the event of cardiac arrest.

She slowly continued to deterioate, and died within 1 week after the discussion.

May she rest in peace.

Coolbrunei Weblog

What's hot in RIPAS at the moment?

Even officials at the ministry are talking about it...

It's a website.... not any ordinary one... A very interesting weblog which discusses many issues that involves the doctors. Although the sources can be controversial, it has so far manage to 'un-earth' issues that has been quite difficult to discuss openly, like pay, promotion, brain-drain etc.

Comments:

At last ... a place where you can just let it out...
A recommended site to visit..

http://coolbrunei.wordpress.com/

Medical Students in RIPAS Hospital Brunei

A Local student (undergraduate from University of Queensland Australia)

Posing with the Orthopaedic Team

RIPAS Hospital continues to accept students from local institution as well as abroad for either just a short period of 'get-to-know' experience, to a 4-6weeks of clinical attachments in various specialties. It is open not just to students who are interested in medicine, but also in other allied health professions such as psychology, dietetics, pharmacy, physiotheray, labs and many more.

For those who have successfully gone through their attachments at RIPAS in whatever speciality... Congratulations. We hope the time you guys have spent with us have not been too boring... hehe... and hopefully the experience that you have gained with us can be of use in the future.

If you are interested in doing a stint in RIPAS, it is a good idea asking your friends who have done the particular specialty, for there is always varying experiences. In general, for surgery & Orthopaedics, I think this hospital is very good at providing hands on experience for the students as you can see from the above picture. The students also get ample teaching from the MOs, SMOs, & Specialists. If they don't... you must nag them!! Of course it also depends on the students enthusiasm. We can usually suss out which ones are the keen ones and which ones just want to get through the painful experience as quickly as possible.

My personal experience, students are usually quite keen to get their hands dirty and get stuck in. However they don't like being asked questions during ward rounds... hey that applies to everyone I think.. but of course the doctors like to pick on the students... don't worry... it's not because they want to catch you out, or make you pay for staying up late at night watching the Euro 2008 instead of reading your Kumar & Clark. It's because it makes them feel 'good' when they can explain things to the bewildered students.... Have you noticed the expression on the doctors face beaming when they explain the significance of an Arterial Blood Gas results? My tip.. an enthusiastic nod... accompanied by 'awh....' when the specialists starts explaining the causes of Acute Renal Failure.. goes a long way.

You also get more points when you ask an intelligent question like.. what is the current trend in Management of Head Injuries... but becareful not to ask too difficult questions... the doctors might think you are trying to be a 'smartass' and ignore you throughout the ward round at risk of not being able to give a decent explanation.

I think the A&E department here are also good at providing clinical attachments. I have seen students clerking the stable acute cases, assisted in life-threatening cases, and learn to make decisions. There are plenty of scope to learn suturing here. Dr Ang, the HOD is very helpful and keen to teach.

In Internal Medicine, you have the likes of Dr Arif (aka Boss) a walking encylopedia of knowledge, Dr Syafiq (HOD), Dr Haslinda (Endocrinologist) to name a few who are more than willing to ensure that the ward round and clinics will be firing you with questions..

In ICU, i have not personally seen students attached here, but I don't see any problem with it, just as long as you specify that your interested in spending some time there. There's plenty of really unwell patients here hooked up to fancy machines that their lives depend on. You can learn a lot here especially when Dr Yazid is around who's always keen to teach. If you bump into a young dashing, handsome Doctor Aamton... I have bad news... he is married hehe.. but I'm sure keen to teach too... right Aamton? Skills to learn here... Arterial Stabs, Central Line insertion, and if your lucky.. intubation.

Alright guys.. I'm running out of ideas plus it's 1am now. Need to sleep coz ward round starts at 7.15am... yes boys & girls if you are planning to do surgery... be prepared to get up early!!

Golf set for sale

Selling my Precept Golf SA71 set with bag.

Bought last year at Empire Hotel Driving Range and used about 4 times.

