Being coerced

An elderly gentleman had a major abdominal surgery and the anaesthetist had ordered a bag of platelets on standby from the blood bank in case it was required during the surgery. Platelets need to be ordered in advance as they take time to be issued, thus having it on standby is a good idea.

The patient comes to intensive care for post-operative management. 2 days after the surgery, the blood bank rings up to ask the staff nurse looking after the patient whether we were going to use the bag of platelets as it will be expiring in 16 minutes. The staff nurse then asks me the same question.

Doc, there is a bag of platelet ordered. It will expire in 16 minutes. Are we using it?

At the moment, there is no indication for platelet transfusion. He is not bleeding, and his platelet count is 72.

The normal range for platelet count is 150-400 but as he was not bleeding, a transfusion is not indicated. Lots of people have thrombocytopaenia but are not transfused unless necessary.

But doc, the bag of platelet will be thrown away then. It cost 400 pounds. Can we not just transfuse since his platelet count is only 72?

No, I am not putting someone at risk for transfusion-related infections and anaphylaxis when it is not indicated.

A bag of platelet has a shelf-life of only 5 days due to the preservatives used in it. Once it has expired, it will be thrown away, which I agree, is a pity. However, this patient did not need the transfusion. I was not going to risk my medical license to give someone a blood product which was not needed but has the added risk of transfusion-related infections.

The staff nurse was not happy with me after that but I was not bothered. She was not the one signing for the blood product. I was, and no way was I going to be coerced into doing so.

Admittedly, the blood bank was annoyed at us as well. Honestly, we had no idea the platelets was ordered by the anaesthetist. In an ideal system, the blood bank should have been called post-surgery to say that the platelets were no longer needed so that it can be re-issued to someone else. In an ideal system....

The Swiss Cheese model

Was very displeased and annoyed yesterday. Found out that my landlord’s dog had somehow managed to sneak upstairs, entered my room and jumped on my bed to have a nap. Argh!

This incident could have been brushed off easily but for me, it’s a perfect example of the Swiss Cheese model of accident causation, also known as the cumulative act effect. Think of a stack of slices of Swiss cheese and consider the holes in the cheese to be opportunities for a process to fail, and each of the slices are ‘defensive layers’ in the process.

An error may allow a problem to pass through a hole in the layer, but in the next layer, the holes are in different places, and the problem will be avoided.

In the incident yesterday, the layers in place are :
1) The living room door to be shut in all instances to prevent the door from roaming in the hallway
2) The wooden barrier at the bottom staircase to prevent the dog from coming upstairs
3) The door to my room to be shut tightly
4) A partially-filled wastepaper basket in my room


The errors that occurred in each layer are:
1) The living room door was left open accidently, which allowed the dog to roam in the hallway
2) The wooden barrier was not placed properly, which allowed the dog to come upstairs
3) The door to my room was not shut tightly by the cleaner who had entered my room to clean it the day before, thus allowing the dog to enter my room
4) My wastepaper basket was emptied by the cleaner. In previous occasions when the dog had managed to enter my room, its first port of call is the wastepaper basket to look for food.

Due to all the errors that happened consecutively, the dog took the opportunity to explore my bed instead. If only one of the errors had not happened, the incident would not have had happened.

When I found out, I was extremely annoyed as it meant I had to wash all my bed linen, when all I wanted to do was to go to bed after a very long day.

Hmmph!

Trip to India - day 8

Today was my last day in Delhi, India. My flight back to the UK was at 3.50am the next day, which meant I could either pay for another night and leave for the airport at 1am, or I could check-out of my room but stay in the B&B until about 8pm. The B&B owner offered me a late room check-out, at about 10pm, at the price of 25% of the daily rate. To simplify my life, I agreed.

I also asked him to help me arrange a taxi to the airport, which he said would cost Rs600, which was rather expensive to me. He justified it by saying its Rs300 each way and you got to pay for the return as well. Rather than choose his service, I googled for metered taxi in Delhi and found companies where you could pre-book it and they charge by the meter. I decided to go for this one instead.

I arrived at the airport at 11pm and was not allowed entry into the airport terminal. Apparently, one could only enter the terminal within 3 hours of one's flight. I had to go into the Visitor's Lounge instead, which was located opposite the terminal. Again, very disappointed with the visitor's lounge. It strongly smelled of ammonia (urine odour). Imagine, this is an international airport. The lounge had a Costa Coffee branch which charged UK prices for their drinks. And they sure didn't know how to make a Hot Chocolate as mine had too much chocolate in it.

