No better

Yesterday I saw 6 month old Amin, and the mother immediately told the husband 'This was the doctor who delivered Amin!' Gosh, it's been at least 6 months already since I left the most exciting posting (O&G).

Motivation level is at an all time low. I am actually now quite envious of my sister's job as an office lady (OL) as I imagine her going into work at 8am completely relaxed, starting the day with a nice cup of coffee and some petty chatter. While me, I start the day feeling very sorry to disturb those poor sick patients in the midst of their slumber at 6:30am before the sun even before dawn, apologetically interrogating them regarding their symptoms, appetite, bowel and bladder habits. knowing that I would run late no matter how early I arrive only because my registrar is such saddist that he would arrive 10 minutes after me and I would get a sounding for not having reviewed all my patients.

Now, with the emergency department, the working hours are much better. But I still feel very empty. I find myself going to work everyday going through the motions of clerking, clerking and more clerking. The patients just wouldn't stop coming in. There is nothing exciting enough to bite me (apart from the other day when I put in my first triple lumen).

Save me, I'm bored.


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Meaningless life

I'm now trapped in a viscous cycle of self apathy. Nothing in life interests me - Unmotivated - Uninterested - Stays at home - Eat - Watch TV / Play computer / Read story books - Sleep.

I wish I could go back to those days in university and college. I was a busy lady. Every minute of my life was filled with something meaningful. The course was hectic, but still a ride in the park. I do part time job, sign myself up to about every extra-curricular activities - literally doing WHATEVER I LIKE! Boy, that freedom was so refreshing and life was so meaningful then.

I long for that life.

Have finished surgery. It's ok. Nothing terribly exciting. Wouldn't say I learnt that much. Just work. I wake up, go to work, finish work, feeling so very tired, eat, sleep, and work again the next day. And work everyday is absolutely the same. Round, jobs, round again, jobs again.

As I'm on leave now, I went to several shopping malls, but have failed to buy anything. I'm so disappointed. I just didn't find anything that I particularly like. The only things I seemed to be buying again and again are soaks and thighs. I don't know what's behind this obsession.

Save me from this routinely mundane.

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Stop moaning - Make it happen

I am angry at my little sister. Angry at her immaturity. Angry that she never takes advice. She just moans and expects people to listen to her going on and on about how other people are always the ones with bad ideas, and no one listens to her brilliant points.


All I was doing was to try to make her realize that she's not the only one in the world fazed with problems. She said her friend suggested a car wash project for her interact club, and immediately she thought of so many problems that could prevent it from happening. I told her to list down all the problems - and when she finished, I thought all the problem were so easily resolved that it shouldn't have been an excuse for rejecting the idea altogether. A leader is one with a vision, and the leader with inspire other to work towards the vision, gathering the support of her fellow teammates and teachers. Someone who only dampens the team spirit by dwelling on obstracles but offer no solution has no place in a team, and certainly is not fit to be a leader of any sort. A car wash project is amongst the easiest way to fund raise at school level, and if even that cannot happen in her opinion, and wouldn't take people's advice to make it happen, I can only think that she is either too arrogant herself or simply incompetent. At that point, she started to go:


'Yes yes yes you are right, you are right, no need to talk anymore, i don't want to hear anything from you anymore... ahh yes yes yes you are right you are right.' She is always like that, silencing others and refusing to listen.


Talking to her nowadays is terribly frustrating. I just cannot get through to her at all. She is having some kind of identity crisis that she just keeps befriending Cheng and ignores me all together. I recognize such behaviour. Stray, insecure kids in school without a gang would try and own a friend like that so that she has a bestfriend, and would get angry when the other person doesn't return the loyalty, or doesn't regard her as the best friend and would get jealous when over time her 'best friend' finds another close company to replace her. Whatever I said is wrong and does not even deserve an answer or an acknowledgement. That is rudeness, that is. Her behaviour is annoying me so much so that I am thinking of moving out. And that she thinks she is better than others and she is able to lead are indeed the most naive ideas. Pity, at such tender age that her minds are closed. And I certainly hope she overcome her own arrogance and learn from others, even from those she regards not as clever as her, with a sense of humility.


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Farewell

So four months have passed and I have finished O&G. I have enjoyed this posting and really would not mind doing it again. The following two points summarises my feeling towards O&G.

