A Visit to Dr. JB Lim at Wound-care Centre on July 13, 2017

A pose with Dr. JB Lim at the wound-care centre, PJ

My most-learned e-buddy Dr. Lim Ju Boo was admitted to the Angels Hope Caring Home in Kg. Tunku, P.J. for “maggot therapy” for his long-standing leg ulcer since Monday, July 10, 2017.

After obtaining the address of that wound-care centre from Magdalene Lim Ai Lian (Dr. JB Lim’s niece), I decided to pay him a visit on Thursday, July 13, 2017.

My wife and I left home at about 10.35am and we reached Kg. Tunku at about 11.15am.  We met Dr. Lim who was currently the only live-in patient in the Caring Home and his caretaker/cook, a certain Mr. Lance from the Philippines.

Dr. Lim explained to me about his leg ulcer problem and most of the story I have already learned from our WhatsApp Chat Group.     

In his own words the story went as follows (abstracted from WhatsApp messages):

“I was supposed to see my friend, a neighbor of mine who is a senior orthopedic and micro-vascular surgeon last Tuesday about my left leg ulcer which is not healing for months now. Just as I was leaving my house to see him I suddenly felt my leg very slippery. I normally do my own dressing at home, and despite the best wound care I gave to myself together with many other leg ulcer medications, the ulcer is not responding. So that afternoon when I felt my leg was very slippery, I thought it was the dressing which has leaked. When I looked down I saw a pool of blood on the kitchen floor. It was bleeding profusely. I must have lost at least 500 ml of blood. Luckily I did not go into hypovolemic shock (shock due to massive bleeding).

As a doctor also trained in emergency medicine in KLH, Selayang Hospital and at UKH (Universiti Kebangsaan Hospital) and also previously a Regional Staff Officer in charge of training for St John Ambulance, I managed to stop the bleeding by compression with layers of gauzes. I then immediately I asked my wife to send me to the emergency department of Kuala Lumpur Hospital (KLH) instead of seeing my orthopedic friend who also works in the same hospital.  

After a preliminary examination of my wound by medical assistants there I managed to see the medical officer after over 4 hours of waiting (too many patients). That was around 5 pm. I explained my problem to him and told him I probably have arterial ulcer from the clinical presentations, features and history (signs and symptoms). It was over the lateral side over the malleolus (outer left side over the ankle bone). Other symptoms was ‘rest pains’ especially at night, relieved by dangling my affected leg over the edge of the bed (gravity assist the blood to flow downwards towards the feet and supply it with blood and oxygen).

The ulcer was a punched hole type, so typical of arterial insufficiency instead of vebous stasis ulcer which normally occurs on the medial (inner) side of the legs. There are many other clinical features too that points it to be an arterial ulcer. But to make a long medical description very short, the doctor at KLH agreed with the same opinion. Anyway he referred me to a more senior vascular doctor who did not come until some 3 hours later as he has to attend to other cases than very busy night.

Then he came around 10 pm and saw me. I explained the same thing, and he too agreed it was an arterial ulcer. But to confirm the diagnosis, he has to measure the blood flow to my legs, and he did not have that Doppler’s machine then. So he asked me to wait. I waited and waited for another 3 hours or so. Then he came with another two other doctors with the Doppler’s ultra sound blood follow machine.

They made several measurements, and found the blood flow was normal, and it could not be an arterial ulcer due to arterial insufficiency? So all the doctors’ diagnosis was wrong then.  All in 4 senior emergency and vascular doctors initially thought the same thing as I thought, until the Doppler’s blood flow measurements showed otherwise.  

So he asked me to wait as he will call in the vascular surgeon for another opinion who was tied up with an emergency surgery that night, and that will take some time. I waited and waited…and waited till past 1 am but she never appeared. So the surgical registrar told me she has gone to the yellow zone (Triage System) to attend to semi-urgent cases.

Finally at around 5 am the next day, the registrar phoned me and also asked another doctor to attend to me. The doctor then asked me also to go for an x-ray on advice of the vascular surgeon whom the registrar phoned (I supposed many times).

But she never appeared. But another medical officer saw me to convey the message the surgeon told the senior surgical registrar that all I need was some daily dressing. It looked like so jokes to me.

Then this other lady (last) doctor told me my x-ray was normal, and that I need not be admitted, but just go for daily dressing and the surgeon will review my case at the SOPD (out-patient surgical clinic in 3 week’s time). So all I got that entire afternoon till nearly 6 am the next day was just waiting and waiting and waiting. It was so crowded even in the dead of the night.

I went for the dressing before I went home at about 6 am the next day. It was nothing great about that dressing. It was a normal dressing anyone can do at home. I have been doing this on my own at home for months now. All I got that entire afternoon till early the next day was some rubbish pain-killers (Tramadol and Voltaren) from the pharmacist who was sleeping at the hospital pharmacy when I went there to collect the NSAID analgesic. I have to wake her up.

