The Silent Majority or the Silenced Majority ?


It is a favourite excuse of the powers-that-be in Malaysia, to say that voices of opposition, discontent and dissatisfaction are coming just from a small group of dissidents, of trouble-makers and 'pengacau'. They often claim that the "silent majority" of Malaysians are very happy and satisfied, and that is why they keep silent. Of course, those who support them will often parrot this argument. Even when the opposition won almost half of all votes in 2008, they still insisted that the "silent majority" was with them.

But let me ask you, the common man, the average Malaysian on the street. Are you happy with the way things are going ? Have you tried to voice out your dissatisfaction, only to realize that you can't ? Have you written in complaints to the Press, only to see only "favourable" letters praising the government of the day being printed ? Have you felt helpless as your leaders brought the country along a direction you don't want to go ? Have you felt that you are not heard, and your point of view not considered ?

Well, you are not wrong. Malaysia has built a large gap in the last few decades; a gap not between the races, not between common Malaysians. That gap is the gap between the people and its leaders. We, in fact, TOP the world, in that we have the largest gap between the common man, and their leaders. Our common Malaysians cannot communicate with our leaders; they cannot hear us (or maybe they just don't want to hear us). For this, of all things, Malaysia BOLEH!!!

So then, are we now the silent majority, happy satisfied content and silent because we have just nothing to say; or are we the "silenced majority", who shout out but are not heard, who tell but are ignored, who suggest but are laughed at, who resist and are labelled trouble-makers ?

I REFUSE to be silenced anymore. I will shout out for me, for my family, for my friends (even those who continue to support BN), for my neighbours and my fellow Malaysians; for our future, and our common path toward that better tomorrow.


Han Chiang college 28 april 2013 - I was there, so were 80,000 others; and I, we, will not be silenced anymore


Les Miserables "Do you hear the people sing?"

So shut up about the silent majority already ....

whewww !      

You mean there was all that MONEY in the other pocket ?



This election has seen government spending on an unprecedented scale. From free concerts by Psy and Taiwan artists, to big-name events like Michelle Yeoh and Alan Tam. From handouts to all and sunder, to free makan, free beer and free T-shirts. From spending on flags and banners (with enough cloth to clothe all the poor in Malaysia for 5 years at least), to online ads on every social media webpage that you may be on.

In any other democracy, this would have constituted vote-buying, an election offence. It is an election offence here in Malaysia too, but as always, there are two sets of rules; one for the governing, where "we'll close both eyes" is the guiding principle; and the other for the rest of us, the governed, where we learn quickly "do as I say, not do as I do".

The amount of money spent is staggering. Where did all this money come from ? Where is this other pocket, where we had all this extra money to spend ?

I wish we had known about this other pocket full of cash when -
  • we were short of money for specialized medicines
  • we had to treat patients 4 to a room
  • we had not enough beds and had to treat patients on wheelchairs, until ...
  • we ran out of wheelchairs
  • we have not enough ambulances
  • we asked for an allocation of just RM 5 per person in the community to provide additional ambulance services
I wish we had known about this other pocket full of cash when - 
  • we treated that retired school teacher who was getting RM 350 in pension to survive on
  • our staff was so much in debt that his six children were just taking one meal per day; the church group came in to support this Muslim family with daily rations
  • the whole family structure disintegrated when the sole breadwinner suffered a stroke; and they are now all relying to donations from fellow villagers
Free beers and free makan ? I really find it distasteful.

Absolutely ….. !!



Rabies is not endemic in Malaysia ie we don't have this. If you have been bitten by a dog in Penang for example (unless there were incredibly suggestive features eg drooling crazy dog who bit you and then died) I would really not think about rabies. 

But rabies is endemic in Thailand. And Westerners, being Westerners, like dogs, and like to pet dogs who don't belong to them. Invariably, some of them get bitten. So, rabies, being endemic in Thailand, it makes sense for them to get an anti-rabies vaccine. This is almost always started in Thailand. But this vaccine requires multiple doses over many days. So this Western tourist decides that they can continue their travels to, Penang !!

Now, when in Penang, they now want to continue their anti-rabies vaccine. Which we don't have. It is not unreasonable for us not to have it, since rabies is not endemic in Malaysia, it is very expensive, and really, should we carry vaccines for something that uncommon ?

Generally, these Western tourists are usually diverted to private hospitals, where apparently they are charged about RM 500 per dose. "What ?? RM 500 ?? Are you trying to rip us off ??" becomes the standard reply because they think we are cheap. 

Bring your sick dog to the vet in UK, and it would easily cost you 100 pounds. Ditto the US. Ditto everywhere in the Western world. But because we are "cheap", these tourists make noise. 

If you make noise at the private hospital, they have one standard option. They tell you to go to the government hospital. 

So, now the already upset tourists appear at your doorstep, expecting something more, and ready to make even more noise. 

Are we wrong not to store anti-rabies vaccine ? 

Remember we are spending the rakyat's money. Each dose costs a couple of hundred bucks; you don't know when you will use it, and it expires in under 2 years. Will you decide to stock up this vaccine ? What say you ?

