Working in Brunei Darussalam

I came across this article about working in Brunei Darussalam, which was published by Pakistan Journal of Medical Sciences. It is a very interesting read about the experience from an expatriate doctor, about working in Brunei Darussalam, and I thought I'd like to share it with our readers.

Hopefully it will give a better insight to other doctors who wishes to come and work Brunei.

Here are the links

http://pjms.com.pk/issues/octdec107/pdf/brunei.pdf

http://pjms.com.pk/issues/octdec107/article/bc3.html

Hospital Medicine Career Pathways + Current Doctors Salary in Brunei

I think this flowchart best summarizes the different career pathways available in hospital medicine, that Brunei Government recognizes at the moment for our doctors. On the left hand side you can see the pay scale corresponding to your grades and your required qualifications in the middle column. Other Post-Graduate qualifications are not included, because it seems to be quite variable at times. We are not sure why this is so.. just an observation. Probably best to direct that questions to the PGATB and relevant authorities.

Also to note is that only Housemanship/Foundation year and Basic Specialty Training (BST) programme are available in Brunei at the moment. For AST, Seamless training pathways and other equivalant, you'd have to go abroad to places like Singapore, Australia, UK and the US.

At least this information will be most useful to our undergraduates whom are still studying abroad especially for those planning to stay in hospital medicine. For GPs and Public Health this flowchart does not apply. Please note that our undegraduates from Australia & New Zealand will be considered the same like UK.

This information is the based on the current scheme of service. Please bear in mind that this does not take into consideration the New Scheme of Service which we're still working on with JPA and it hasn't included the On-Call Allowances which is still awaiting it's implementation.

Xray of the month

Male 92, unable to remember fall, wounds on forehead and wrist, neck pain. No neurological deficit. Whats the abnormality?

courtesy of rpullinger, BMJ.

Application for Renewal of Licence to Practice - from Brunei Medical Board

Dear Doctor,

Application for Renewal of Licence to Practice

The Brunei Medical Board would like to inform you that all Medical Practitioners and Dentists in the government sector need to apply for renewal of licence to practise by 1 December 2009, for the year 2010.

Please find attached the application form to be used, which is to be returned to the Brunei Medical Board before 1 December 2009, with the following:

1. Two recent passport photographs

2. Evidence of 30 CME points in the past 12 months or from 1 September 2008 to 31 August 2009. This will normally be in the form of the CME log book and supporting certificates

3. $50 fee in cash, which will be waived if the complete application is received by the Brunei Medical Board before 1 December 2009

The form can also be downloaded at http://www.moh.gov.bn/bruneimedicalboard/regform.htm

This form will also be coming to you by post, in case contact by email fails. I would be grateful if you could ensure that your colleagues and those under you also know about this requirement to renew licence to practice for next year.

Yours sincerely,

Dr Melanie Chin

Secretary

Brunei Medical Board

Ministry of Health
Commonwealth Drive
Bandar Seri Begawan BB3910
BRUNEI DARUSSALAM

Email: bmb.brunei@moh.gov.bn

Tel: +673 2 384 182

Festive season's mishaps

This year we did not get any serious 'fireworks' accident or 'sugar-cane machine' crush injury like we used. Perhaps increased public awareness kept these occupational and home injuries at it's minimum. Unfortunately Road Traffic Accidents are on the rise and we've had at least two major accidents just during the fasting month, where in one of them a husband lost a wife and his 4 children ended up with multiple fractures of long bones.

The public has been warned about Safety whilst driving incessantly, No talking on the phones, No texting, No cutting corners, No drinking alcohol, Keep to your speedlimit, Safety belt.. but still these accidents do occur. The sad things are, the culprits escape with moderate injuries, the innocent law abiding road users lose their precious ones.. how many times have I seen this is .... one to many.

Anyway please guys... becareful on the road.

This time we feature some interesting mishaps that occured around the festive season. Perhaps some lessons could be learnt from them...




You may have heard recently on the news about a young child who was the victim of a kite string accident. The above picture is the neck of the child which got caught in kite string. Unfortunately the string was directly at the child's path as the child was cycling through a residential area. It was so sharp after being treated with broken glass (a common practise amongst kite enthusiasts) that it severed the Sternocleidomastoid and Superficial veins. Luckily it missed the arteries otherwise it would have been a different ending. The surgeons repaired the injury and the child now has been discharge home.

Moral of the story: Don't treat you kite strings with smashed broken glass, you never know what or who it might injure....


This was an elderly lady presented to Accident & Emergency department with a gangrenous finger. The story, it was bitten by a cray-fish a month ago and was treated by a private GP with oral antibiotics. A month later the swelling persist and the RINGS in her finger is still there!! Ofcourse the blood supply to that digit is completely obliterated by then and the finger developed dry gangrene.

It still baffling how this was kept at home for 1 month until it came to this stage. It took a double action ring cutter to remove the rings, but eventually the digit was amputated anyway.


Moral of the story: Remember to Remove your rings at your fingers if its stung or injured!

What happen to our On-Call Allowance?

6 months ago JPA (Department of Public Service) approved the doctors On-Call Allowances, through its memo to our ministry dated March 2009.

About three months ago a form for applying the on-call allowances were released by the Finance department at the Ministry of Health via our CEO's office. It was claims for the month of March, April and May. The forms was filled and handed in.... 3 months later we're left wondering what happened to our claims...

March On-Call Allowance form

Doctors Mess approach a senior officer at the Ministry to ask some questions and Here's our answer my dear doctor friends....

Apparently NO on-call allowances will be given yet, because there are no allocated budget for it .... as yet. Yes the oncall allowances have been approved by the highest authority, and permission has been granted through JPA for the ministry to proceed with the on-call allowances... however the Finance department is still figuring how to 'correctly' award the on-call allowances to the doctors.

So what about the forms that were filled in 3 months ago for the month of March, April and May? Well it turns out it was only a "PILOT" study to gauge how much the ministry will be spending on On-Call claims. So who's idea was this pilot study... BDMC found out it was the Finance Department..

Before I elaborate on some of the querries brought forward from the "Pilot" study that was done where None of us were told about, let me just elaborate on the different type of On call allowances that you are entitled to claim.

