A young man was brought in after he came off his motorcycle. He was conscious and breathing well but in shock (very low blood pressure) and pale. A quick examination reveals that he has a guarded abdomen (this means that the abdominal muscles are tensed up and indicates that there is some irrritant in the abdominal cavity, in this patient, probably blood.) He also had broken both femora (thigh bones). These injuries could kill if not attended to speedily.

After initial resuscitation, he was taken to operating theatre and a laparotomy (surgery on the abdominal cavity) was performed. He was found to have a ruptured colon. It had spilled its contents (faeces) into the abdominal cavity, soiling it. “Dilution is the solution to pollution”, my mentor used to say. The abdominal cavity was washed out with plenty of warmed fluid.

There was a large hole in the colon, so direct repair was not safe. There were 2 alternatives: 1. resect the affected portion of the colon and anastomose (re-join the colon); or 2. bring the perforation out to the skin as a stoma.

Since he was unstable, the stoma was a rapid and safer option. A “stoma” means an “opening or mouth”. A “colostomy” is an opening from the colon to the skin. This was done to divert the bowel spillage externally and allow the contamination in the abdomen to resolve.

This particular colostomy is a “loop” colostomy. It means that a portion of the colon is brought out and opened without disconnecting the two ends. After a period of a few weeks, when the abdominal inflammation has resolved, the loop of colon will be released from the skin, closed and returned to it’s normal location in the abdomen.

I just read about Dr. Norbaizura Yahaya’s story in the Star. This is a sad event. My condolences to the family.

The Ministry of Health does not provide any mechanism to compensate junior doctors in the event of an injury or death due to an accident while on duty. Whenever, patients need to be transferred from one facility to another, an appropriate personnel will accompany the patient. If the patient is very ill, a doctor needs to go along. There’s no complain about that, it’s all in the line of duty.

I recall my medical officer days in Sarawak when we had to transfer patients to another hospital. The ambulance run took 2 hours each way by pot-hole infested, winding roads, usually going above the legal speed limit, often in the dead of the night. Sometimes the driver had to go 2 trips in a row. That’s 4 hours to-and-fro twice. Can you imagine how tired he must have been?

Once, an ambulance went off the road. The driver and the patient were killed and the accompanying nurse became paraplegic (paralysed from the waist down). Treatment was, of course, free of charge. However, there was no accidental insurance coverage for them.

Usually the most junior doctor in the hierarchy will be the one to accompany patients during transfer. Being a junior officer in the civil service, before confirmation, these doctors are not eligible for compensation. Only the officer’s own personal accident insurance will provide the relief for the family.

What’s more, I remember the days when we went of flying service. Doctors and medical teams fly frequently in Sarawak’s Flying Doctor Service and medevac services. Medevac heli’s have crashed before. They are not immune to the laws of gravity. The helicopters employed for these services are chartered aircraft. If you’ve read your personal accident insurance, you’ll notice that chartered flights are not covered by most P.A. policies.

I wonder what the Ministry of Health has done to alleviate the uncertainty of junior doctors and other pre-comfirmation medical staff in terms of compensation when accidents happen.

Okie… who can spot the hidden mickey? (Those of you who have kids of Disney-Channel-watching age will know this favourite clip.) Or the hidden appendix?

Firstly, the appendix looks inflammed (red, swollen and angry.) During laparoscopy, however, we have the advantage of motion and the ability to look at the appendix from various angles. Plus, we can hold the appendix in the forceps and follow the appendix back to its base. But here, on this photo ( the same one as the previous post), I’ve outlined the appendix with a yellow line; in true hidden mickey routine. (Open the single post view.)

The appendix is a worm-like structure attached to the first part of the colon (a.k.a. large intestine), called the caecum. It’s function is to assist in defense of the body against infection, much as tonsils do. When the appendix is inflammed, it called an acute appendicitis.

What happens to an acute appendicitis if an appendicectomy is not performed at this point in time? There are a few scenarios that may follow. The appendix may burst into the general abdominal space (called the peritoneal cavity). This is the worst scenario as the patient will become very sick, very quickly. Alternatively, a fat-laden structure in the abdomen (called the omentum, a.k.a. “the abdominal policeman”) may move to the the appendix are and wrap up the appendix to prevent it from bursting. This results in an appendix mass (=lump). Eventually, the appendix may be “eaten up” by the body defense mechanism.

There is a third scenario. If the appendix bursts inside this walled off area and pus collects, then an appendix abscess occurs. This is different from an appendix mass because there is active inflammation and pus formation going on. The patient is in persistent pain and may be having fever. Appendix abscesses are usually treated by surgery to remove the remnants of the appendix and drain the pus. The patient will usually require a course of antibiotics.