What next, you may ask ?

Well, let me tell you. We have no King Cobras in Penang. Cobras, yes; vipers, yes. Kraits, probably yes. No King Cobras. So we keep anti-venom for Cobras, Vipers and Kraits. Being good people, we also keep some anti-venom for sea snake just in case, considering that we are an island, and a sea-snake bite is rather deadly. A few thousand RM per vial. We did not keep any antivenom for King Cobra.

Last year, a zoo in Kuantan imported and kept King Cobras without informing anyone. One of their staff got bitten, and of course, everybody was in chaos. A King Cobra anti-venom was sourced finally after many hours, and administered. The blame game then started. Easy to blame. Why no anti-venom stock ? Why govt hospital so lousy ? Interestingly nobody blamed the zoo.

But similarly to rabies, would you stock an anti-venom which costs a thousand RM, and lasts less than 2 years, if you have no King Cobras in your expected area ? Would you ?

I wouldn't. And we didn't. 

Until a couple of weeks ago, and I nearly fainted when I found out; that the Snake temple people have imported King Cobras and are conducting snake shows, where the handler will kiss the head of the snake. 

And now we are hearing the some people like to keep exotic pets including rattlesnakes.

So really, what can I say; I am absolutely ..... !!   [speechless!]

How Doctors Die



A magnificent article by Ken Murray. Original link here. Worth reading to the very end.


Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.
To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.
How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.
The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.
But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.
Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.
It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.
Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.
Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.
But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.
Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.
We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.
Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.
Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.

The Perfect Evidence Based Emergency Doc



Let's just say that there is this PERFECT emergency doctor. Just perfect. Evidence-based references, guidelines, NNTs and all that. We all wish that we worked with someone like that, right ? Or even better, we all wished sometimes we were as good as that, eh ?

Now, one day, whilst managing a patient, he applied a guideline correctly. Performed a score, applied a guideline and made a decision based on that guideline. Something goes wrong. A diagnosis is missed and an adverse outcome occurs.

Until now, everything has been done as would have been done in usual practice. Even more, the guideline applied is well accepted both locally and internationally. But looking deeper at guidelines and evidence, nothing is ever 100%. It is always in the high 90's percentage points but never 100%.

So the real question is, what do you say to the patient or family members, who have suffered the adverse outcome ? Those who were unfortunately in the small percentage points not covered within the guideline ?

How do we answer the allegation that the guideline is not good enough, or that the doctor who we all think is perfect, was negligent and incapable ? Can we actually say that the guideline was good enough, when it had failed in that particular rare occasion ? 

And how do we counter-argue when (invariably) some Googles and finds some loophole or some other obscure guideline which would have picked up this patient ?

Is there a way to win the scientific argument, legal argument, moral argument and at the same time, reconcile that with what the heart says ?

Help. I don't know this one.



EMS Asia 2012 – Welcome Address


On behalf of the Organising Committee, I am most honoured to welcome all of you to the inaugural EMS Asia 2012 Conference, to the island of Penang and the country of Malaysia. We are most honoured to be able to present this conference to all of you and to share in an experience which we hope you will find most memorable. If you look around this hall, you will see more than 500 participants - all of them EMS leaders, experts, trainers and providers, from 20 represented countries in Asia and beyond. What an opportunity to make friends or renew friendships, seek collaborators and exchange ideas.

The EMS Asia 2012 Conference was built on this very foundation - To bring together experts; and to learn from best practices in the region. To develop models of good care and to raise the standards of prehospital care. To conjointly develop standards and safety specifications for ambulances. And to develop a road map for the further collaboration between EMS systems in Asia.

This inaugural conference is co-organised by the Asian EMS Council, St John Ambulance of Malaysia in Penang, and the Penang General Hospital. The theme of "Safety and Quality in Pre-Hospital Care" highlights the conjoint effort of us all to develop better safety standards and specifications for our ambulances and to provide better care in our ambulances as we all move toward developing our EMS systems in Asia.

I must thank Assoc Prof Marcus Ong and the Asian EMS Council for giving us the honour of hosting the Inaugural EMS Asia Conference, and for believing our assertion that an EMS Conference here would be able to attract participation from around the region. I would like to thank Dr Sarah Shaik Abd Karim, our Scientific Chair, and her team for her tireless work in bringing together our faculty of more than 60 Malaysian and International experts. I must also thank the team from the Penang General Hospital for their very admirable effort in coordinating and supporting the entire conference. I would also like to express our gratitude to our partners and sponsors from around the world, who have worked with us to make this event a success. 

I must especially thank the St John Ambulance of Malaysia team in Penang, who have yet again, taken up the challenge of working towards improving EMS in Malaysia in bringing together this international congregation. The many months of shared work have resulted in this magnificent conference and this unique opportunity to share and learn. I am very proud of this team.

Do take some time to enjoy the beaches of Batu Ferringhi, the food and shopping that Penang has to offer. Take some time to explore some of the heritage tours or hiking trails. Soak in the sun or try the fun-filled beach activities that are just outside that door. 

We are most happy to welcome you all, and we look forward to an enjoyable conference and a memorable time.

Thank you.