There are 3 types of on-call allowances, Resident On-Call, Non-Resident On-Call and Consultant On-Call.

1) Resident On-Call are given to those who stay in-hospital during the 24hr On-call period, mainly Medics, Surgeons, Orthopods, Anaesthetist, Gynae, Paeds & ICU. The rate depends on their grade whether it's Medical officer or Senior Medical Officer.

M.O. - $11/hr

SMO - $14/hr

2) Non-resident On-call are given to those who are on-call from home. e.g. OMFs, ENTs, Opthalmology, Neurosurgeons. These doctors will have to claim the hours they come to hospital only and attend patients. Calls taken from home are not counted apparently. The rates are similar to the above.

3) Consultants/Specialists Oncall are given only to specialist. Its fixed amount of $1,250/mth. However If you are Acting Specialist, you will only be entitled SMO rate and you get paid only when you come to hospital.

We overheard Several querries were brought forth, I thought we'd share with you some of them:

1. Some doctors were claiming to be on-site when they are not.

2. How do we know if the doctor claiming for 3 hours duty, actually came for 3 hours?

3. Some specialists were claiming on-site oncall allowances, although their on-calls are fixed.

Well, firstly we think the Pilot study was a bit on the unfair side. It's fine to do a pilot, but at least let us know so that everyone understands there will be a long delay.

Secondly, the doctors claiming wrongly, would probably have been avoided if there was a proper briefing held by the Finance department on How to Fill in these forms.. If you have a look at those forms, there is no way to differentiate between who is on-site and who is not. How do you expect the doctors to fill in the forms correctly.... if no body actually tell them how to? It is not surprising that some of the doctors would have filled them incorrectly..

Thirdly, the claiming of correct hours can be overcome by using 'thumb finger-print' recognition technology. You just 'thumb in' and 'thumb out' when your done. I'm sure the money used to acquire this technology is much less than the money some of the doctors would try to claim wrongly... right?

Or have somebody in each ward and department to log in the doctors that were on-call everytime they see a patient... including at 3 am when a Neurosugeon gets called in for a Road Traffic Accident.

Or alternatively, trust the doctors who really should be professional, honest and trustworthy. I prefer the later. I think $14/hr versus a sleepless night when you have to wake up at 2am to put a Cardiac Pacemaker or help your junior put a central line in is well justified.. Plus on top of this they are yet expected to work the next day from 7.30am till 4.30pm. You do the maths...

So what now... BDMC heard that we'd have to wait for an official letter from DGMS to officially allow us to claim... then there will be another form - 'The Official one' where we can start claiming.

There is going to be some delay as well, because the current on-call allowance does not include those who are 'daily-paid'. This include our newly appointed Pre-registration House Officers and some of the new Medical Officers. Fortunately our DGMS are already looking into this matter and is in the process of getting this approved by JPA.

Finally on behalf of all the doctors, we'd like to say thank you to all those who have continuously given support to improving the medical profession in Brunei. We hope this profession will continue to strive, and continuously contribute to the society, religion and country. May Allah bless you.

Comparing Doctors pay

Due to popular request, we have compiled a table that summarizes and compares the salary of doctors within 4 countries, Brunei, Singapore, UK and Australia. We have chosen these countries for comparison because most of our trainees either graduated from these countries or usually chose these countries to further their training into specialty areas, as recommended by the Post Graduate Training Advisory Board.

However in comparing these figures, we have to bear in mind that our beloved country is blessed with other factors such as a peace, no income tax, heavily subsidized petrol price, excellent education facilities for the kids and one of the lowest inflation rate in the region.

Also these figures are the current figures when we collected them and of course other countries like Singapore changes very quickly (almost yearly) according to demand of health service. The figure from Brunei has remained the same.

We also apologize for the incomplete information for it is difficult for doctors (esp consultants) to disclose their total pay especially when it comes to their private practice. This is of course understandable. We can only assume that it is somewhat more substantial than their basic pay working with their government.

The salary stated above are starting salary for each grade, and can vary widely even within each grade depending on experience and qualifications.

In providing this information, we try to be as honest as possible with the figures. The information also came from various sources such as websites, journals and individuals who have been very kind to share their information with us.

Holiday Allowances & 10 years service allowances

To most perhaps the above subject is very familiar, but to most of us who have worked less than 3 years in the government service, a holiday allowance after every 3 years of service and a 10 year service allowance is very much welcomed.

For those who have not come back to Brunei yet and medical students abroad, we are entitled to the allowances below:

1. 3 year holiday allowance of $2,500 each for you and your wife and up to 4 children below 18yrs old
2. For children below 12yrs old it's $1,250
3. 10 years service allowance of up to $21,700 (husband & wife) and if your single it's $10,850. Pls note this one is one-off allowance.
   

Don't forget to apply for these allowances well in advance (at least a month) before your due date i.e. your appointment date as medical officer.

To apply, first go to Ministry of Health, 1st floor and ask for the Allowance section. Then ask for a form to apply for the above respective allowances. Go back and fill it up. You need a copy of your appointment letter, Identity Card & Bank Card or statement (if your married I suppose you need the marriage certificate and your wife's details). At the time of writing this article, only male government officers are entitled to apply for their wives and not vice versa. Then hand in this form to RIPAS administrative department at the CEO's office - claims section (it's room 1).

The CEO then will draft a minute to confirm you are entitled to the above allowances. Once the minute is ready 2 days later, I have been advice by the Finance dept to hand this minute back to the Ministry of Health my self. Because as we all know, letters easily get lost on the way causing you to get delayed allowances. Hand it in to where you got the form from, 1st Floor MoH.

Simple right!

Other allowances that you are also entitled to are:-

1. Overnight allowance. e.g. if you are posted to Temburong - $40-45 / night
   
2. Moving to a new workplace allowance - $350 / one off
3. Mileage allowance from home to RIPAS - $29/mth if within 9.5km etc...
4. Ad hoc mileage allowance if your posted to KB or Tutong and you use your own vehicle - $0.45 / km (to and from)
5. Interest free car loan up to $15,000 (repay within 4 years)
   
6. Interest Free Housing Load up to 4 years basic pay (repay within 30 years)
7. Free Haj package worth $3,500/per person after 15 yrs of service
   
8. Education allowance for your kids

• $800/mth for overseas education
• $120/mth for local schools
• $800 / mth if you send them to JIS (Jerudong international school) Year 7 (?up till or from)

Happy Applying!