Price $400 or nearest offer.

ps. Amy, bali tah since you are now an SMO .... hee hee

Anyone interested can contact Ero sennin directly in ICU, or jst leave a message here. Cheers

Vacancies for doctors to work in Brunei

We have received a lot of requests on how to apply for work in Brunei. I'm not sure what is the official requirements for doctors in Brunei, but having worked here for almost 2 years, I can say that we are still short of doctors both in the Health Services (GPs) and in the Medical Services (Hospitals).

We have about 460 doctors working with the government of which 2/3 are expatriates. We serve a population of about 300,000 people at 4 different districts, Brunei Muara, Tutong, Kuala Belait & Temburong. So the ratio of doctors to population is about 1 to 800 not taking into account the attrition rate.

If you are interested to work in Brunei, below are information regarding on how to apply

This information has been extracted from the official MoH Website

Vacancies are follows:

• Department of Medical Services
• Department of Health Services

Requirements

• Recognized basic medical degree
• Relevant post-graduate qualification
• At least 5 years of post-registration working experience
• Working in a job relevant to the post being applied for

Salary and level of appointment will be determined by qualifications and experience.

Benefits:

• Tax-Free salary
• Passage to Brunei Darussalam for you, your wife and up to four children under the age of 18 years.
• Heavily-subsidized housing, charged only at BND130 per month.
• Education allowance of up to BND800 per month for up to four children.
• Free treatment at government facilities for you and your wife, and your children under the age of 18 years who are resident in Brunei.
• 48 days of paid annual leave.
• Shipment of personnel effects.
• 25% gratuity on successful completion of contract.

How to apply:

• Download and print application form (SPA 1).
• Send completed form with required documents to relevant Department (Medical or Health).
• Required documents:

a. Up-to-date CV giving details about the work you are doing now and have been doing in the last 5 years, and your clinical skills and responsibilities, as well as information about the hospital or clinic you are working at size, workload etc.

b. Proof of registration after completion of medical training.

c. Copies of your certificates

d. A copy of a letter/certificate of Good Standing from your present Medical licensing board (under which you are currently practicing) which should be less than
6 months old.

e. The names, full postal addresses and other contact details (and preferably email addresses) of at least three referees.

Please also provide an email address for ease of contact.

Applicants considered suitable will be invited by the Public Service Commission to attend an interview. Successful applicants will normally be given 3-year contracts. In exceptional circumstances two year contracts will be considered.

Applicants must be prepared to work in any of the four Districts of Brunei Darussalam.

---

Department of Medical Services

Vacancies for Doctors In Department of Medical Services

Specialty	Specialist	Senior Medical Officer	Medical Officer
A&E Medicine			Yes
Anesthesia	Yes		Yes
Cardiology	Yes	Yes	Yes
Respiratory Medicine		Yes	Yes
Critical Care Medicine			Yes
Dermatology			Yes
Infectious Diseases/Tropical Medicine	Yes	Yes	Yes
Internal Medicine (Endocrinology)		Yes	Yes
General Medicine		Yes	Yes
Neurosurgery			Yes
Obstetrics & Gynecology	Yes	Yes	Yes
Oto-Rhino-Laryngology			Yes
Renal Medicine			Yes

Applications should be sent to the Director-General of Medical Services at:

Director-General of Medical Services

Department of Medical Services
Ministry of Health
Commonwealth Drive
Bandar Seri Begawan BB3910
Brunei Darussalam

Or by email to moh_dgms@hotmail.com

---

Department of Health Services

Specialty	Specialist	Senior Medical Officer	Medical Officer
Maternal and Child Health Services			Yes
Primary Care Services + School Health Services			Yes

Applications should be sent to the Director-General of Health Services at:

Director-General of Health Services

Department of Health Services
Ministry of Health
Commonwealth Drive
Bandar Seri Begawan BB3910
Brunei Darussalam

Or by email to phc_moh@hotmail.com

An Interesting Chest X-Ray

A busy ICU

ok, first photo is of some of busy people in Surgical ICU. Note our hardworking nurses, Dr. Izzati & Dr. Nurul (surgical).

