Christmas eve dscharges

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Everyone of those bulleted names needed to be discharged.

Merry Christmas and Happy New Year everyone!

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Overlook, discharge and admission

1. Overlook

Last week I missed an important blood result in one of our seriously ill patient which indicated that the patient might have had a heart attack. I was taking blood for our patient in another ward when a staff nurse told me that my ward called me back as prof was doing her rounds (she does come randomly and unpredictably). I quickly settled that and went back. Just as I joined the round, my MO then asked me in an alarmed tone ‘why didn’t you informed us that that patient’s trop-t was raised?’ In a reflex to defend myself, I said I did and said I dismissed it because it may raised due to the patient’s underlying chronic kidney disease. But on second thought, I really cannot recall noticing that particular result. The patient was already on day 2 of admission and has been treated for sepsis and respiratory failure and the team was concentrating on the inflammatory markers (WCC, CRP) and the ABG. Only on that day that they have noticed the raised Trop-T and treated the patient for a possible heart attack. Prof told me off for not realizing and informing the team about it. I was not the only one who has seen the patient. The blood was taken when the patient was admitted – the oncall HO, MO, registrar would have seen it; prof, my registrar, my MO and myself have seen the patient on the day before, so why do I feel like I alone have to take full responsibly and the blame for everything? In the past, an MO had told me to really be careful to double check every clinical decisions with our seniors or other specialty as there is a strong blame culture in this hospital, and I finally had a taste of it. Fair enough, I have overlooked it, but I’m not the only one who is in charged of the patient. Still doesn’t stop me from feeling bad – what if the patient has really had a heart attack? Anyway cardio came to review the patient and also thought that the raised Trop-T was due to the underlying kidney disease and there’s no heart attack. Relieved.

2. Discharge and admission robot

On average, we have about 4 discharges per day, shared between two of us (Debbie and I the house officers). On Friday as it was Christmas eve, Debbie took leave (which our specialist, registrar, MO and I had to sign to approve – what a task!), and my seniors decided to go crazy with discharges - 13 patients all together. 13! That's clearing half the ward!

My record before this was 9 discharges on my first week of work, then the team was nice enough that the specialist, registrars and MOs helped me out with a few. My personal discharge that I've done myself was 7. Yesterday, without Debbie around, I was completely overwhelmed. There were 2 registrars and 2 MOs, but they all disappeared after the ward round. I know we have patients at other places to see (ICU, HDW (High dependency) etc but only a few, 3 patients I think) but I was hoping that at least one of the MOs would stay behind to help do some of the post-round referrals, phone calls while I do the blood taking, prescribe, fill in forms and other small jobs. Nop. I had to do everything myself. Started discharge at 3:30pm. Then my MO did a pleural tap, and threw all the samples for me and asked me to label and send them of and do some more bloods (WTH!!! When I’m stressed even small things like this can wind me up. Staff nurse ended up helping me – I love her). Did not stop at all, finished last discharge at 9:30pm. Dreaded to think that I was also oncall after. By then, already 3 new admission and numerous cannula and blood waiting for me to do. Settled everything by 5am. Had a quick lie in until 6am. Two new unstable admissions came in. Settled those by 7:30am. Went to HDW to do the morning bloods but did not do the usual morning bloods in my ward. No time to shower or wash up, did not eat but couldn’t care less. Continued with ward round, then take the routine bloods during lunch time (which was supposed to have been done before the round). Had something to eat (which my mum so kindly brought in the day before), (forced to) made a ridiculous request for an US guided pleural tapping (which was supposed to have been done my MO but she wanted to go back home), then hid in the seminar room to sleep for half an hour. Sigh… trying very hard not to be angry with my MO because she is very nice and very hardworking and is pregnant and would not have any maternity leave after because she’s a masters student (not allowed to interrupt her studies) and she has been covering the ward alone for a few weeks now (the other MO cannot because she hasn’t got her MMC registration and cannot write or sign anything in documents, nor do any procedures), but I do feel being taken advantage of and get the blame for everything. Staff nurse said on discharge day my face was red and admission day my face was white. Reviewed all the bloods I’ve taken then went back home at 5pm. Totally drained. Called Debbie to pass over and de-stress. Messeged prof to rant. ‘Well done!’ she replied. Robot is flat and today is strictly for recharge only.