Are we ready for a Disaster?

Following the recent disaster drill which was organised by the Royal Brunei Police Force, it left us thinking and wondering, do we really have the ability to respond to such a disaster call. Police Force, Firemen and Army usually take central role in managing these disasters which leaves us medical personel on the sidelines... treating the wounded...

What happens during a disaster from the medical point of view?... How is our response to a disaster call?... Do we have enough personnel and equipments...? Is our protocol for disaster management solid...? The experience from the recent disaster drill raised these issues that I think we have to look closely and try to solve. We can never be ready 100% for a disaster but we can at least be prepared for it.

The scenario painted, albeit a little bit on the un-realistic side (An anthrax bomb, followed by hostage taking at sheraton, followed by another bomb blast in BSB, and ended with a stand-off between the police and terrorist at a house in Kg Bebuloh) which went on from 2pm till 3am (13hrs!) was nevertheless ..... Exhausting!

Although we failed (bomb squad) initially to identify the anthrax powder in the beginning of drill...in other words the containment procedure were somewhat 'delayed'... because Everyone was already exposed to the anthrax! Tq... in theory ofcourse we all will eventually succumb to Acute Respiratory Distress Syndrome and die!. The rest of the disaster drill was pretty much the Police show really... The police rounded the 'terrorist' at Sheraton, the Special Police Squad i.e. 'Brunei S.W.A.T. team'... (aseh..) stormed in and caught the bad guys. then The police bomb squad diffuse the bombs in the Capital city... and the rest I fell asleep....

The medics... well the 1st scenario (anthrax bomb) we responded really fast.. did our job and went.. The second scenario...again faster response... but the waiting was almost unbearable.. altho the S.W.A.T. team put on a good show for us...plenty of shooting and bombs.... the 3rd scenario at midnight we realized that we were just there for the show... then the 4th scenario at 3am... we were not involved coz most of us decided to go to bed. I suppose if it was a real disaster or the medics were actually given task we would be busier of course.

Was it a good drill? For Police yes... for us yes and no. Yes because we exercised our response time to the scene and despatch our 4 Rescue teams within 5 mins. Yes because we identified that food for our teams on the site is equally important as sending teams there. No food and drinks.. No efficient team working on site. Yes because We identified that we don't have facility to build 'Field' medical area, which we need. Yes because we have identified our Disaster Alert Response Team personnel which are a solid bunch of people! I really enjoyed working with them.

No.. because the full Major Medical Event protocol was not exercised yet.

Unfortunately or Fortunately.. the drill was exercised for 'on the site management' only.. i.e. once the patients were brought to RIPAS, it ended there. The problem with this is that we will never know how our own hospital team will manage and respond if a disaster as such were to happen. Do we have enough manpower and logistics to handle a disaster of such scale in the hospital?...Can we handle the traffice in and out of RIPAS?.. do we have enough space and beds? some questions for 'us' to answer there...

But my opinion our MME (emergency) plan is pretty solid, on paper ofcourse. But exercising this plan by playing it out on a drill is equally important, because a good plan is only as good as it is on paper.

After this drill...I think I can see a full-scale disaster drill coming up soon.. like a plane crash drill... hint hint... hopefully after raya...stay tune for more updates

In the meantime let us entertain you with a video clip of the 'MME Activation'. This clip was done in collaboration with Doctors Mess & Accident Emergency Dept. Also special Thanks to Dr Ang (HoD) Hj Lamat (Cameraman), and Army personnels (make-up).

Orientation Course for New Local Doctors

Every year since 1999, the Ministry of Health have been organizing Orientation Course for the new Officers in the Ministry of Health. These usually include new doctors that have recently join the ministry and include all levels including specialist.

Unfortunately due to work commitments only 7 doctors were able to join this years orientation course. Amongst those were Dr Jackson Tan (Renal Specialist), Dr Pg Siti Rafidah (SMO-ENT), Dr Rozzy Idros, Dr Firdaus, Dr Nora, Dr Caroline (MO) and Dr Hidayati (Dental MO).

The course which usually runs for 2 weeks usually includes lectures about the General Order (G.O.), briefing from all the various departments under the Ministry Of Health, visits to the 4 district hospitals and labs. But the highlight of the course have always been the overnight trips to Sukang and Temburong. This year however the Sukang trip have been cancelled due to the difficulties in acquiring transport.

But this year the venue was changed to the Outward Bound Temburong. We've heard from our previous predecessors their 'unique' experience of the Orientation.. (no names mentioned) but ofcourse the tradition continues... and what happens on the final night remains in the camp ofcourse..

The course designed to build a spirit of teamwork within the ministry of health has always been a success solely due to the hardwork by the main organizers, Malai Abdullah, Hjh Norsiah and the Gang. This year is no different, I'm sure everyone had a great time in Temburong. Let's hope Malai and the gang will continue to organize this very enjoyable course for the docs.

The Outward Bound Temburong

Team 'RAJAIR' presenting their proposal Healthy Lifestyle

Malai Abdullah (a.k.a. President of SMARTER BRUNEI)

Team 'PADIAN' posing

Dr Firdaus explaining their team Objectives

Dr Jackson Tan

Dr Caroline helping her teammate back on the kayak

Dr Rozzy Idros .... floating down river Temburong to Bangar

Activities continues on at night

Relaxing after completing the Tent building

Dr Hidayati posing after the Flying Fox experience

Two Thumbs up for the Flying Fox

The Flying Doctor

Falling backwards onto a stretched cloth.. requires trusting your teamates

Dr Pg Siti Rafidah

Ok guys... hold it together now!

Eeeek!

Ooops...

Another x-ray

42 year old male, a weapon specialist in the military complaining of 2 week history of pain in the wrist. No recent acute trauma apart from usual day-to-day testing of weapons. 1 year ago had a fall on an outstrectched hand.

Spot diagnosis?

BONE DENSITOMETRY SOON IN RIPAS

Bone Scan will soon be available in RIPAS!