Anyway, the Chest Xray I've got here is of a 50 plus year old lady who has had a prosthetic metallic mitral valve replacement. She's basically come in with severe breathless. A&E saw this Chest Xray and thought she was in severe pulmonary oedema, gave her frusemide and intubated her & admitted to SICU.

On initial history taking from her relatives, she has been unwell for the past 5 months, easily irritated, not eating well, having chronic dry cough WITH on average once weekly haemoptysis. She has no previous history or contact of pulmonary TB. She normally takes warfarin for her metallic mitral valve replacement.

What's her INR or clotting profile ?

It was so high, it was beyond the scale readable to the machine !! & yes, she was having pulmonary haemorrhage visible in the endotracheal tube.

She was very unwell & went into Acute Respiratory Distress Syndrome (ARDS) and we managed her to improve her lungs or rather her ventilation after a couple of days. Magic, isn't it ?

At this point, it has to be Tuberculosis until proven otherwise. We sent 3 sputum samples and so far negative, and the PCR AFB is negative. We note that she has a hard enlargened left supraclavicular node.

Her ventilation requirements have improved and right now she is awake, and we are continuing to keep her on heparin infusion for her MVR.

What's our working diagnosis....

Could this be Wegner's granulomatosis, SLE, some other vasculitis, malignancy ?

We're still waiting for the autoimmune screen / profile to come back and she's not stable enough for a CT everything (thorax, abdomen, pelvis)

If the autoimmune screen and the CT comes back negative, what else could it be ?
Was it a warfarin overdose of the massive kind ?

Will let you know when we have the answers.

Ero Sennin

The Temburong One Week Duty

I’m back! Phew… just got back from Temburong duty last week and still recovering haha… not from the travelling but from catching up with my post-poned outpatient appointments in RIPAS. I thought I might write something about Temburong Hospital for the benefit of future doctors who will be posted there, unfortunately I could not dig out much information from the web, so had to do a bit of research. The information provided below is based on the 2007 Temburong hospital statistics and my observation during my one-week stay there. Enjoy…

Introduction:

The Pengiran Isteri Hajah Mariam Temburong (PIHM) Hospital is one of the smallest district general hospitals in Brunei Darussalam and supposedly houses no more than 50 beds with two main wards (Male + Children & Female), 1 isolation ward (converted into doctors on-call room and a multi-function area) and a newly furbished day-care renal dialysis ward. The hospital provides general medical services to a population of around 9,000 people in its district.

On average Temburong hospital sees around 123.5 patients per day in it’s Out patient Department (General & Specialists). The ratio of doctors to population in Temburong is approximately 1: 3000 with only 3 permanent doctors to serve the whole district.

Amongst the services that it is able to provide includes Outpatient & Inpatient services, Outpatient specialists clinics, Pharmacy & dispensary, X-ray, Accident & Emergency, Dental Care, Physiotherapy, Laboratory services and until recently a Day care Dialysis centre for 11 of it’s patients requiring Haemodialysis. 3 permanent medical officers have been dedicated to this hospital; one of them is a female doctor with experience in Obstetrics & Gynaecology. There are no local doctors posted permanently here as yet.

Doctors’ duties in Temburong

During a regular working day, the doctor who has been on-call for 24 hours the night before will be responsible to do a ward round in the morning before going Off Duty for the rest of the day. This leaves the other 2 doctors to run the general outpatient clinic, which regularly sees around 85 patients a day, and admits around 2-3 patients per day during their on-call period. Majority of the cases they see in clinic are mainly cases you would see in a typical General Practice, and for those requiring admission to hospital 70% are medically related, 13.3% Paediatrics, 11.8% Obstetrics & Gynaecology and only 4.7% Surgically related.