In the airport terminal, I forgot to change my remaining Indian Rupees back into UK pounds before I had cross immigration, thus am left with 20 pounds worth of Indian Rupees. Will try and see if I can change it with some of my Indian colleagues here.

All in all, my trip to India has been very tiring and exhausting for me, due to the constant travelling, the endless hassles from touts/drivers and the smog-polluted environment. It was an experience for me, but I don't think I will be coming back to India anytime soon. And if I do, I will be visiting South India instead.

Trip to India - days 5, 6 and 7

Today was the start of my 3 days conference. Honestly, I was not very impressed throughout my 3 days there. On arrival at the registration hall, I made my way to the booth for surnames starting from H-M. Although I was second in the queue, others cut in front of me to register their attendance. I was mildly annoyed but decided not to create a fuss. Finally, I got registered. Was given a free backpack, and guess what, the zip broke the next day. Sheesh...

Although I do not claim to have much experience with conferences, with this being the second conference I have attended (the first conference was in Malaysia), I confess that this was a major disappointment for me. There were lots of issues that could have been improved on, considering that this was an international conference.

Firstly, the poor attendance at the lecture halls. There were 2 lecture halls with seminars/free papers going on concurrently. The lecture halls were pretty much empty. Only a handful of people attended the lectures. But when it came to tea time and lunch time, the food area would be full of people, requiring one to queue for about 20 mins for food. So where were all these people hiding?

Secondly, I have the impression that one attends a conference to learn new developments and upcoming research or ideas. However, I found that in some of the lectures, they were basically reiterating basic information. As health care professional who are involved in palliative care, there is no point lecturing us on what Dame Cicely Sanders defined as palliative care or the concept of total pain. We already know all these material. You are not lecturing to the common public. You are lecturing to people who are practicing palliative care day-to-day. Give me something new. Tell me something innovative. Do not go over old material which is already been published in textbooks eons ago.

I could go on and on, but the gist of it was I did not find this conference educational. Maybe I am being too harsh or maybe I am only seeing this from an outsider's perspective as palliative care is not my main area of specialty. I only came to present my paper. Maybe the palliative care specialists found this enlightening and educational? Maybe.

My oral presentation was on the last day, which I thought went alright. Could have been better but considering I only prepared my slides while in India, I couldn't ask for more.

After my presentation, I was approached by a doctor who wanted to discuss with me about an audit she was doing. She is undertaking the Certificate in Palliative Care via distance learning with Cardiff University, a course that I did myself last year. One of the assignment was an audit and there is an audit proposal form one had to complete. Rather than discussing her audit topic with me, she basically ended up asking me how to complete the audit proposal form. I felt as if I was giving her the answers, step-by-step, on how to write up the proposal form. She didn't contribute much of her own and took most of my ideas and wrote it down. She then gave me her namecard, which read that she was an assistant professor at a university in India. Hmm....

After the conference had ended, we were offered a free complimentary Delhi tour. According to the website, they offered a visit of the vibrant shopping complex of Connaught Place, Delhi Haat for handicraft goods and delicious food bonanza from 14:00-19:00.

They had 5 coaches available and it was full. And instead of the comprehensive tour they promised us, they only brought us to 3 attractions, India Gate, Qutb Minar and the Lotus Temple. I found the Lotus Temple quite interesting. As its name suggest, it is shaped like a lotus. It is a Bahá'í Houses of Worship, and is open to all regardless of religion. It functions as a gathering place where people of all religions may worship God without denominational restrictions.


And shopping was at the Lotus Mall, which was a high-class tourist attraction where everything was highly marked up in price.

The tour ended at about 18:00 and I went back to my B&B. Maybe I have too high expectations? All in all, I was majorly disappointed.

Trip to India - day 4

This morning, I had the luxury of sleeping in as I had no early morning train to catch. Only an evening train back to Delhi.

Had a good breakfast, consisting of a mixed fruit lassi and roti paratha, which is actually quite similar to roti canai (a famous type of flatbread in Malaysia). Then, I hired, through the hotel, a driver to Amber Fort, located in Amber, 11km from Jaipur.