As recently announced by the Department of Radiology RIPAS Hospital, Bone Densitometry service will be available in RIPAS as of May 2009. At last.. no longer will we be guessing whether is this osteopenic bone actually osteoporotic, confirming bony metastases, suspected hot spots for infections etc.etc..

We not sure yet whether it will be able to do Renal DEXA scans, but I'm sure with time the service will extend. This news will certainly be good news to Rheumatologists, Oncologists, Orthopods and many more.

This service will start in May 2009 and will be available only once a week to begin with. Every wednesday and only via appointment requests.. 6 per day. Requests forms will be distributed by the Deparment of Rheumatology soon.

Update on On-Call Allowances

We have received information that our proposal for on-call allowances have been approved. Unfortunately this does not include the Accident & Emergency & ICU doctors due to the fact that they operate on a shift system. According to a reliable resource, the department concerns are coming up with a new proposal to compensate for their work and it may come as some special critical care allowance.

As for the rest of the medical personel who are on full 24 hour rota system and are resident (i.e. on-site during on-calls), they should be entitled to claim for on-call allowances soon. For those who are non-resident on-calls, (this includes the specialists) they will only get paid when they come in to hospital during on-call period. This means after office hours and weekends only. The ministry is currently working out a system where this can be implemented and monitored easily and not be abused by others.

We have not received any confirmation as to the rates of the oncall allowances yet, but we hope the implementation of this system will not be to long ahead. Something to look forward to..

Proposed New Hospital Block for Mother & Child

These pictures were taken during the recent World Health Day 2009 exhibition. We manage to speak to one of the architects from the 'awarded' consultants Arkitek Idriss, and he said that the project is estimated to cost around $BND 60 million and if all goes well (i.e. budget approved) is due to start end of 2009 (Need to verify this information).

It is suppose to accomadate the Obstetrics & Gynae, Paediatrics, Accident & Emergency and the RIPAS Administration... hey what about Doctors Mess! We put that question forward too and still awaiting answers.

After doing a bit of asking around amongst the doctors, two very common comments were forwarded. One is that... it's quite an impressive and nice building... but secondly is that the worry about congestion it will create to an already congested Hopital area. Relevant issues considering we have just undergone a workshop for ensuring safe hospitals, and that one of the indicators of a structural risk is that the location of the the hospital... in this case right at the hill. I'm sure the professionals would have already thought about it, but we are not sure if the congestion problem can be minimized. Something to ponder...

In the following posts we will elaborate on another project that RIPAS is planning to undertake, which is renovation of the 4th floor (where the doctors mess is) and converting it into 2 full wards, the coverage on World Health Day 2009, and the update on On-Call Allowances...

Major Disaster in Brunei??

At approximately 8.35am the ambulance service received a distressing 991 call, a 6 storey business building has collapsed in the capital city. Following this, Major Medical Event was immediately activated and before long RIPAS A&E Department was already receiving some of the 50+ casualties that was trapped within the rubbles.


















Ok...ok maybe the scenario was little drammatic, but it could happen right. Eversince a series of 'man-made' and natural disasters that has hit the country in quick successions, the Accident & Emergency department with co-operation from various other specialties are preparing ourselves for the worst case scenario. One of the objectives is to ensure that the medical services are prepared and able to cope if a Major Medical Event (MME) was to happen.

This mini-drill was just to demonstrate the chain command during such an activation, the role of allied professional like radiographers, labs, security, paramedics, nurses and the deloyment of medical personels to the disaster area. The casualties are professional actors... ok ok we borrowed the staff nurse that was working later that day in the afternoon duty, but thanks Norazli.

Doctors Mess Club along with it's NEW committee members participated in this exercise that was organised earlier today and with support from the military made the casualties look more realistic. Well done boys & girls, and special thanks to Act SSN Hjh Nora, Dr Ang (HoD A&E), SN Norazli for their big role in todays exercise.

The Doctors Mess Team winding down after the exercise from Left to Right
Front - Azmi, Ady, Nurul & Athai
Back - Munir, Ezam

The man himself Dr Ang (HoD A&E)

Update on the Scheme of Service & On-Call Allowances

We heard the Jawatankuasa Tanggagaji (JTG) resided on the 18th December 2008 to discuss an urgent issue, the doctors proposal for improved salary. The proposal consisted of three main issues, the revised scheme of service (i.e. basic pay), the on-call allowance & a proposal for professional allowance.

We don't know exactly what went on in the meeting because no doctors were allowed to be represented in it. However from a very senior doctor in the ministry the JTG has concluded that they will only approve resident and non-resident on call. Extended hours duty at On sum ping, medical cover and shift duty at A&E and CCM will not be considered as 'on call'.

According to a member of the team that represented our paper in the meeting, if MOH wants to compensate us for the extended hours, medical cover or shift duty, we should call it something else but not oncall allowances because he said JTG says it is not really oncall.

So if we want to be compensated, we have to prepare another paper? Hmm... basically it's up to our executives what would be the next step of plan. Either accept the deal from JTG where only resident & non-resident on-call will be given, i.e. medics, surgeons and any doctor who is on the oncall rota at RIPAS with exception of A&E and ICU doctors because they work shift duties or prepare another paper and start back again. Or maybe there is another solution...

What's your view??

We await the decision from the executive meeting and update us with the other issues with regards to the Scheme of Service proposal.

Reporting for Doctors Mess.

More Skin Lesions

Lesion 1

This is a 70 year old male, presented with a 2 month history of skin lesion on his anterior shin. He has a past medical history of COPD and still a smoker with a 40 pack year history. The lesion initially started as a small itchy lesion which developed into the size you see now on the picture above over 2 mths.

What is your diagnosis of this skin lesion? How would you confirm your diagnosis and what is your treatment plan?

Lesion 2

This is a 45 year old diabetic female with lesions on her lower limb. She was referred to a specialist clinic with a non-healing ulcer on the medial gaiter area. What is the diagnosis of her skin lesion?


Answers: Posted on 27th December 2008

Lesion 1: Squamous Cell Carcinoma

Lesion 2: Diabetic Dermatopathy

A persistent Wrist sprain

A 35 year old male attended casualty after falling onto his dominant outstretched hand. He was tender all over the wrist joint but more so medial to the scaphoid area with an obvious deformity. There was no neurovascular deficit. The above xray was done and patient was sent home with a diagnoses of soft tissue injury and follow up appt in clinic.