Since March 2008 the Department of Medical Services through RIPAS Hospital initiated a new move to support the medical services in Temburong. It offers a separate paediatric service every working day and sends one local medical officer from RIPAS hospital to spend 1 week working in PIHM Temburong Hospital. These extra doctors were incorporated into the on-call rota and will also be doing clinic sessions during their time in the hospital.

With the new initiative Temburong Hospital Medical Service can now operate with a 1 in 5 rota and relieves some of the burden in managing paediatric cases in the outpatient. However if a paediatrician is doing the on-call, there will be no next day paediatric cover, and if a RIPAS junior medical officer is on-call, there should be a senior person to be 2nd on call as well.



After completing a week’s duty in Temburong hospital, several observations has been made and are as follows:

1) The majority of the cases seen in the outpatient are very much cases you will see in a general practice.
E.g. Cough & Cold, Headache, General Obstetrics & Gynaecology, Management of Diabetes & Hypertension.

2) Despite Paediatric Cover, there will be a day in the week when the Paediatric On Call will be off the next day, leaving you and the other doctor to deal with Paediatric Cases. (NB Paediatric admissions accounts for 13.3% of total admissions, the majority are medically related adult admissions).

3) Hesitation in management of Paediatric & Medical Emergencies for the surgeons and expecting a paediatrician/medic to handle an Adult trauma case is sometimes a concern.

4) Certain important drugs are not available and some were found to be out of date
E.g. Intravenous Phenytoin for management of prolonged seizure (not available during one of the RIPAS doctors week of duty)

5) There were actually only 27 beds available & functioning (instead of 50 beds)


6) The person On-Call is supposed to do the next day Ward Round alone. The problem arises because the M.O. is sometimes quite junior and inexperience in certain specialty cases like Gynaecology and Paediatrics, but most importantly there is an issue of Continuity of Care.

7) No CME Activity listed or planned for the month

However there are some positive feedbacks about this hospital service

1) There is 24 hour Lab Service & X-ray Service
2) All round pharmacy service
3) The On-Call Room is decent & Clean
4) Good food provided by the hospital (apparently this is not a common phenomenon, if you are nice to the nurses and attendants you might get it I guess)
5) Dr Elangovan, the Senior medical officer is very helpful
6) Small Hospital, therefore very friendly environment
7) Hospital Drivers are helpful in transporting us to wherever needed (very useful when you need to get some food for dinner when you are on-call)
8) Helicopter transportation is prompt and almost 24hrs weather permitting


Taking into consideration that it is a small and fairly remote hospital, it is quite impressive that this hospital is still able to provide a fairly good all round medical service.

Suprisingly although the doctors’ population ratio is huge (5x of Singapore) the in-patient activity only accounts for 2.85% of its total activity, the majority of which is medically related. Below are several issues that have been highlighted and followed by suggested recommendations.

Suggested Recommendations:

1) To incorporate Local General Practitioners into the Temburong Hospital Initiative. This would definitely be beneficial for the population of Temburong. Not only it fulfils the objective of exposing our local doctors to Temburong, but also the added benefit that the majority of illness treated are very familiar to their expertise.

2) Incorporate a period of 1-2 month compulsory placement to Temburong Hospital for all Basic Specialty Trainee (GPs, Surgeon’s and Medics) during their A&E placement, perhaps the last 2 months of their rotation in A&E. However a permanent senior A&E staff (specialist preferably) should be placed in Temburong to ensure training continues for the trainees.

3) To give a Special Allowances for any Health Staff working in remote areas, especially in Temburong district in this case. This is to act as an incentive and appreciate the hardship our staffs have to go through to work at remote places where many facilities are limited, and to recognize that some of them have to leave their family behind to work at these places. Not only will this promote good morale but may even attract health professionals to work in the rural community. The allowances should be awarded to temporary, visiting and permanent staffs at the particular hospital/health centre. The ministry of health can help ratify the rates, so that it is appropriate and always-in line with the standard of living.