As Amber Fort is located up a hill, one can actually hire royal elephants to carry one up the hill. I personally thought it was animal cruelty and walked up instead.


While in Amber Fort, Salman Khan's latest movie, Veer, which was directed by Anil Sharma was being filmed there.

I found out the next day that an accident had occured at Amber Fort later that afternoon. Apparently, a portion of the wall at Amber Fort collapsed, injuring at least 15 people. The stretch of wall collapsed due to the pressure exerted by thousands of spectators standing on it. As a result, there was a minor stampede of people trying to evacuate the scene.

I thanked my lucky stars that I fortunately avoided this. I had left Amber Fort at around 12 noon and it apparently occured around 3-4pm. Phew.....

The driver took me back to Jaipur city and I set out to explore Jaipur, the Pink City on foot. At this point, my camera ran out of battery, thus no more photo-taking opportunities. And I had forgotten to bring my charger with me.

I visited the City Palace, which was built by Maharaja Sawai Jai Singh during his reign. It is quite an impressive palace, quite pretty with his outstanding architecture and art.


Next stop was Jantar Mantar, which is the largest stone observatory in the world. It is one of the five astronomical observatories build by Majaraja Jai Singh, the founder of Jaipur. It is wholly constructed with stone and marble. The observatory has fourteen statistical instruments for measuring time, predicting eclipses and other astronomical events. Amongst all the instruments, the Sundial is the main attraction which tells the time to an accuracy of about two seconds in local time of Jaipur.
As time was running out, I headed back to the hotel and rushed for my 5.40pm train to Delhi. The train was only delayed by 30mins, but this meant that I would reach my destination at around 11pm at night. I could just imagine the chaos at the New Delhi Railway Station at 11pm, with me trying to find a taxi to take me to my B&B and being charged exorbitant rates again. I decided to call ahead and ask the B&B owner what would be a reasonable price to pay and was quoted roughly about Rs200-250.

As predicted, I was hassled by lots of taxi drivers and auto-rickshaw drivers as I got down the train. They try to grab your luggage from you, hoping that you would then have to follow them to their vehicle. Fortunately, I only had one trolley luggage and firmly held on to my luggage, pushing them aside. The prices I was quoted ranged ridiculously from Rs300 to Rs500. I finally managed to bargain for a taxi for Rs250, and it turned out, the driver didn't even know where my B&B was located. He had to stop a few times along the way to ask people. Definitely not reassuring for me.

Finally, I reached my destination, which was a residential home. In a way, the driver was pretty decent as he waited to make sure I was at the right destination before driving off. Thus, I paid him Rs300, which was his original asking price anyway. I probably overpaid again, but oh well...

I was glad that I was now based in this B&B for the next 4 nights. It is extremely tiring to be travelling from one location to the next every day. The constant packing and unpacking is exhausting.

Trip to India - day 3

Woke up early again to catch my early train to Jaipur. Was initially worried that my driver wouldn't turn up. In fact, the hotel management advised me to walk to the Eastern gate checkpoint and catch an auto-rickshaw there as they didn't believe he would turn up as well.

Nevertheless, I thought I would wait and see and if he failed to turn up, then I would walk to the checkpoint.

At 5.15am, he turned up. Yay! Was very glad he did. It was a quick short ride, about 2km to the train station. As he did not mention a price, I gave him Rs100, which I thought was a reasonable amount. During the daytime, the same trip would have only cost Rs50 and one is expected to pay 25% extra for out-of-hours (11pm-5am). And this was actually in-hours now.

And guess what? He complained it was too little. I asked him how much he wanted, and this time he said, another Rs100. What a total rip-off. Rs200 for a short 2km ride. I could have refused to pay him or give him less but it was in the early hours of the morning, with me, alone with my bags in a desolated train station. I decided it was smarter to pay him off.

At the same time, I stupidly blame myself for not agreeing on a price at the start. I have no one to blame but myself. Boy, was I pissed at myself.

The train was scheduled to depart at 6.15am and I was informed that it was delayed by an hour. Oh well, that's not too bad, I guess. Delays are to be expected. However, as time passed, we received information that the train was delayed again and again and again. It was miserable waiting at the train station, where there were no proper seats, no decent food facility and definitely no functional toilet facility. At this point, I really hated travelling alone.