All the same treatment (wound dressing, antibiotics and painkillers I have been doing this for months). The only benefit I got that entire day till dawn was the measurements of the blood flow to my legs using the Doppler Ultrasound machine which I had wanted to buy months ago to do the same measurement. It cost RM 12,000. So I did not want to buy. What for? Just to measure the blood flow? I can do this myself by palpating the posterior tibial artery over the ankle joints, and over the dorsalis pedis artery (on top of the foot). I have done that, and both pulses can be felt, including the popliteal artery (behind the knees). There was also no “femoral delay” suggesting the blood flow to the lower extremities. But I wanted the Doppler US machine to make a more objective and direct measurement rather than a subjective clinical assessment which I did and other doctors also did.

Now the machine tells us the flow is normal, and so it cannot be an arterial ulcer?

I then asked the senior surgical what is it then? He thought for a while and told me probably it is a venous stasis ulcer which I totally do not agree. The clinical presentations between an arterial and a venous ulcer are entirely different. We all know that. Furthermore, I am not diabetic nor do I have varicose veins to diagnose it as venous ulcer. I asked him, and he said that in medicine sometimes the signs and symptoms are quite un-classical and opposite. That is the only thing I totally agree with this senior surgical registrar.  The rest are all rubbish including the dressing the nurse gave later and the pain-killers.

This afternoon I went to see my heart and vascular surgeon youngest brother at Gleneagles Hospital and he will attend to me with surgical debridement of the wound later. His very experienced and qualified Pilipino nurse gave me a good dressing this afternoon. I shall go back to her tomorrow.

I have also seen a doctor at Selayang Hospital 3 weeks ago and he just gave me Solcoseryl jelly to apply once a day. But that is also useless. It is not healing. In fact it became bigger.

Even hyperbaric oxygen therapy at RM 400 per session has not worked, and I have already undergone 25 sessions.

So I am at a loss what to do with my leg ulcer which is not healing with the best wound care I have given to myself. But I know that arterial and venous stasis ulcers are extremely, extremely hard.”

In another message, Dr. Lim wrote:

“There are a lot of doctors of various speciality in this chat group, and in another chat group in our university alumni, there are almost entire (99.99 pc) doctors. My own family of siblings and their children are also almost 80 pc doctors of various speciality, but most of them are working in various hospitals in Singapore, except my youngest brother Lim Yew Cheng who is a Professor of Surgery, formerly at SGH, then at UH University of Malaya, now at Gleneagle KL as a Consultant Cardiothoracic and Vascular Surgeon. My neighbour in Gombak Mr Jaremin is also an orthopaedic surgeon at KL H. With so many many doctors in this and another chat there is no shortage of doctors whom I can seek help but none so far has been able to help me. Initially I tried to manage my ulcer on my own until I gave up. I just cannot manage it on my own anymore.  I have already seen 5 doctors so far at IJN, Selayang and at KLGH including my brother Yew Cheng who suggested I do a biopsy and go to another hospital. But I would be going round and round the bush like a rolling stone gathering no moss, because I already have a medical record there. In fact my initial self diagnosis is an arterial ulcer which normally occurs over the malleous ankle bone on the lateral side of my left leg. It was initially very small with a punch hole feature and very painful (rest pain), and with intermittent shooting pain which disturbs my sleep. It is not on the medial aspect of my leg which would be venous stasis ulcer. I sometimes get relief by standing up or sleeping with my legs dangling over the edge of the bed. These clinical presentations are so characteristics of arterial insufficiency although I do not suffer from intermittent caudication. I am not diabetic or have prominent varicose vein. Neither am I a smoker. This was my initial provincial diagnosis, and 4 others doctors at Selayang and GH initially also agreed with me except one. When I saw a surgical registrar and later a trainee vascular surgeon at GH, initially they too think the same, until they did a Droppler, followed by an ABI (ankle.brachial index) they found my arterial flow is not compromised. So now they changed their diagnosis and feel it is probably a venous stasis ulcer. The vacular surgeon then sent me for wound dressing daily, but the GH wound care unit told me they do not open everyday, but only on Monday and Friday. 

I really do not know what they are doing in between.  But when I told them the surgeon wanted me to go there every day, they said the surgeon does not know, as she is new. This amazes me. I do not know what they do in between Tuesday and Friday?  When I went to my brother clinic at Gleneagle, the nurse there did a C n S for me to find out which is the best antibiotic to select. The result showed a very growth of Stapaureus which is a very common skin infection we all know. The culture gave a list of antibiotic for the clinician to select, but the surgeon at GH ignored the result of the C n S and prescribed Augmenting instead much to my horror whereas my far more experienced and much more senior vascular surgeon brother said I should actually be given intravevous antibiotic augmented by proper wound care. So I really do not know what's going on in all these government hospitals. KL GH is the biggest govt hospital in the country but their appointments in between are weeks and months apart. Just imagine there is a lot of slough on the ulcers every day even with daily dressing, but GH wound care unit only open twice a week, and the last appointment with them is 2 weeks apart before and after Hari Raya. What's wrong with all these doctors and care givers in all these govt hospitals? Their care and services beats my understanding. 