4) Provide a simple guideline handbook to management of common Paediatric, Medical & Surgical outpatient & Emergencies.

5) The morning ward rounds should be led by the Temburong doctors every day, to ensure good continuity of care and provide a potential teaching session for the junior MOs. It also promotes the sense of teamwork amongst the Temburong doctors. A timetable should be set to do ward rounds and all MOs should make an effort to come to the ward rounds.

6) Regular update of important emergency drugs.

7) The more experienced visiting MOs can do teaching sessions during their week stay for the Temburong health professionals. This not only gives the opportunity for the permanent staff to score CME points, but also encourages a teaching & learning environment for every health professional.



Conclusion:

In general approximately 97% of the activities in Temburong Hospital are outpatient based and only 2.85% are inpatient work, of which the majority of the cases are medically related followed by O&G and paediatrics.

This raises two important issues, firstly is the proportion big enough to justify having a hospital in Temburong. If it is, then should we allocate more money to ensure that it has adequate expertise, facilities, drugs and equipments. Perhaps we can start by placing a A&E specialist there. I could suggest Dr I.... from RIPAS for a start. Alternatively if it’s not, then we should concentrate on making it a better equipped health centre, with the current facilities that it already has.

However I think the general picture is quite clear from the figures mentioned earlier (derived from Temburong Hospital Statistics 2007) Temburong hospital would benefit from having more generalist clinician around to support the population’s demand of healthcare provisions.

The one-week experience of working in Temburong Hospital has highlighted several issues on how we can better improve the quality of medical services to a small population district general hospital like Temburong. It has also given us the 1st hand experience of working in a hospital environment where facilities, manpower, and expertise are sometimes of limited supply.

The objective to expose our local doctors to our people is most probably a very good step forward not just enriching the doctor’s experience as an individual but also in identifying & highlighting issues for improving our medical services in the future as a whole. After all it is our own people that we are looking after and it is our Health Service that we want to better. My last comment would be, the choice of doctors sent could be better.. ahem.


Btw .. Don't forget to:

1) Be at the RIPAS Jetty by 7.00am for a boat to go to Temburong
2) See the Temburong CEO (Pg Sabtu) on your last day there and ask for the overnight form to claim for your allowances working there

More future Budding Specialists

Congratulations to our latest graduates Membership of the Royal College of Surgeons, Dr Amalinda Suyoi and Dr Amy Thien who recently sailed through (hehe... nda kan?)the final part of the gruelling 3 part MRCS exams at Edinburgh, UK. Both Miss Amalinda (graduated from Nottingham) and Miss Amy (graduated from Southampton) are currently working in the Department of General Surgery, RIPAS Hospital and will be pursuing Higher Specialty Training abroad in their respective field of interest.

Miss Amalinda Suyoi
MRCS (Edinburgh)

Miss Amy Thien
MRCS (Edinburgh)

Also who recently passed their membership exams are Dr Anas Naomi Hj Harun, Dr Yong Chee Kuang (I may get the spelling wrong) & Dr Dk Hjh Norzieda who have successfully completed their PACES of the Membership of the Royal College of Physician Exams last year. Dr Naomi & Norzieda are pursuing a career as Neurology Specialist and Dr Chee Kuang will be training to become an Endocrine Specialists in Singapore soon.

Dr Chee Kuang
MRCP (United Kingdom)

Dr Dk Hjh Norzieda
MRCP (United Kingdom)

So congratulations again to these guys for achieving their exams.. I was just thinking as I'm writing this article, the question why do we need to get our membership exams? Is it absolutely necessary? What is our motivation to achieve this exam? After all it is very very tough... and expensive! Doing the final part of MRCS exam can cost you easily $5,000 bnd! and usually it takes 2 to 3 try to pass.. Is there an alternative around it?

Hmmm....it's quite controversial issue since membership exams only apply to UK recognised Health Care System. What about Malaysia, USA, Australia... does having membership exam offer an advantage there?