Agra Fort Railway Station in the early hours of the morning

The train arrived 4 hours later, which I was very thankful for. This time, I was not seated in First Class as it didn't have any. I was seated in a Sleeper coach, where there are 3 levels of bunk-bed type seats. At this point, I was extremely miserable on the train. I was hungry but was afraid to buy food from the children who walked by selling sandwiches, thirsty as I did not want to drink water for fear of having to use the toilet and also there would be no one to watch my bags if I did, so so tired and sleep-deprived. Furthermore, there are no announcements on the train, so was also afraid of missing my stop. I tried to take short naps every now and then which was made difficult by a toddler speaking non-stop. At the end, I succumbed to buying a hot egg sandwhich for Rs10.

The journey took 5 hours and by the time I arrive in Jaipur, it was 4pm in the afternoon. A whole day of sight-seeing wasted due to the train delay. I stayed at the Hotel Pearl Palace which was pretty decent with an awesome restaurant on the rooftop. And best of all, it had free internet connection.

As it was late, I decided to rest and relax for the rest of the evening.

Trip to India - Day 2

Woke up really early to catch the early morning Shatabdi Express train from New Delhi to Agra. The hotel was kind enough to sent one of their employees to walk me to the train station as despite the hotel being only 100m away, one had to walk through an extremely dirty and busy street to get there. The employee walked me to the right platform and waited there until my train arrived. I had initially asked him to leave as I waited at the platform but he refused and said he would wait until the train arrived. I then tipped him generously for his kind efforts (or maybe that was why he was waiting?)

The train ride was quick, only 2 1/4 hours and the service was reasonable. Well, I did book first class Executive seats.

As usual, at the train station, I was constantly hassled by auto-rickshaw drivers. It can be quite intimidating, especially for a single woman travelling alone. I randomly picked a driver who did not look too dodgy and we agreed on a price (Rs60). On the way to the hotel, Hotel Sheela, which was located very conveniently near the east gate of the Taj Mahal, the driver tried to convince me to book a full day tour with him. He showed me two small notebooks which was full of reviews and comments from previous tourists, praising him in all languages (Japanese, French, German) of his good service. I was hesitant at first but then I thought, well, it would be much easier than constantly searching for an auto-rickshaw to bring me from one location to the next. So, we agreed on a price (Rs350).

The first stop was Mahtab Bagh, a park situated on the sandy bank of Yamuna River, just opposite the Taj Mahal. The main reason for visiting the park was because it was the ideal spot for taking picturesque view of the Taj Mahal.

A smog-polluted picture of the Taj Mahal from the park

Next stop was Itmad-ud-Daullah's tomb, which is fondly known as Baby Taj.

Mausoleum of Itmad-Ud-Daulah

The third stop was Agra Fort, a UNESCO world heritage site. Apparently, it is the most important fort in India where the great Mughals had lived and governed the country from here. It was often visited by foreign ambassadors and travellers during its time.

The Bengali Mahal

Inside the Musamman Burj, where Shah Jahan spent the last 7 years of his life under house arrest by his son

Diwan-i-Am (Hall of Public Audience)

After that, it was time for lunch where the driver took me to a so-called clean restaurant, which belonged to his cousin! As expected, all the customers in the restaurant were foreigners. =P

Later, the driver took me to a few emporiums (shawls, pashmina, marble etc) in the hope that I would purchase something and that he would get a commission. The prices they charged were really exorbitant, even for UK standards. These people would persuade you to buy, buy and buy and if you refuse, they would reduce the price accordingly up to the point that they asked, how much you want to pay for it. I blanketly refused to give a price as I really did not know what would be a suitable price and secondly, I didn't really want any of the things there.

I did succumb to purchasing 2 cushion covers (Rs100 each) and a lovely cream-coloured pashmina/wool shawl (Rs800). I think I overpaid for the shawl.

Finally, it was the main attraction itself. The Taj Mahal.

The Taj Mahal

The entrance fee was rather steep (Rs750) for foreigners and only Rs100 for Indian nationals. For the steep price, we were given a bottle of packaged drinking water and a pair of shoe covers. The Indian nationals didn't get anything.