4 days later in clinic his pain is no better so he was given more analgesia and a high arm sling. There was no neurovascular deficit noted.

2 weeks later patient requested to be seen again after complaining of un-abating pain on his wrist and swelling which has not subsided since his initial injury. He also complains of numbness over the medial 3 and half fingers.

What is the diagnoses based on the x-ray?
What is the cause of the neurological findings?
What is the preferred option for treatment?


Answer: (posted on the 20/12/2008)

It is a Perilunate dislocation, with scapho-lunate dissociation.
The Neurology is a median nerve compression
The treatment is immediate MUA (closed reduction), however with a 2 week old injury it can be difficult (almost impossible)

Well done to those who got it right!
In this case we attempted initially closed reduction but was unsuccessful. So we went for open reduction. After open reduction, under image intensifier the scapho-lunate dissociation was very obvious so k-wire fixation was necessary to maintain reduction. These are the post-operative xrays.

Good Luck Dr Lim Kian Soon

The Head of Diagnostic Division and also our only practising local Radiologist Dr Lim Kian Soon has recently left RIPAS Hospital to join his wife who was also a practising Breast Surgeon Miss Hani Trasil to work in Singapore.

Dr Lim was well known to all the doctors working at RIPAS for his work in improving the services at department of radiology, and of of his many achievements was to obtain the 64 slice CT scanner for RIPAS Hospital which had tremendously improve our imaging capability. We are now able to diagnose diseases with better precision, do 3-D CT Reconstruction, Cardiac CT Imaging and perform interventional radiology procedures with better precision and outcome. We are definitely going to miss having somebody of his calibre around, but nonetheless wish him all the very best in his future career abroad.

Send us a postcard Dr Lim!

THE LAUNCHING OF BRUNEI MEDICAL ASSOCIATION

Finally the day has almost arrived! The Association that will represent the voice of us will be be launched soon..

The date: Sunday, 2nd of November 2008

The time: 8.30 AM

The place: RIZQUN hotel, 4th Floor

Guest of Honour: The Honourable Minister of Health

All medical professionals in Brunei are invited (locals & expatriates).

Hari Raya with MoH

Assalamualaikum, hello guys. Recently the Public Health Services held a Hari Raya celebration for all the MoH staffs at RIZQUN Hotel. I have to say the organization is much better than last year celebration because I think almost everyone who bought the tickets actually got seats! The food was good, but the highlight of the evening was the entertainment ofcourse.

We had a couple of performances from the districts, but the best must have been from Tutong with Rashidah belting out her voice and her 'associate' rapping.. yeah yeah aha aha.. Dr Wadi and Dr Rizal made the doctors proud with their unplug version of Aizat's Hanya kau yang mampu.

But the highlight of the evening was saved for the last... a very sporting participation of our minister and datin during what I can only describe as salsa/cha-cha/aerobic dance towards the end of the evening, led by the one and only Dr Anie Rahman... go girl!

It was definitely worth my $15, coz you will never see the minister, deputy minister and our perm secrectary dance again till hopefully next year hehe. Plus I also won a hot water dispenser! Which I have donated to our department :-) Look forward to next years Hari Raya Celebration

For those not in Brunei or did not manage to get tickets to that evening, doc mess shares some pictures taken that night.

Dr Anie leading the group...

Our minister, Deputy minister and Permenant Secretary

The Deputy Permenant Secretary (middle) singing along to Hari Raya song

Rashidah and the Gang, performance from Tutong

$100 if you can guess who this is?

Wadi a.k.a superwoman - Doctor / Emcee / Singer / many more....

Getting the chords right... Dr Rizal

Now this guy can really shoot photos... :-)

Update on the Scheme of Service

Efforts to improve the welfare of doctors working in Brunei has long been around. Pensions, On-Call Allowances and Scheme of Services has been the talk of many, but like myself many of us didn't know what was going on in terms of effort done to address these very important issues pertaining our welfare.

From a reliable source eversince 1997 (this might be slightly off) when our then DG proposed for on-call allowances to be implemented, the paperwork has gone through various hands and gone through several revisions until now. Alhamdulillah the final version of the proposal has now been agreed by everyone (Medical & Health services) and in the process of submission for approval to the Jawatankuasa Tanggagaji at JPM. The proposal package now consists of On-call allowances, a new Scheme of Service and 'special allowances' for doctors working in the Ministry of Health.

For everyone's information, prior to the proposal for the revised scheme of service, a proposal for pensions to be returned to the doctors was submitted. Unfortunately the proposal was unsuccessful.

Going back slightly it was since early 2007, Our Minister of Health agreed to form a committee to look into the current scheme of service. The committee is headed by a very senior member of the health ministry and were represented by Hospital doctors, GPs, and Public health to come up with a scheme of service which would be in line with the current international trends, competitive and career progressive. About 2 months ago this committee met with senior representatives from JPM and members of the Jawatankuasa Tanggagaji to discuss the proposal and a few amendments to the proposal was recommended.

Just to highlight some of the challenges that we face are that

1) The number of doctors we produce is still not meeting our demands. As of 2007 our ratio of doctors to population is around 1:900 (that includes ALL the doctors working in the Ministry of Health). Singapore has 1:600 and are still lacking and actively head-hunting qualified doctors to work there. According to OEDC the figure that we should aim for is 1 : 350.

2) The number of doctors leaving the service is increasing. Doctors are highly marketable professionals and continuously poached by agencies with attractive renumerations.

3) Medicine is not an attractive career choice for students. Lengthy undergraduate period, Health-risking career, Stressful & Long-hours of work appeals only to the very few. There are now many other career options that provides a better lifestyle and a better renumeration for the 'cream of the cream'.

In brief the committee want this package to achieve 3 things

1) Attract - Attractive to students to want to do medicine, attractive to qualified experts and doctors to come and work in Brunei.

2) Retain - retention of doctors who are currently working in Brunei to continue working with the Ministry of Health

3) Possess - For the country to possess talented, skillful, knowledgeble Clinicians, GPs, Public health, Scientists, Researchers and propel the quality of health service forward.