In Brunei we have a scheme of service for the doctors and we follow a certain set of criterion advised by the Post Graduate Training Advisory Body. And most of these criterion has been set quite a while ago during our predecessor time. So within the guidelines already set we will see that MRCS, MRCP, MRCGP, MRCOG etc. exams play an important aspect in deciding that a doctor will be entitled to

1) Senior Medical Officer Post & Pay!

2) Ticket to Higher Specialty Training sponsored by the Government

It was one established method of deciding that a doctor has undergone sufficient amount of basic specialty training and are now ready for Higher Specialty Training with more responsibility.

But as training in medicine evolves, newer method of training & assessment has been developed and perhaps the days where Membership Exams will be over and replaced with SEAMLESS training like in Singapore where trainees are chosen right from the start of their post graduate period and undergo a 5 to 6 year period of training straight into a specialty.

In Malaysia the system is slightly different, where you can become a specialist after completing 4 years Masters programme in a particular specialty. What about USA, Germany, Australia, India, Pakistan.. ? I'm not sure how the training is like there but certainly the requirements for training will also be different.

As we get many doctors local and also our expatriate friends coming to work in Brunei, it's necessary that we are able to recognize these qualifications that they come back with and allocate them a post that they deserve and of course the correct pay. Something like a Specialist Accreditation Body like the one they have in Singapore is good start, comprising of local and invited oversea specialist with no conflict of interest, that can recognize and filter the right person for the right job.

Next topic we will discuss the pay of doctors in Brunei, the exact figures according to the current scheme of service according to your qualifications. If you are interested to find out the payscale of the doctors in Brunei from Medical Officer level up to specialist, please tune in next week, after I return from my 1 week duty in Temburong. We will also try to update on the latest with our ON-CALL Allowances...

The Real 'Mat Kilau'

Do you remember the time quite a while ago when Brunei army recruits on some hill in Tutong were struck by multiple lightning strikes ? I think this was last year in March or February. Violent lightning storm it was. I was told that a few soldiers were hit directly by lightning and died on the spot. Many were 'electrified' through water or direct body contact.

About a 4-5 soldiers were admitted to ICU as there were 'bradycardic' but this was a misinterpretation of their normal physiological state. These are fit fighting soldiers hence you would expect them to have a normal low heart rate.

One of the patients there was struck by lightning directly. Note the picture of this patient's chest, right nipple on the left, and white 3^rd degree burn marks into this skin of the chest (gauze is covering the burn area) like a fingers of lightning protruding and burning into the chest. The lightning went into his chest, and somehow did NOT defibrillate his heart and went out the exit wound ie. Left thigh. Note the 3^rd degree burn on the thigh. He was intubated and observed in Surgical Intensive Care Unit for a few days.

Miraculously, this man survived with no internal organ damage. He must have had a low 'resistance' to electricity. Unfortunately, I was told that his colleagues who were next to him died instantly.

This man must be Mat Kilau.

3^rd degree burn on the thigh

patient's chest

Article contributed by Dr Doom

Finger Trauma

These are actually two different patients with what I would call 'Avoidable' trauma to their hands! The reason why we choose to post it this week is to highlight some important lessons that can be learnt from these cases.

The first picture is a 35 year old male who had this infected little finger 2 weeks before presenting to A&E RIPAS. If you were a casualty officer apart from giving him a good telling off for not coming earlier what would be your next treatment plan? By the way it's a ring on the little finger just incase some people are wondering.



This should be an easy one too. What is wrong with this hand x-ray? This is a result of someone trying to escape from the 2nd floor of a house using a rope... tsk.. tsk.. tsk.. Bad Rope!

AED for the public

About 2 months ago we posted a story of a male patient who suffered a cardiac arrest whilst performing friday prayers, but was revived because 3 doctors happened to be around and a Defibrillating machine was available in time.

