Cause of Death was?

today's class opened up another window for thought.

Medico-legalism. in the world of Forensics.

Ensuring you're protected.

Affording yourself protection.

(just a word of caution that the word dead and death will be mentioned numerously in this post. hope it doesnt cause uneasiness)

Doing an autopsy as a forensic specialist doesnt start with dissecting a patient - a body i mean. saying a patient sounds like he/she's alive.- and using all your years of expertise to analyse the cause of death and injuries on / in the body and then writing the autopsy report. This part, would be what most of us think as the most important part or the part that matters most. Determining / Confirming the cause of death.

Nope. Not really as I thought.

It starts with:

the Dr. in charge correctly identifying the person to be dead.

so i thought: ok that should be easy.

and then the Dr. asked: So, tell me, how do you know a person is realllllyyy dead?

*hmmmm.... awkward silence..

Answer:

There're 7 criterias that confirms a person to be dead:

1. No body movement

2. No respiration

3. No pulse / heart beat

4. Pupils fixed and dilated

5. Fragmentation of column of blood in retinal vessels

6. Primary flaccidity of limbs

7. ECG flat for more than 5 minutes continuously.

Misjudging the death of a person can bring a Dr. to face lawsuit. even pronouncing a person to be dead at the wrong time can bring you to court.

(most of us would think, sure, if a Dr. wrongly pronounced some1 who's still alive as being dead, that would be a really grave mistake that acceptably warrants a court case)

i do agree with that. but there're more technical things that we can worry about as well.

there was a case whr the Dr. clinically judged (without ECG) that a person was dead before arriving at the Hospital (as in he was dead already at the crime scene before being brought to the Hospital). the Dr. did, upon the arrival of the victim at the hospital, confirm his death with the ECG (showing the flat line).

later in court, the Dr. was bombarded by defense lawyers (of the suspected murderer) who tried to make the Dr. look incompetent for saying that he thought the person was dead before reaching the hospital.

with the reason that he couldnt be 100% sure of that (whether the victim was dead before reaching, or upon reaching the hospital) cz his clinical judgement cannot beat that of an ECG machine.

yups...

ok maybe that was quite confusing.

but conclusion is: be especially careful if u're facing a homicidal case. only officially confirm death when the ECG machine is there.

standard protocol when pronouncing death.

1. check that patient has fulfilled the 7 criterias. report as 'clinical death'.

2. reconfirm the death 1 hour later. then only register the death with time of death being the time 1 hour earlier.

before this bores u to the bones, thr's more. :P

Before performing the autopsy:

1. Ensure the police officer bringing in the body, the relative / next of kin of the body (is there for identification purpose and consent for autopsy) and yourself are there beside the body.

2. snap a photo where all can be seen clearly.

(to protect urself from false claims by the relative that he was not aware or explained to about the autopsy. relatives have tried suing Dr.s, accusing them of performing autopsy without their knowledge)

3. snap a photo of the next of kin looking with opened eyes at the body.

(eyes cannot even be closed in the photo cz in court they can say they were in too much stress to correctly identify the body and u as the Dr. who's not in apparent stress at that moment is at fault) - in cases of suing the Dr. for wrong identification of body.

now i think i just made the 'relative' sound like unethical ppl who would do anything to swindle ur $$ by suing you in court at any opportunity. no offense. not my intention at all.

but things like that have happened before. (innocent Dr.s performing autopsy, forgetting a protocol, ending up in court and swindled from their life savings) and can / is likely to happen in today's society where things do get screwed up, ill moral is everywhr and $$ matters a lot to most of us.

putting legal issues aside, i'd say that the forensic lectures did feel a little like watching the Professor analyse dead bodies CSI style.

wow. quite awed. but quite grossed out as well. lol >8P

wasnt mentally prepared to see images of mangled / strangled / suicidal remains esp right b4 dinner.

ok. that aside as well, it's been a pretty good week. 1st week in psychiatry has been relatively relaxing cz no assignments/presentations/case write ups due yet. missed home and taiwan so much last monday but the feeling has somewhat diminished. thank goodness. hav a great wkend ev1! :)

some photos: my housemates in our 4-person sharing unit in the taiwan hospital hostel (min jie, pei sun, wendy)

a group photo in front of the administrative office. the white coats for medical students are this length. residents@registrars wear slightly longer 1s, and specialists wear knee-length white coats like our med students ones back in Msia.

come to think of it, thats a pretty good way to differentiate ranks which can be really confusing for patients. hehe. sometimes patients wonder how come 10 different Dr.s visited them in 1 morning when in actual case 9 of them were medical students. heheh.