Where are we now? This process is certainly not as straightforward as we think. It has to go through to so many levels before approval. Then when approved it will take a while before implementation can take place. How long? I'm not sure if anyone can answer that.. but at least we know that the ball is rolling.. and insyallah hopefully not too long.

Medical Superintendant

Assalamualaikum w. w.

First of all Doctors Mess would like to wish all our muslim readers in welcoming the month of Ramadhan. Hopefully we will all be blessed during this holy month and our 'amal ibadat' be accepted Amin.

Secondly, we'd also like to congratulate Dr Hjh Norlila (ex-CEO of RIPAS) on being promoted as the new Director General in the Ministry of Health. We all wish the best for her, and we'll promise to try and make her life the least miserable as possible...hehe... kidding.. (ops there goes my promotion). We all know it's a very tough and challenging post and we will try to support her as much possible, and I think it's fair to say that the majority of the doctors are very happy with the appointment made so far. All the best to Dr Hjh Norlila and congratulations again.

Now back to business. I'm sure most of us have heard and if not been to the recent meeting that was held between our DG and the RIPAS doctors at the lecture hall in RIPAS Hospital. For those who couldn't make it, the outcome of the meeting was to nominate a medical superintendant.

What would be the task of the medical superintendant? Unfortunately we don't have the official job description yet... however from the talk that our DG gave we gather that the person that will be appointed will be tasked MAINLY to look after the welfare of the doctors working in the medical services. This means he/she will ensure that issues pertaining salary, allowances, housing, and others that is within the realms of welfare for the doctors are taken care of. The medical superintendant is suppose to be the link between the doctors and the DG, and is responsible to ensure that there is minimal delay in addressing these welfare issues. As for promotion, we not sure if the medical superintendant has authority to promote doctors but I'm sure the M.S. can recommend them to the DG.

The DG also conveyed the message that our ministry is seriously looking into this welfare issue and is working very hard to ensure that our welfare is looked after. The ministry would like to make sure our doctors are happy working in Brunei and will continue to stay working here.

The medical superintendant will be chosen from amongst the Local Specialists and will be working directly with DG, thereby bypassing the CEO of RIPAS. And will receive a certain amount of allowances which we are not sure yet of the figure. Apparently this post is not something new. Before there was CEO and Director General, the medical superintendant post had already existed, but after the Ministry of Health was reorganized, the medical superintendant post was replaced with CEO, and since was left vacant until now.

So who has been nominated? That we don't know but we've heard a few names being mentioned several times. Perhaps it's too soon to mention. However that person will have a busy task ahead because as well as performing their responsibility as a medical superintendant, he/she would have to perform their normal clinical duties. Whoever it is we wish them the best. May god mercy on their soul coz these bunch of doctors are quite feisty! Kidding.. ofcourse we are very nice people aren't we ;-) Aammton that includes you, behave yourself!

Next post insyallah we will give an update on the current efforts made by the ministry of health to improve our welfare. This involves On-Call Allowances, proposed salary scale and other allowances. Happy Fasting!

More locals passing their Membership exams

Congratulations to Dr Ady Adillah (General Surgery) and Dr Helinie (ENT) for having passed their Membership exams from the Royal College of Surgeons, and to Dr Rosmonaliza (Internal Medicine) another fresh graduate from the Royal College of Physician (UK).

Well Done guys, this means there will be more SMOs in RIPAS... keep it coming! And ofcourse we hope to hear an invite for lunch soon ;-)

Dr Ady Adillah (MRCS)

Dr Helenie (MRCS)

The Bowling Doctors of Brunei!

Dr Aziman, Dr Azmi, Dr Athaai, Dr Natalie & Dr Norwani

Today Doctors Mess marks it's 4th Anniversary by bowling it's way through Charity!

45 bowlers comprising of 9 teams from various departments in RIPAS Hospital and Public Health took part in the Doctors Mess RIPAS Charity Bowling Tournament 2008 which took place at Utama Bowling at 2.30pm.

This Charity event raised BND $1,000 which will be donated towards the 'Tabung Kebajikan Pesakit RIPAS" di Kementerian Kesihatan and at hand to receive the donation on behalf of the charity fund was the Guest of Honour Dato Seri Laila Jasa Dr Md Arif b Abdullah receiving the mock cheque from Dr Azmi Mohammad on behalf of the Doctors Mess.

The tournament began with an opening throw from DSLJ Dr Md Arif who was also the team captain for 'Gutter Balls 1' representing Internal Medicine 1.

The Public Health team "Healthy Sihat" led by Dr Fakhri did not waste any balls and commanded superiority throughout the tournament dwarfing other teams with score of 684 - 710 - 658 and collected 31 strikes and a total score of 2052 to be crowned champion of the tournament.

Following at 2nd place was the team representing the Lab Services "Mighty BAMLS" led by Hjh Aishah collecting the score of 616 - 578 - 667 (21 strikes) and a total score of 1861. 3rd place went to the team representing the Department of Radiology "T.N.T - tarik nafas tahan" which scored 548 - 590 -581 (15 strikes) with a total of 1719.

Highest Score went to Hj Shamsul (Public Health) and Hjh Aishah (Lab Services) in their respective categories, each receiving 6 month free membership to Fitness Zone.

The most Stylo-Mylo player for the tournament was awarded to Dk Herny Sharnie (Radiology) for her stylish kick at the end of each throw, and to Pg Ya'akob (Admin) for his verbal & physical antiques.

Prizes were also given to the player with the lowest score (hehe..) and we're proud to say Dr Aammton secured that prize without any difficulty. Well done Aamton! Dr Norainun was disqualified from receiving the prize because she had to leave early... tsk tsk tsk...

Anyhow everyone appeared to have enjoyed the afternoon. There were lots of cheering.. shouting... jumping... and cupcakes (thanx Wadi!) Thank you to the sponsors for making it possible to organize such an event. And special thanks to our docs Dr Athaai & Dr Aziman for getting the sponsors. Dr Norwani & Dr Natalie for their lightening mathematical calculations of the scores and setting up the tournament. Dr Ayu & Dr Rizal for the prizes & deco & Dr Ady our treasurer. And to the rest of the Doctors Mess Committee... Thank you all and well done!