AED (Automatic External Defibrillator) is a life-saver and should not just be available by the paramedics and hospital, but should also be available at all peripheral clinics and even public areas, such as the mosque, shopping malls, stadiums & popular recreational parks. You never know when this handy little machine can save someone's lives... it could be your beloved ones.

Our neighbouring countries like singapore have already taken steps to ensure this. If you've been to Singapore you may have seen this machine at the shopping malls.

AED machine in Takashimaya

AED machine in ISETAN

Swelling at the Wrist

This is an interesting case of a 64 yr old male who presented with a Four year history of swelling at his wrist. Apparently in some parts of the world this is quite a common and significant sign of a serious illness, which has gradually reduced over the years. Nevertheless if you see this in your clinic there should be 2 important diagnoses that comes to mind.. What are they? What is the name given to this particular swelling?

The above is a radiograph of the affected wrist. If you were thinking along the correct path, you probably would have asked for a chest x-ray. What do you think?

Answers will be posted next week.


ANSWERS:

1. The two commonest differential diagnosis are Tuberculosis & Rheumatoid Arthritis

2. The name given to this swelling is Compound Palmar Ganglion

'The Culprit'

Immediately post-op
Surgeon: Dr Phillip, Assisstant: Dr Herry Zul

The histopathology came back as Tuberculosis and it turns out that he actually had this swelling and cough for more than 4 years already.... suffice to say that he is currently on anti-TB medication.

BMA Roadshow

The Brunei Medical Association (BMA) aims to represent the voices of the Doctors working in Brunei Darussalam and will strive to unite all the doctors from various specialties including the Dentist. One of it's first main priority is help improve the welfare and wellbeing of the doctors here by addressing certain issues at heart, one of which is the On Call Allowances that has been in air for sometime. This was echoed by the interim President Dr Hjh Susalnoor when briefing the doctors at the BMA roadshow held at RIPAS Hospital recently.

Dr Hjh Susalnoor

The talk was also attended by Dato Paduka Dr Hj Abd Latif (Special Duties Officer at the Ministers office), Datin Paduka Lim Meng Keang (Specialist Paediatrician), various heads of department from RIPAS Hospital, Dentists and trainee doctors.

Some of the doctors attending the talk

The first step after recruiting new members would be to hold an election and elect the 8 members of the Executive Committee which includes the President and Vice-President. These committee will bear the tough responsibility to unite it's members and address the issues concerning them. Only members are allowed to nominate and vote who will sit at the executive committee. These include all GPs (government & private), Dentists, public health and hospital doctors. Doctors holding administrative role (HOD and above, including DG) will not be eligible to be nominated according to the current BMA constitution. Every members will be updated via e-mail regarding the nomination and the date of election which would be in the next couple of months.

If you are interested to become a member a copy of the registration form can be e-mailed to you.

p.s. Special Thanks to Tracey of GSK for sponsoring food that afternoon, but next time it would help to deliver the food at the right location... like RIPAS and not JPMC! Yep a few stomachs were growling towards the end... :-)

BRUNEI MEDICAL ASSOCIATION LAUNCHING SOON!

A group of doctors from various specialties have began efforts to re-launch the Brunei Medical Association (BMA), which will act as an independant body that can represent the voice of doctors working in Brunei.

Currently led by the Interim President Dr Hjh Susalnoor, the interim committee will begin to distribute information and for ALL doctors and dentists who are interested to know more about BMA there will be a briefing done on the 13th of March at RIPAS Hospital, 2nd Floor Lecture Theatre during Lunch time.

The objectives, role and details of it's constitution will be elaborated more in detail during the briefing, so do come along if you are free this Thursday Lunch time.

Application forms to join the BMA will be distributed then, or alternatively via e-mail.

Medical Officers to be sent to Temburong

The latest news on the block is that ALL local RIPAS doctors (medical officers only) will be ordered to go to Temburong hospital and take turns to work there for a week. A schedule beginning march 1st has been distributed and every department are suppose to take turns and nominate their MOs who will be sent to Temburong that week.