Rants

i'm in a mess. i'm not sure if i should emo about

1. missing taiwan- the friends, the serenity, the people, the shopping, my cousin and his wife penny, the hospital, the friendly dr.s and staff

2. starting the term tmr - tho i'm quite excited about starting psychiatry cz its an entirely different posting and quite interesting. just that missing taiwan kinda kill joyed the excitement of starting this new posting.

3. the absurdness of msian issues - the Obedient Wives Club promoting sex classes to enable women to 'serve' their husbands better. it's so absurd i just do not have the energy to comment on it. i don't know where to even start criticizing the way they execute measures to highlight the principle they stand on. like it wasnt bad enough, they had to bring in 1st class prostitutes as a comparison. any educated person would know that you didn't have to go to the extent to bring up prostitution to make your point. so why draw prostitution into the picture. as a mere gimmick to illustrate women as sex objects? ridiculous. all drama.

4. unpacking my luggage and cleaning up my room - dont we all resent this part. heh.

5. missing home. i wish i had another week of holidays to go back to kuching.

that's bout it. i still cant decide which one of these 5 things are most worthy to emo about lol. but by hook by crook i gotta finish unpacking real soon if i wana get some proper sleep tonight. yargh.

last few thoughts in Taiwan

i reached the official end of my 3 week elective posting in the Tzu Chi Hospital and left with a pang of sadness. heh. i'll miss that place. particularly bcz the surgeon i attached with in this last week was most kind, patient and really fatherly. he specializes in Breast and Endocrine Surgery and has taught me a lot about reading sonograms and mammograms in clinic and the OT. even allowed me to scrub in for a thyroid surgery. that's another story grins i was creating a mini chaos in the OT with the scrub nurse and anaes dr. trying to instruct me in mandarin to make sure i donned on the sterile apron and gloves correctly. extremely pai seh...

i previously mentioned i had knowledge ego problem lol hee and had loads of trouble reading chinese characters off the computer etc. i had wanted to give up and go back to msia to tell juniors who were so called bananas like me not to do an attachment in taiwan. but i've had a change of mind. :D

i seriously learnt a lot in this hospital. not just knowledge wise, dissecting ecg charts and x rays and ultrasounds (still horrible at it but less blur), but humanity wise.

the nurses and dr.s here treat the patients really really well. the rapport established is extremely strong and the patients love their dr.s. ev1 treats one another with utmost respect. ev1 greets each other in the hallway / wards / lunch place. regardless whether they know you or ur status. i never saw enough of this back in msia.

and technical barriers can be overcome. hehe. its also partly bcz i've got friends doing the attachment with me and helped me a lot in reading signs and all that. i'm not sure if my mandarin improved? grins. but i picked out (not up) some taiwanese accents that i find pretty amusing teehee. so... i think i would really recommend ppl who are even tho partial bananas like me to come attach here. :D

owh! and i found a cousin i've never met before in taipei. huge surprise lol. but extremely pleasant. heheh.

its my last day touring taipei today b4 i head home and start sch again. i'll miss this place. XP

starting 4th year with psychiatry. wish me luck. :P

Ergonomic?

today we visited the Tzu Chi temple/headquarters in should i say the heart Hualien? hehe. and did some voluntary work there. it was a privilege and an honour to be able to meet the founder of the Buddhist Tzu Chi Foundation, Dharma Master Cheng Yen in person. she was really friendly and welcoming :) we split into 2 groups to work on 1. gardening - the foundation has their very own vegetable garden where they mass produce their own organic vegetables. great for a very healthy lifestyle.

2. and secondly, in the Dried Rice factory. we did packaging work.

being air-con loving and having extremely enthusiastic outdoor loving friends teehee, i ended up in the 2nd group doing packaging indoors. now this is a 1st hand and 1st time experience working on packaging in a factory. (it wasnt really a factory la actually cz the condition was pretty comfortable and it was air coned. :D) so throw away all images of a dusty grey room filled with machines.

now after about i think 4 hours more or less of standing and sorting out packages + sitting down packaging small packets of dried rice + preservatives + flavoring working on a low table, i say:

SALUTATIONS to all factory workers in this world.

*thundering applause*

midway process i was suffering from:

1. superficial scratches on my fingers

2. boredom

3. stiff neck - cervical disc prolapse alert!