These are the final scores.



p.s. more pictures of the tournament will be posted once we get the pics from our un-0fficial photographers that were scattered everywhere.. tune in..

Bowl for charity

Hello everyone! It's time again for our annual sporting event. Last year during the pool tournament we saw Herry Zul triumphed over Dr Ang, Dr Amalinda beat Dr Dk Norzieda and our Minister demonstrated his skills to defeat DGMS in their respective categories.

This year we would like to see who amongst us health professionals are top kegglers! Personally I'm terrible at bowling... only averaging 180 or so hahaha.. I wish! However the idea of this event is just for us health professionals and other allied health professionals to get out from our stressful working environment and trash it out at the bowling alley... Kidding... just have some fun alright and at the same time do some charity work lah.

And of course since we are all very nice people.. and we like to help others (sincerely)... why not give some to the less fortunate aye. So we are also inviting kind individuals, groups, companies, anybody to donate money towards the 'Tabung Kebajikan Pesakit Hospital RIPAS' which was officiated by our honourable Minsiter not so long ago, to help boost their funds.

This will enable the Social Welfare Unit at RIPAS to channel the funds into buying essential household equipment, food, clothings & blankets, and alleviate some of the burder faced by our less than fortunate patients.

This year insyallah, we will see 2 teams from internal medicine, 1 team from surgery, 2 orthopaedics, radiology, lab services, administration, operating room & public health. There is still room for 2 more teams who ever is interested. Sponsors are always welcome!

See you guys at the alley!

For our MRCP Candidates..

EXCELPACES - MRCP PACES Course

A comprehensive 3 days intensive MRCP PACES Course called EXCELPACES is being organised by 12 Senior MRCP teachers from UK, Middle East and India. Date:- 5,6 and 7 October, 2008.

Venue:- KIMS, Hospital, Trivandrum, Kerala, India.

The aim is to provide a low cost MRCP preparatory course for candidates preparing for PACES exam from outside the UK who needs training in examination technique and presentation skills. It is a known fact that the failure rate of non UK candidates in PACES is as high as 60 to 70 % because of inadequate preparation despite having good theory knowledge. This course will get you battle fit for the PACES exam by demonstrating around 60 cases and with Mock exams, all under the scrutiny and supervision of experienced PACES teachers. Only limited seats to maintain good teaching standards and seats are fast getting filled up by candidates from, Middle East, Malaysia and India.

Visit our website www.excelpaces.com or contact our program secretary Jessy Ajith by mailing to enquiries@excelpaces.com

All the best

Thank You


Dr Prasad Nair
Organising Committee Member, EXCELPACES


Disclaimer: We are not sure if Bruneian candidates will be sponsored for those 1st timers taking the preparatory course, best to double check with DGMS office first. However it's nice to know there are other options available if you've already done the traditional course.

Doctors Mess

Condolences to the families involved

Yesterday, as we are preparing to celebrate one of the most Auspicious occasion in our Islamic calendar a disaster struck right in the middle of our beloved capital city. A total of 4 cardiac arrests on-site most likely due to Crushed injuries and Asphyxiation and many others with injuries requiring admission to RIPAS. It was a very very sad day.

The pre-event incident occured around 1015am as thousands (as many as 4,000) of women rushed into the gates of the garden. An eye-witness account from one of the doctors attending the medical cover at that time, Dr Herry Zul said the victims were piled up on top of each other and situation worsen by the crowd pushing and shoving and even stampeding over the fallen ones. At this point it was evident that there was going to be a high number of casualties.

A major disaster call was activated immediately. With the help of the authorities, Dr Herryzul's team manage to retrieve the victims and prevented what would have been a bigger number of fatalities. Within 5 minutes more ambulances arrived and more back-up doctors and nurses arrived on the scene.

Out of the 4 cardiac arrest, one was revived on the scene by the medical team, but only to succumb later in ICU last night. The 4th victim was revived in A&E and is still in ICU, so 3 fatalities in total. Around 27 patients were admitted with sprains and minor injuries.

Our Deepest condolonces to the victims family who lost their loved ones.... Al-Fatihah..

INTERVIEW WITH DATO YAPP

INTERVIEW WITH DATO YAPP

Q: When did you start medical school?
A: 1961, Leeds Medical School

Q: Were you a Government Scholar?
A: Yes, fortunately

Q: You must have passed with flying colours?
A: No, I happened to be a citizen. In fact we were the first batch to take the exam, at that time the citizenship were just introduced. I was among the first to sit for the citizenship exam.

Q: At what age did you start medical school?
A: 19 years old, but I sat for the Higher School Certs in Brunei, and that was also the first batch ever to take Higher School Certs. There were six of us.

Q: Who were the rest of the six Dato?
A: There was one doing engineering, three doing science and another one doing microbiology. Another two on the art side, one doing law, another one don’t know what happened to her.

Q: When did you graduate, Dato?
A: In Leeds, I must have started in 1962. It’s a six years course. I qualified in June ’68.

Q: And you work there for how many years?
A: I work in Leeds in St. James’s hospital for a year. I was in the professorial unit doing a medical job because at first I wanted to do medicine. After that job I changed my mind to do Surgery

Q: That leads me to my next question, why did you choose surgery?
A: At that time, the surgery was in two parts, one three months each.Three months in urology and three months in general surgery. It seems to be a good job for me, and after that I went to Glasgow and the job was anatomy demonstrator, but the actual job title was assistant lecturer in anatomy.

Q: Was it a full time job? And being a doctor too?
A: Yes, it was a full time job and being a doctor too because at that time at Glasgow university in fact one of the biggest medical school with 250 students. 1968 to 1969, I did one year. After that I passed my primary, then I came back to Brunei. At that time actually we should come back after our house job. It was a compulsory three years, you must come back but because I took up this anatomy demonstrator job, I came back a year later. I started working in Brunei in October 1970 and work under Mr Harris for three years as a surgical trainee.

