Hospital, hospital, hospital!!

Hospital, hospital, hospital!!

Recently received an email from one of the readers of this blog asking me to write something about myself.

I also received another email from UK asking me to update this blog more frequently if possible. OK, OK......., certainly many doctors in a Malaysian public hospital will share with me the same feeling that while serving in a government hospital in Malaysia, you are mentally and physically prepared to be underpaid and overwork!

Today, there are 44 patients in my ward and three of them are critically ill. You can expect that you will never get enough ICU beds in hospital because there are simply too many patients in this country and too few beds!! I am running up and down of my ward and calling up other wards to beg for extra beds for my overflow patients.

We do not have enough beds not because we do not have enough hospitals but simply that our people just cannot afford to pay to go to private hospitals. There are more than 6 BIG private hospitals in Penang but these hospitals for the RICH only and of course, for those who have a medical card.

I do not know what the policy makers are having in their minds in this country. I anticipate that our country is going to be broke soon if we continue to practise subsidized healthcare system.

What I can see everyday in my hospital is our people are getting poorer and poorer although you may be bombared by news that our economy is great and we have produced the every first muslim astronaut in the World.

We need changes in our healthcare system. We have to make our healthcare more affordable for everyone and people can assess the healthcare system easily. No point if you say that we have the cheapest healthcare system in this World when large number of patients are clamped in a congested ward with limited numbers of staff nurses and doctors.

If we overwork and underpaid, we are providing sub-optimal care to our patients. And you can't expect our people to have first world mentality when they are getting third world salary!!

Flow Volume Loops in MRCP

OK, if we talk about respiratory in MRCP, there are two important topics to learn before you decide to take your MRCP part 1 and 2. I think all MRCP candidates should learn by hard flow volume loop and spirometry because you will be expecting a lot MRCP questions about these two topics.

Today, we are going to learn about flow volume loop, a flow volume loop is produced by plotting flow on the y axis against volume on the x axis.

If a subject inspires rapidly from residual volume (RV) to total lung capacity (TLC) and then exhales as hard as possible back to residual volume, then a record can be made of the maximum flow volume loop.

1) Normal Flow Volume Loop


Normal. Inspiratory limb of loop is symmetric and convex. Expiratory limb is linear. Flow rates at the midpoint of the inspiratory and expiratory capacity are often measured. Maximal inspiratory flow at 50% of forced vital capacity (MIF 50% FVC) is greater than maximal expiratory flow at 50% FVC (MEF 50%FVC) because dynamic compression of the air-ways occurs during exhalation.

2) Obstructive disease ( asthma, COPD)


Although all flow rates are diminished, expiratory prolongation predominates, and MEF < MIF. Peak expiratory flow is sometimes used to estimate degree of airway obstruction but is dependent on patient effort.

3) Restrictive Disease ( interstitial lung disease)



The loop is narrowed because of diminished lung volumes, but the shape is generally the same as in nor-mal volume. Flow rates are greater than normal at comparable lung volumes because the increased elastic recoil of lungs holds the airways open.

You may find the graphs very confusing, just remember a few principles here,

1) In obstructive airway disease, due to airway obstruction, the PEF ( Peak expiratory flow rate) is lower than normal ( refer to above graph).

2) In restrictive lung disease, patient total lung capacity ( TLC) is compromised due to pathology ( such as fibrosis), therefore, you notice that, TLC in restrictive lung disease is smaller as compared to normal flow loop.

( One thing to remember, the value of X axis of the flow loop get smaller toward the right!!)



Source:
1) The Merck Manual