4. freezing arms (ok lar i hav no reason to complain about this 1 hehe)

note note: i am in no way complaining about the work. i was really happy to help out and after how much the tzu chi foundation has been helping me, giving me the opportunity to do my elective posting in their hospital, this is just sth really minor i can pitch in to contribute. plus the ppl are really nice and hospitable.

i'm just illustrating what a factory worker goes through in her workplace. :) dont get me wrong yeah :P

now i really know how important it is to establish a safe and comfortable working environment (cue Public Health posting hehe) esp, for blue collar workers. most of us have taken for granted that hard manual labour = suffering uncomfortable conditions

not so after all. and shouldnt be the case.

even hard manual labourers should be afforded and given the best (meaning safest, least ergonomically hazardous) working environment.

1. gloves to protect the hands

2. tables / chairs at the correct height to avoid painful neck bending for long hours

3. necessary safety precautions

4. music? to soothe the senses hehe. or varying jobs for the worker once in a while.

i wont go into too much of that in detail. most of us do know what needs to be done to form an optimal working environment. reducing risks via reducing hazards and exposure.

let's just not forget about helping and giving others the most humane working environment we can afford them when we are in the position to. :)

From Where I Am

being in a foreign land makes the heart grow fond of home.

truth to be said, i'm homesick. lol.

it all boils down to being optimistic or otherwise i guess. cz everything has its ups and downs, pros and cons, challenges and sweet memories.

i'm currently doing my elective posting in Tzu Chi Hospital in Hualien, Taiwan. now most ppl paused for 1 second for the msg to sink in, then open their eyes real big and ask,'dont u hav2 speak mandarin in Taiwan?' n i'd say 'awww come on, my mandarin has improved over the past year with me being forced to practise speaking to elderly chinese uncles and aunties in the hospital... i'll survive.. it cant be thatttt bad.'

3 days into the posting, (in internal medicine, Respiratory) i've been complaining non stop to my friends about hitting my mandarin quota, listening (mostly) and communicating in mandarin. on my 1st day i was utterly lost, blur, slightly miserable at being unable to read the instructions on the computer, building signs, not understanding what Dr.s are discussing in seminars esp when they discuss management cz they use a lot of mandarin medical terminology.

plus the style of teaching in this medical school is really different. every student gets attached to one supervisor. 1 to 1 or 2 to 1. they are given 2 patients each and they plan out the management, write case notes like a houseman for that patient. every morning they consult their supervisor about their patient and they offer suggestions on Diagnosis n plans to the Dr.s, even if the Dr. is like an MO or Specialist.

now think what would happen if i tried to offer management advice to a specialist back in msia. *shudder*

the Dr.s take in every suggestion seriously. and explain to the student the rights and wrongs of that decision etc. in a super nice non sarcasm filled way. this makes their students very voluntary in offering suggestions and answers when questioned. the students tag the Dr.s like 8am-5pm every single day unless they have classes. WOW...

i was taken aback at this culture n it took me some time to get used to it. found it extremely pleasant. n the Dr. even requested every1 else to communicate in English bcz he knew my mandarin's horrible.

the dr.-patient relationship here is really amazing. super ppd skills alert!

however, i find myself spiralling down into depression bcz i feel so inadequately equipped with knowledge compared to the students here. gosh. the students here are like super whiz kids with compartments in their brains for physiology, patho, pharmaco, everything.

the Dr.s are extremely nice and understanding and give leeway for my dumbness tho thank goodness. bt that doesnt take my ego of feeling miserably dumb away. lol. i went through a cardio lecture today where we're suppose to identify heart sounds. now in UKM the Dr.s say u dont hav2 go into too much of details, MR/MS/AR/AS is enough. fullstop. here, u have to be able to identify S3, S4, gallop rhythm, ejection sound etc.. they identify murmurs without timing with the carotid pulse. nt sure if that's a good thing, but, big wow.

but thr's a different side to it i guess. while Msian universities place emphasis on History taking and PE, the hospitals here focus on Diagnosis, Investigation and Management. CT scans are really really common. n students here know how to read ecg (super detailed, even those uncommon stuffs they know), xrays, ultrasounds, PET scans, CT scans almost like a pro. they were given very detailed classes on it and study it with detail as well. another wow.

there's 2.5 more wks to go in this elective. but as i mentioned in front, although i do know it really is beneficial and certainly good exposure, i miss home. where familiarity breeds comfort. i guess that;s how it feels when i start working whr the environment's going to be totally different too. maybe its just bcz i've not been in any transition period for a long time, the last 1 being my 1st sem in uni. been in my comfort zone for too long. n i miss church. heh.

home, home. how i long for thee. XP

New Discoveries

Just had a tour around Kuching for the past 3 days together with Pei Sun, her sis and her parents. They are extremely good touring company. XD

perfect excuse for me to savour all i-dare-say healthy Kuching delicacies annually. :D

even tho this was my 4th time touring Kuching over the past 3 years, i still keep discovering things i didnt know about this lovely city i call home.