Dislike: Treated like slave, too many oncalls (max for me 12 in a month), calling the whole of Peninsular Malaysia hospitals to find ventilator for our prem babies, TDS round, medico-legal issues, having to refer ridiculously simple problems to our registrar (eg: can I give Paracemtamol?), treating doctors I know (most doctors and nurses are at their reproductive age)

Like: My HO friends (Amy and Sha), my specialists (all of them!), my registrars (most of them), daily grand round, presenting cases and getting feedback and teaching, having time of eat, O&G night, labour room calls, caesarean sections, gynae-onco attachment

When I started things were pretty challenging. Including me there were three HOs, but one left a week after I started (he finished) and another one was down and out with depression (and never came back after the long sick leave). So, soon after I started, I was the only HO in the ward. (Déjà vu: I was also the lone HO in the ward when I started in medical, replacing another HO who quitted because he couldn’t cope with the workload). Luckily, the registrars were helpful and specialists were not too fussy. Still, I nearly died on one day, when all the ladies in Cheras decided to fall ill or go into labour at the same time. I clerked in all 9 patients who came rolling in non stop all by myself, whilst having to think about the review VE due, taking baby’s blood, pm round which I haven’t even started (and the ward was full), and with discharges not done yet by 3pm, and nurses and relatives kept asking if I have finished this and that. I was so ready to just drop everything and run out of the damm ward to bury myself under the blanket. But the registrars were ever so understanding and encouraging, so I hang on. With the arrival of another HO came on my second month, the workload was much more bearable and life became a super-relaxing with the arrival of our third HO in my third month.

The nicest thing about O&G is that we save lives, literally, on a daily basis. Babies quite often come out requiring some sort of resuscitation. We do a hell of a lot of caesarean sections to prevent life-threatening complications of pregnancy. But we also deal with death. It is interesting managing cases of intra-uterine death and miscarriages when psychological issues come in.

The hands-on part of O&G is addictive. I found labour room was so enjoyable that that I have requested extra calls (LR rather than ward calls, and it’s easy to get because other HOs generally prefer ward call so they can sleep for more hours at night).

With practice, skills can only get better, and the better I get, the more I want to do it. For example, I started off really dreading suturing the perineum after delivery because I take so long that midwives keep coming into the room to hurry me along, and I almost always had to let someone else take over. There was once the patient whose vaginal wall tear I repaired ended up with a haematoma and I was really scared. What have I done? From then onwards, I really paid attention to how I suture for the wound to heal up nicely. After a while, I was surprised to find that even a clumpsy and slow learner like myself can actually suture. From the second months of the posting, I was confident enough to manage all the perineum repair, easy or difficult, on my own and was proud to not need to call my registrar. Registrars are normally supposed to do the suturing after instrumental deliveries, but I have been asked to do it a few times, and the patients recovered without complication. I started timing myself, learnt to use the forceps rather than my finger to grasp the needle (more difficult, but better to prevent needle stick injury), think how I can improve the cosmetic etc.

I respect doctors who choose to take up O&G. It is certainly not a specialty for the faint-hearted. Trainees are oncall as often as the house officers. Their training can be extended too if they do not perform up to standard. They get bashing from the specialists more often than us. They need to live up the constant pressure. But I can see the attraction. Life is quite good as a specialist with plenty of opportunity for private practice. It is not too difficult and one can really make a difference to people’s lives.

I have really enjoyed O&G and am so sorry I am leaving this fantastic place.

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Ward round wind up

In my team, it is not compulsory for HO to present the patient in ward round. When the medical students were around, they presented all the patients. And when they were gone, the registrars would present all the cases. Nevertheless, every weekday morning is a stressful time in my team because there is a daily grand ward round. So sometimes, when few registrars have gone on leave, she/he in th ward would not have seen all the patients before the specialists arrive (at 8am). When no one is volunteering to present, the house officer has to step up and say something (although my fellow HO Amy was lucky enough to not have to present a single patient since she started working in this ward).

Presenting in the morning grand round is an intimidating affair. Four specialists scrutinize every detail you say and would jump at the chance to attack you, sometimes with clinical mismanagement, other times with the way you present or would simply ask question that you cannot answer. It is not only the house officer. The medical students and registrars get plenty of that as well. Shouting and scolding are the norm in the daily grand ward round.

Today was such a morning. Started with a patient who has been leaking and started Prostin induction yesterday, and was due for a review vaginal examination (VE) done at 5pm, which I had done and informed the registrar. Usually the registrar does these Prostin review VEs. When I told the oncall reg about my findings, he said he would review the patient himself later after the ward round (at 10pm) as he was not going to put in a second Prostin so late in the day. That was why I didn’t write down my 5pm findings. The specialists said I should have documented the things that I have done and that the registrar should have been called to insert a second Prostin at 5pm. I do feel bad for this because if I had insisted for the reg to come and put in the second Prostin at 5pm, the woman may not have been left leaking for so long (which put her and the baby at increased risk of infection).

Later on, I presented a case of hyperaemesis gravidarum rather smoothly, with only one point missed on the scan. (Prof S asked ‘Is it a viable pregnancy’ inpatiently). And when I finished, she said ‘Continue same’ and moved on. Phew.