As one approaches the Taj Mahal, we had to remove our shoes, but since we were given shoe covers, we didn't need to. The Indian nationals all had to remove their shoes and walk barefoot across the cold marble floor. I wouldn't have minded it that much but I would be really annoyed if someone ran off with my shoes. Maybe that's why they offer foreigners the luxury of shoe covers? Or is it just a scam to charge the steep entrance fee? Anyway, it was raining lightly when I was there and the floor was filthy with dirt and mud, making me glad of my precious shoe covers.

The Taj Mahal was indeed magnificent. There were beautiful marble carvings all along the walls on the outside of the building. On the inside, there were fake marble tombs of the Emperor Shah Jahan and his 3rd wife, Mumtaz, with the real ones underneath. It was difficult to see much inside as it was very dark, with very limited natural sunlight.

The marble carvings on the wall

I was tempted to hang around the area to take a picture of the Taj Mahal during sunset but I was extremely exhausted by then. There was an option to return later that night as during the night of full moon and 2 days prior and after that, the Taj Mahal is open for night-viewing. And the next night was a full moon.

As tempted as I was, I was too tired to wait around until sunset, which was another 1 1/2 hours to go. And I did not want to pay the entrance fee again for the night-viewing. You had to leave the area at sunset and pay again to enter. And I had to catch an early morning train again to Jaipur at 6am the next day. Thus, I went back to my hotel and slept.

My driver for the day offered to take me from my hotel to the train station the next day. We arranged a pick-up for 5.30am. As my hotel is located in the so-called Taj Trapezium Zone, which is supposedly a 100% pollution-free area, the entry of vehicles were prohibited from the checkpoints to safeguard the beauty of the Taj Mahal. The distance from the Eastern entrance checkpoint was about 500m to my hotel. I did not fancy walking alone at 5.15am across the 500m and asked the driver to walk to my hotel to pick me up, which he willingly agreed.

I asked how much he was charging for the trip, and I *stupidly* and *naively* believed him when he said, "Pay me whatever you like."

Trip to India - Day 1

Left for New Delhi, India yesterday to attend a conference on palliative care, where I had submitted an abstract of my audit project and it was selected for an oral presentation.

The flight to India via British Airways was okay. It was a full flight, made worse by screaming babies everywhere. What irritated me the most was the in-flight food. Instead of offering a choice of meals for dinner, I was given an Indian vegetarian dish, which consisted of rice and kidney beans. The meal tasted so bad that the world's best passenger complaint letter came to mind. I asked the air stewardess if there were any other options, and she basically said this is our Indian sector flight thus this is the food offered. I was not pleased and was glad that I had eaten a full meal prior to the flight.

I landed at Indira Gandhi International Airport at 5am. After passing immigration, I went to the Foreign Currency counter to exchange Indian Rupees. Apparently, it is not possible to change Indian Rupees outside of India. The customers ahead of me were exchanging huge sums of money that they were given huge stacks of Indian Rupees. When it was my turn, I only exchanged 50 pounds worth of Indian Rupees (Rs 3500) and was told-off for asking for a receipt with the reason being that I had only exchanged such a small sum of money. Hmmph!

Then, I took a pre-paid taxi to Ginger Hotel, which was located next to the New Delhi Railway Station. I purposely chose this hotel as my train to Agra was leaving at 6.15am the next morning and I wanted to avoid the hassle of finding a taxi in the early hours of the morning.

I arrived at the hotel around 7-ish am. The traffic in New Delhi was amazingly chaotic and honestly, terrifying. I wasn't allowed to check-in until 12pm, unless I was willing to pay 50% extra for my room for early check-in. I decided to wait out in the 24-hour hotel restaurant instead to have my breakfast.

The long 5 hour wait in the restaurant was physically-challenging due to sleep debt. I sat in one corner of the restaurant, had my breakfast, and tried to take short naps, while trying to pass the time. Things got a bit more interesting when a team of people came to shoot a video commercial of the restaurant. And I was in the video commercial! They went around asking people what they thought of the restaurant and came to ask me as well. I just gave a generic answer of good good, clean environment, reasonable ambience. The usual...

Finally, I got my room at 11am and went to sleep. I am getting old. Previously, I would have set out to explore Delhi, sleep debt or not. But now, my sleep took priority. Slept for about 3 hours and then went out to visit Connaught Place. The area is instantly recognizable on any map of Delhi, as it has a big circle in the middle with radial roads spreading out in all directions, like spokes on a wheel. It was modeled after the Royal Crescent in Bath, England.