The objective of this 'exercise' is to allow local Junior doctors to be exposed to working in a hospital environment apart from RIPAS, and allow oppurtunity for the junior doctors to be interacting with patients from other districts closer. It is hoped that after this exposure, some doctors would be more attracted to work at other districts hospital apart from RIPAS.

Since it's announcement on the 19th February, the move has not been met very favourably amongst many of the junior doctors. Though the objective of this mission is understandbly noble and necessary, as it is quite apparent the lack of local doctors working not just in Temburong, but also in Tutong and KB.

However some of the doctors believe that the decision to send the doctors away for a week is a little bit on the hasty side, and some even voiced concerns about doctors looking after other specialties at which they are not trained for and there are no specialists mentor at the hospital site (Temburong), to guide them.

Others mention concerns about doctors who have been trained in their specialty field for so long and not seen an ischaemic ECG for many years to correctly diagnose one, or doctors who will be asked to examine patients of a different age group than the one that they are routinely used to.

All these are valid concerns, but nevertheless the objective of the 'exercise' is also equally important. Further discussions between the doctors and the administrators are to be planned this week. What is your say?

Well Done Docs!

It was only moments before the friday prayers sermon, a 72 year old male collapsed following a cardiac arrest at the Serusop Mosque in Berakas.

Thanks to the quick response from 3 good samaritans, prompt resuscitation was delivered which saved the man's life. We would like to acknowledge these 3 fantastic young local doctors for their heroic effort, and convey huge gratitude from the patient and his family.

Well done Dr Nirwan (Navy), Dr Fakhruddin (RIPAS A&E) & Dr Ahmad Fakhri (Public Health)!

Dr Fakhruddin

Dr Ahmad Fakhri

The story unfolds...

Mr I was a 72 year old male with a history of Hypertension and Hypercholesterolaemia. As usual he was about to perform his friday prayers at his local mosque when suddenly he felt unwell and collapse. He was brought aside and help was called upon. Dr Nirwan, who was about to join the prayers was first to arrive at the scene and assessed the situation, quickly followed by Dr Fakhruddin. After confirming it was a cardiac arrest, CPR was initiated immediately. Dr Fakhri arrived at the scene moments later to lend assistance and the paramedics arrived bringing with them the defibrillator, soon proven to be another life saver.

As soon as the leads were connected, Ventricular Fibrillation (VF) arrest was diagnosed and shock was delivered immediately. Normal Sinus Rhythm was regained but Mr I was still apnoeic. Manual ventilatory assistant was continued as Mr I was transferred to RIPAS Hospital by the paramedic team.

Upon arrival, Mr I was intubated and admitted to Intensive Care Unit where again he had another VF arrest which reverted back to Sinus rhythm after receiving another shock.

Grave prognosis was feared for Mr I, as the survival rate for out of hospital cardiac arrest is low. It is estimated that less than 60% of cardiac arrest will survive hospital admission and only about 12% will regain full neurological recovery, if resuscitated on the scene.

Alhamdulillah, praise to god almighty, within a week Mr I was extubated and 2 weeks after his admission, Mr I was discharge from RIPAS with full Neurological Recovery.

In the most recent literature, it is estimated that the survival rate of Out of Hospital Cardiac arrest event which did not received CPR on site was 7%. This is improved to 9% with good CPR.

However the rate is significantly increased up to 30%, if the patient received a shock with an Automated External Defibrillator (AED), (Hallstrom AP et al. N Engl J Med. 2004;351:637-646).

Having AED and equiping the public about using the machine and performing CPR do save lives as demonstrated in this particular event.

We support the idea of having AED machine in public areas such as the mosque, shopping malls, stadiums and recreational park. This paired with increase awareness and knowledge of the public on how to perform CPR may help save another life in the future.

Finally well done to the paramedics, Accident & Emergency staff, the Intensive Care Unit and the 3 doctors on site, Dr Nirwan, Dr Fakhruddin & Dr Ahmad Fakhri, for their outstanding work.