Relatives and patients: please note that discharge and speaking about progress on condition, in the doctor’s book, is not urgent. We do have lives to save and I am sorry if you have to wait two hours to speak to the doctor, or until 10pm to be discharged.

Signing off. Recharging continues.

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Work pictures

Debbie, me and my ex-registrar (Dr Yusniza)

Pink day - students, me, Aida, Yusniza, Dr Rosmadi (my ex-registrar - standing in the middle without whitecoat) and Dr Andrea (my ex-specialist - petite one standing next to Rosmadi on the right)

Me, my ex-MO (Dr Aida) and my ex-registar (Dr Megat)

Blue day - students, me, Aida, Megat and Andrea

Oncall room

Me at work and post-call (can you feel my exhaustion?)

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Surviving house jobs - excerpt from the bible

If some fool or visionary were to say that our aim should be to produce the greatest health and happiness for the greatest number of our patients, we would not expect to hear the greatest cheering from the midnight house officers: rather, our ears are detecting a decimated groan - because these men and women know that there is something at stake in house-officership far more elemental than health or happiness: namely survival. Here we are talking about our own survival, not that of our patients. It is hard to think of a greater peacetime challenge than these first few months in the wards. Within the first weeks, however brightly your armour shone, it will be smeared and splattered if not with blood, then with the fallout from very many decisions which were taken without sufficient care and attention. Not that you were lazy, but force majeure on the part of Nature and the exigencies of ward life have, we are suddenly stunned to realize, taught us to be second rate: for to insist on being first-rate in all areas is to sign a kind of death warrant for many of our patients, and more pertinently for this page, for ourselves. Perfectionism cannot survive in the clinical world. To cope with this fact, or, to put it less depressingly, to flourish in this new world, don't keep re-polishing your armour, rather, furnish your mind and nourish your body. Do not voluntarily deprive yourself the restorative power of sleep. A good nap is the order of the day - and for the nights, sleep for as long as possible. Remember that sleep is our natural state in which we were first created, and we only wake to feed our dreams.

Copied from the Oxford Handbook of Clinical Medicine, 7th edition.

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I dread

I'm not bad at blood taking and cannulation, so I do get called a lot to help out especially with difficult ones. But who knows my hidden hatred for such patients? The sorts of patients that i hate are: 

1. Nephro - cannot use one hand because needed for AVF formation; needs blood taking daily to monitor renal function and VBG, stays in hospital for ages because they just don't get better. Worst ones are when AVF failed on one hand already, another hand not allowed to use, leg veins already ruined by other house officers - how and what do you want me to do?

2. Obesity - Obese patients should be barred from coming into hospital. Do you have any idea how difficult it is to see or do anything through those thick subcutaneous tissue? Same applies to oedematous patients.

3. Relative - who refuses to go out, who peeps through the curtain when I specifically asked you to go out and wait faraway. Yes, torture session of your grandmother in progress and I don't think you would derive any pleasure from seeing me poke her for 10 times and I asked you to go away for good reason.  

4. Patient - who tries to be helpful by moving around, thinking that they are smarter than me, who demands for left leg instead of right when I have another 5 new patients to clerk in, who kicks and jumps, who has ridiculously low pain threshold, who moans and groans non-stop when I am doing you a service and trying to save your life (be informed that any plea, prayer or piss would not stop me from doing what I do, which is usually to persist until I get it, even if I have to poke you 20 times). 

I value my relationship with my colleagues. I try my best to be a good team player. I am usually willing to help out with anything whenever I can, but doesn't mean that I don't dread it. But sometimes I wish I'm not, so someone else can be called to help, because I am spending ages to deal with these difficult bloods. A difficult cannulation will take at least 20 minutes and I'd much rather be doing something else. As well as a pair of good hands, I think I have good brains as well and I'd like to use it more often rather than just spending so much time picking up other people's mess.

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