1. We visited the Semonggoh Wildlife Rehabilitation Centre today in search of orang utans. a few facts that were new to me today.

- 1st of all i kept calling it Semonggok n only realised its correct name today. lol.

- Feeding Time for the orang utans are at 9-10am & 3-4pm. so if u're planning a trip here, u'll wana arrive just slightly before the feeding time :)

- The orang utans had really awesome names.

There's a female orang utan nicknamed Hot Mama due to her temper (not bcz she's irresistibly attractive to the males). Later after the hype only we rmbed her name's actually Delima. the park guides have great sense of humour :D

A dominant male orang utan called Ritchie who caused 2 fingers of George (another male orang utan) to be bitten off and poor George to be sent off to the Matang Wildlife Centre to separate the two.

and a female dubbed The Grandmother cz she's oldest.

one can never get bored watching the antics of these primates that are so irresistibly adorable, esp the babies! awww......

-The centre has 20+ orang utans. They are orang utans seized by Immigration Officers from poachers / smugglers and thank goodness, saved.

- and it's a lot nearer than i thought from my house and very easy to find. :D

2. I never knew there were that many Vegetarian outlets in Kuching. Pei Sun's family is vegetarian. so as we cruised around town, we started spotting more and more vegetarian restaurants around. We tried only a few, but out of those we tried, i have some good reviews.

- Popular Restaurant on the same road as the Air Asia Office opposite Swak Plaza, but much further down nearer to the Padungan roundabout. for restaurant standard, ordering dishes chinese styled.

- Beside the police station on the same road as Hong Kong noodle house in Padungan. 4got the shop's name tho. :S but it's vegetarian laksa, kolo mee, tomato noodles are not bad :P similar to non vegetarian 1s. it has kueh chap too , much to my surprise :P cz i didnt noe they could have mock pig intestines. hehe. bt it tastes different, more like bak kut teh. so i was glad they could all have a taste of Swakian food.

so if u've got vegetarian friends / am craving for vegetarian food, these are the places to be.

3. and rediscovered many routes around Kuching as i drove, drove, drove. :P

when i was small -yes in age and size- lol., i used to think that a 30 min drive down to the Damai Beach was horrendously long and super tiring.

after being in kl whr getting u to a destination requires a minimum time of 30 mins, a drive to Damai Beach felt like a drive in KL on any ordinary day. and much more pleasant with long endless empty roads and lots of trees. hehe. thank you KL for developing my travel time tolerance. :P

as the tour reached its end, nostalgia set in. i miss sunny and family already! she claims ownership over a certain Hill in Kuching selling ice cream. 8P

and its time for me to leave home once again. tmr.

sad..... :S

The Bridegroom

Ps. Dennis mentioned sth more important than the royal wedding this morning.

Wouldn't it be more exciting anticipating the arrival of our heavenly bridegroom Jesus Christ?

Meeting this glorious bridegroom in a wedding matching the grandness of heaven?

How mystifying, wonderful and astounding it would be.

Just to explain a little about the use of reference to Jesus as the bridegroom and the church as his bride as in the bible:

Taken from: http://www.followtherabbi.com/Brix?pageID=2097

In order to communicate his deep love for us, Jesus described his love in terms of a family community. He compared himself to a bridegroom who paid a steep price for his bride and then went to his Father?s house to prepare a place for her.

Jesus made this comparison especially clear during the Last Supper. Taking a cup of wine in his hands, he told his disciples, ?This cup is the new covenant in my blood, which is poured out for you? (Luke 22:20).

No doubt his disciples immediately recognized the imagery of a marriage proposal. And they were able to picture the depths of Jesus? love—a love so deep that Jesus made a covenant with them and was willing to give his life for them.

By using marriage imagery, Jesus said, in effect, ?I love you as my bride, so I?ll pay the bride price. I?ll give up my life for you and to go my Father?s house to prepare a place for you. And one day I will return and take you to be with me forever.?

Writing to the Corinthians, Paul used the bridegroom picture as well: ?You are not your own; you were bought at a price? (1 Cor. 6:19—20). His words reminded Jesus? believers that they were his brides-to-be, waiting for the day when he would return and take them home.

For more information, you are encouraged to refer to the above website.