Q: How many doctors were there in Brunei?
A: You mean, in the whole hospital or the locals? We were the first group of local doctors, there were five of us; Dato Joe Lim, Dato Sherlock Chin, myself, Dato Johar, later became the Minister of Health, and Dato Hussin Daud, who was later became the Director of Medical services. After the first group, there was a vacuum of 13 years before Datin Intan and Datin Lim Ming King came back. When we came back, our salary was exactly the same as any graduates either arts or science, that means not only it is more difficult for us to get into the university but we spent a much longer time in University, so at that time our salary was only $1100 when we came back. Because of that, Dato Hussin and myself wrote in to get our salary revised. The two of us wrote in and they reconsider, that’s why the “M” scale came in.

Q: What other changes in term of health care in Brunei do you see?
A: For a start, previously there was only a Director of Medical Services. There was no Perm Sect, there was no Minister. So the Director General, in fact was the head of Medical Services. He controls or runs the service. Now, you have perm sect, in fact you have two Director Generals, one for the Medical Services and the other one for public health. The other thing that was introduced during these years was decentralisation for the clinics in the periphery. So as to make the Hospital less congested. Also an increase in the numbers of doctors. During our time in the old general hospital, the specialist, there were only four. A gynaecologist, which is Dr Datin Lapru, there were two phycians, Pehin Dato Dr Hart, and Dato Sinatambi. Dato Hart was in charge of the general services and Dato Sinatambi runs the chest clinic and Tuberculosis. And surgeons, at that time there was only one general surgeon, Mr Harris later become Pehin and under him, at that time was Dato Joe Lim and myself. When Dato Joe Lim was away, I was alone for little while, until Dr Gouse came in 1974. And there was an eye surgeon, Pehin Frank, he was also the Director of Medical Services. And later on, Dr Nayan’s (Eye spiecialist) father, Pehin Joshi came. So at that time in the Medical Services, there were four Pehins. That’s another change, from four Pehins to two Pehins today (laughing).

Q: How about in terms of working conditions?
A: Working conditions are better, because it’s so small, it’s like a family. So you almost know all the doctors working in the hospital. Infact you often make referral on the corridor or when you see each other. It a lot less formal and more intimate (smiling).

Q: In terms of investigative machine like x-rays, CT scan?
A: We didn’t have any CT, in fact to begin with, we didn’t have any radiologist. There were two radiographers, Hj Ismail and Pg Mohidin. And often say like IVP (Intravenous Pyelogram) we have to do our own injection and we tell them what pictures we want and then we read our x-rays. If we want to have barium meal, the technician would do the x-ray and we do the interpretation, so our investigations were fairly basic. The CT scan didn’t come in until we moved into this hospital (RIPAS Hospital) in 1984. And there were two radiologists who came, Dr Tony Jones and his deputy Dr Robinson. They came in the 70’ but they didn’t stay for a long time, I think only one or two contracts. I think it was during their senior register time they came to Brunei and then they went back and became consultants. Dr Jones was in Cardiff and Dr Robinson went to North Wales I think.

Q: How about the changes in surgery, Dato?
A: Surgery at that time, Mr Harris was doing all the major surgery. He was a very good all round surgeon and he was thoracic trained as well. He was able to do General Surgery and Orthopaedics. I went back to UK again in 1974 for another five years. I came back to Brunei in 1979. So when I came back I took over most of the General Surgical work, Urology and Paediatrics. Mr Harris still do Thoracic and Orhopaedics. We had two wards, one for General Surgery and one for Orthoaedics. He retired in 1987 and then Mr Wie came. Mr Wie graduated from Leeds and he was orthopaedic and neurosurgical trained. So he took over the neurosurgery and orthopaedics, and because he was also trained in plastic surgery, he took over the burn’s as well. That’s why Burns Unit came under Orthopaedics.


Interviewer: We, that all we have time for now Dato, thank you for spending time doing this interview.
Dato: My pleasure, thank you.


Thank you Ady, Amalinda & Khairul for doing the interview

DERMATOLOGY QUIZ

This is a skin lesion found on the medial aspect of the right thigh. A 16 year old male who has had this for the last 13 years. It was initially excised when he was 3 years old. He presented to A&E with pain and limping of his right Leg because the area surrounding the lesion got swollen. The lesion to begin was not as bad as it is now according the the patient, only recently exacerbated after playing bouncer!

Any guesses?

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

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.

The Peril of Drink & Driving

The Peril of Drink & Driving

A 30 year old Thai worker was involved in Road Traffic Accident along Jalan Telanai which involved 3 other vehicle. He was unrestrained driver and was under the influence of alcohol. When the paramedics arrived on the scene, it took 20 minutes to free the patient from the vehicle.

Upon arrival to the A&E at RIPAS he was agitated and confused. His BP was 80/40 and pulse 120. He had deep laceration on the occiput, bruising around the flank and an open fracture dislocation of the ankle. There was some movement of both his upper limbs, but he was not moving his lower limbs.


After primary survey was done the trauma panel x-rays revealed this x-ray.


Question:

1. Give two abnormality on this x-ray?

2. How does it correlate with the clinical findings?

3. After stabilizing his vitals, what would be your next investigation of choice?

ORL UPDATE 2008

ORL UPDATE 2008
ON ALERGIC RHINITIS &
OBSTRUCTIVE SLEEP APNEA

DATE: 19TH JANUARY, 2008

VENUE: RIZQUN HOTEL

TIME: 19:00HRS

Limited Seats, Please RSVP before 16th January 2008 to
SN Hjh Noraini / SN Tai Mei Lian
2232111 ext 4114

JPMC organised Osteoporosis CME

OSTEOPOROSIS CME

The Organising Committee with Guest Speakers

Dr Wang explaining the pathogenesis of Osteoporosis

Dr Hjh Haslinda (Endocrinology Specialist)

Mr Ketan Pande from Orthopaedics sharing his knowledge

The Special Guest Speaker from Singapore

HSBC brings magic to children's Ward

HSBC brings magic to Children's Ward

27th October 2007

HSBC once again brought smile all around the paediatric ward at RIPAS hospital by doing its charity rounds and bringing gifts and prizes to the children's ward. The group led by the Manager of Kiulap Branch Hjh Rohani and her crew from various branches kept the children entertained and even brought in a magician to liven up the day. Thank you HSBC for your continuous charity work, perhaps one day you will visit the Doctors Mess as well :-)