It was basically a shopping and tourist attraction. Walked around, had my dinner, then came back to my hotel to rest and sleep for my early morning journey the next day.

Roses galore

Came across The Real Flower Company, and was amazed by how pretty the roses are. Maybe it's because, according to their website, each stem is individually selected, cut, prepared and tied by the people who grew them, thus ensuring the highest quality at every stage, from planting through to the beautifully finished bunches.

I am never a big fan of spending huge amounts of money on flowers, especially since in previous experience of flowers that I had received, the roses were not very good quality. In a dozen roses, one or two would be half-wilting and almost half would never bloom, and they fade away after 3 days. Thus, I found it a waste of money to buy flowers.

However, I must admit, these gorgeous bouquets of flowers on their website look absolutely divine, and will definitely melt any girl's (including mine) heart.

My address will be provided on request.

Mistake

It snowed again as I was coming home after my night shift at work. Usually, I would cherish the thought of being able to play in the snow. But it's horribly cold, and wet everywhere and I am tired and annoyed at myself.

I made a mistake at work today.

It wasn't a fatal mistake, thankfully, but it had the potential to become one if the mistake was left to continue and wasn't noted in the morning hand-over. More importantly, it was a mistake that I should not have made. I should have known better as it was a situation that I had came across many times in the past, and made the right decision. So, why didn't I do the same this time?

The only excuse I could come up with was that I was distracted. I can't say what I was distracted by in such public domains as it would involve making accusatory comments on another health care professional. Nevertheless, I should have known better and not have let the distraction affect my decision-making skills.

I went back to the hospital later in the evening to check on the patient's status. Fortunately, there was no lasting-damage due to my error.

The only lasting damage is most likely on the consultant's perception of my capability. All it takes is one error to undo everything else.

The big freeze

Views from my bedroom window

I woke up this morning to a winter wonderland. And it's still snowing...

Apparently, this is our worst snow seen for 18 years, causing schools to be closed across England, public transport to be withdrawn and the advice to only make essential journeys.

The prediction is more heavy snow later this afternoon, accompanied by strong winds in blizzard condition. I will be at work then. I, unfortunately, cycle to work, thus can't use the excuse of no public transport to arrive at work (unlike the people in London who have a day off as the trains and underground tube are not working).

Better enjoy the snow while I can....

Day out in London

Went down to London yesterday to meet an ex-university friend. We were originally planning to eat at Rasa Sayang restaurant in Chinatown but the streets in Chinatown were close as they were busy preparing the decorations for the official CNY celebration on Sunday. Thus, we moved location to Malaysia Kopitiam instead.

Through her, I found out that 2 of my ex-university friends, working in investment banking, have been made redundant and they were offered 6 months pay. Pretty generous, I must say, with the current economic crisis.

Then, met up with friends for dinner and an opera. We went to Asia de Cuba, a small restaurant at the St Martin's Lane Hotel, to try out their Bento Boxes. They were having their 10th year anniversary, thus offering their Bento Box meal for only 10 quid. Well, only one box was 10 quid. The others were priced higher.

20 pounds Bento Box - seared spiced tuna with avocado and wasabi, tempura shrimp with chilli mayonnaise, asia de cuba salad (curly endive, chayote, hearts of palm, banana, cashews, roquette, adicchio, sesame orange dressing) and shanghai noodles

10 pounds Bento Box - grilled salmon with wasabi sour cream, beef dumplings with plum sauce, thai salad (avocado, shredded coconut, orange segments and asian greens with hot and sour dressing) and havanna noodles

25 pounds Bento Box - tamarind chicken, asian pesto prawns, honey-run glazed roast of pork with sauteed shanghai bok choy, fried plantains and enoki mushrooms and coconut rice

The ambience was nice, but the food was definitely over-priced. I didn't particularly enjoyed it as it was too salty for my liking.

After the dinner, we proceeded next door to the English National Opera, at the London Coliseum, to watch the Magic Flute.

It was a nice opera, and the first opera that I have been that was sung in English, which surprised me at the start. I am used to watching the subtitles as previous operas have all been sung in Italian or German, but I didn't need to in this one.

And then, it was a rush to catch the train back as I had to work the next day. Sigh....