Just imagine, I saw my surgeon at GH one month ago, and she told me to come back to see b her again after the "daily" dressing on the 21st of July. She promised me I will get better and better after "daily" dressing and will do for me a Duplex scan in two weeks’ time to confirm it is not an arterial ulcer I supposed?  All these government hospitals are the same. Many of these doctors are beyond belief in their diagnosis and management.  I have a lot of trouble with them when I was working with them when I was working at the Institute for Medical Research.  Their knowledge is beyond belief.  They are completely out of tune. Many of these young Malay doctors these days do not know what are they talking about. Their knowledge, diagnosis and management are just completely "outside this world" of modern medicine. You talk to them in very elegant medical language, they reply you in pasar malam Malay. I just do not know which Arab country they graduated from. Maybe from Indonesia or from Bangladesh?  Definitely not from British universities or from NUS Singapore. 

So now  go to my brother's clinic at Gleneagles every 2 days for dressing only. Gleneagle hospital is far too expensive for me to be admitted. 

But before that I went for 25 sessions hyperbaric oxygen therapy on my own and some 30 sessions of intravenous oxygen therapy. The hyperbaric oxygen therapy initially showed wound closure, but when they started to renovate that place in Titiwangsa, I could not use it anymore. Then the almost closed and responsive wound started to break open again until now it is much larger in area but more shallow as if it is like a venous ulcer. 

I am confused now with my own diagnosis along with 5 or 6 other doctors, because the clinical presentations, history, features etc are all suggestive of arterial insufficiency, but the scans showed otherwise, now suggestive of venous ulcer.

I am supposed to go back to GH tomorrow just to get the compression socking to support my vein (if it is truly venous ulcer). Mine you this is just to get this socking over one month after I saw this vascular surgeon.

This is the way they do things in goverment hospitals only twice a week for wound dressing, one month later just to get the compression stocking, and some two months apart for the next doctors appointment. 

Meantime, my ulcer is getting worse.

That's why I now go to a private wound care centre in PJ for maggot therapy to clean up all my necrotic tissues, to be followed up immediately by hyperbaric oxygen therapy at 2.5 atmospheric pressures for 90 minutes per session. As long as the yellow slough is there granulation and epithelization over the ulcer can never take place, and the wound can never heal. It is as simple as that.

The mistake I did was I went for hyperbaric oxygen therapy first, as I did not know where to go for maggot therapy.

Very few govt hospitals in Malaysia knows about maggot therapy even though it is approved by FDA as well as our Ministry of Health (MOH) All doctors know are treatment by drugs, dressing and surgery only. Even hyperbaric oxygen Mx are found only in two government hospitals, and both are military hospitals in Lumut and Tuanku Mizam hospitals in Wangsa Maju for manganing diabetic foot ulcers and bends for undersea divers and cannot be used by civilians. 

Hopefully this modality will bring a swift wound closure I have been suffering for nearly a year now.

Lim ju boo Msc MD PhD FRSPH FRSM “

Dr. Lim with the Filipino caretaker Mr. Lance

Dr. Lim poses a photo sitting on his bed

Dressing room

Bedroom on the left and kitchen on the right

The gift I brought for Dr. Lim

During our chat, I reminded Dr. Lim about the preparation of materials for his presentation at the upcoming “7th International Conference for Holistic Healing in Cancer” to be held on Saturday, August 19, 2017 from 9:00am to 5:00pm at Brickfields Asia College (BAC), VSQ @ PJ City Centre, 11th Floor, Block 2, 6,  Jalan Utara, Section 14, Petaling Jaya.

There will be 8 speakers from China and various countries including Malaysia, and Dr. J.B. Lim and his brother Professor Dr. Lim Yew Cheng will be two of them.

Dr. JB Lim will be speaking on the title of “Cancer: The Past, Present and into the Future”.

He stressed that normally international conferences like this cost around US $1,000, but this conference lasting the entire day with morning and afternoon tea, plus lunch is ENTIRELY FREE, but one need to register in advance

Dr. Lim informed that he had already prepared some 75 slides for his presentation. He said:

“They are highly technical slides, but I shall translate and bring them all down to earth with my simpleton explanation in such a way that from highly learned professors to the man-in-the-street can understand every sentence of what I try to explain. The hardest section will be on epigenetics and therapeutics responses of medicine of the future where the super computer will replace the doctor for the "best fit drug for epigenetic variations among individuals". But bear with me it shall be clear and interesting as crystals a futuristic medical vision we need to leave this to the future scientists whose brains shall evolved far better than ours. Just come and listen. I shall fly with you high up to have a birds eye view on this exceedingly complex challenge. Your presence there is all what I need, not here in this care centre.”

My wife and I left at 2.30pm wishing Dr. Lim that he would get well and be discharged soon to return to his home soon.  I feel great after visiting this wonderful friend of mine.

  

(Note:  The reproduction of Dr. JB Lim's messages from the WhatsApp chat group serves as educational information and does not mean to offend anybody.)