Then I kept on being attacked on my handwriting – apparently too small. ‘Can you write any smaller?’ Dr L kept on shouting at me as we moved from one patient to the next. ‘Do you have Parkinson’s? Write smaller. Yes, just keep telling her to write smaller’ Dr N joined in the bombardment. At least my writing was neat and legible, although admittedly small. The thing is: the more stressed I am, the smaller my handwriting becomes. Specialists ought to know that.

The last straw came when Prof A (who had finished round on the other side of the ward) rejected a letter to a patient’s employer that I have written because I had just addressed it ‘to whom it may concern’ and rather than the employer specifically (and drew big circle around like a school teacher correcting someone's essay. The other four specialists read the letter out loud and agreed Prof A's point in unison. ‘What if she brings this letter to claim insurance? A big responsibility for someone as young as you to shoulder isn’t it?’ Prof S’ final words of advice, and left. Malu-nye...

‘Why do I keep on getting shot at today?’ I asked Amy, the other HO. Right after the round, we went down to the canteen and ate away our resentment.

Actually despite all of these, I do like presenting because we always get feedback on the way we present, clinical management and get asked difficult questions. I much prefer to learn this way than the British – ‘well done’ always because we pick up things much faster. I have learnt so much and have become more confident with each case that I’ve presented. I am an aduIt, I don’t take scolding and critism personally, and I have never been made to feel less than human, which is good enough for me.

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A new jungle - O&G

I have been in O&G for more than a month and a half now. The reason that I have not written about it was because I hated it. But it has changed now and it is really out of expectation.

I hated O&G at the beginning because everyone seemed so hostile. Whenever people speak they speak to me or I speak to them, it’s as if they want to pick a fight, even with some of the fellow HOs. The atmosphere was just so hormonal and unfriendly.

But then over time I got to know my colleagues better. Few, I realized, are truly nasty from the core. But most are actually good men and kind women. They teach me and help me with lots of stuff. When I started off, I had two fellow HOs in my ward. But not long after, for 2 weeks I was the only HO in the ward. That was crazy. I couldn’t even do my labour room daycall as there was no one covering the ward.

There are four specialists in my ward. Of all the teams’ specialists, they are the most hardworking ones. They come everyday at 8am for grandround. So we have to see all the patients and sort out all the pre-round jobs before 8am, which is bloody mad. I come so early, sometimes as early as 5:30am but still never seemed to have enough time to see all the patients. But round usually finishes by 9am, which is nice. If the day is not unusually hectic, we can normally go home by 5pm.

At the beginning, I was assigned to 14 oncalls for my first month. But as more new HOs arrived, my calls had reduced to 11 per month, which was still quite a lot but bearable. Labour room is fun although it is a rough jungle and really need to learn fast – not only in terms of skills but also which midwives and registrars to look out for. Some are more likely than others to make your life hell. O&G calls are generally dreaded, but no where as bad as the medical calls. At least we can expect to sleep for an hour or two.

Now I’m coming to the second month of this posting and I’ve still have not had a day off since I started. That’s working everyday continuously for nearly two months! Exhausted… And now they tell us that we are not allowed to claim for ward cover on weekend anymore. Great.

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Last day of medicine

Postcall. 9 admissions, two unwell patients, slept 1.5hr last night, which was luxury for house officer. I think I am getting better at managing my call jobs, like having a quick rest while waiting for IV lines and blood taking to accumulate first, then go and do them all at one go. Also getting more efficient at clerking new patients. I'd like to think that MOs like being oncall with me because I'd usually have done everything that needs to be done and sort out the patient before I call them. He/she would just come along examine the patient, look at the investigations results and just add on any management plan that I'd missed out. I still can't quite accept the sleep deprivation part, also why some wards with 3 house officers still manage to leave 8 IV lines for oncall to do, but overall feels much more in control of my job and is spending less time running around like headless chicken.

I'm now at the nephro ward. So far it's been much nicer than my previous general medical ward in terms of the pace, intensity and the work load (and the nurses). Expected the day to be quite relaxing because I am starting my ward work early (7am). Only two bloods to take this morning on my side. Haha, even better. Then at 8am, the other ward house officer messaged me to say that he's taking emergency leave today. Aghrrr! Should have just done the rest of the blood taking this morning then. OK, not to panic. It's still early. So I started the bloods and finished by 8am. Just when I finished and about the send the bloods off, a staff nurse told me that a patient has collapsed at dialysis. I attended stat - no doctor there yet, just nurses doing CPR. Can I hide? OK, again not to panic. ABC. Airway airway. I started bagging the patient, but he started vomiting... noooo don't vomit on me. Laid him to the side and suction suck suck, and continue bagging. Then another house officer arrived, also looked as scared as I was. OMG what to do what to do. I asked for a laryngoscope and an ET tube, the other HO looked at me. Just when I was about to stick the scope into the poor guy's mouth, a familiar senior figure appeared (a surgical registrar whom I met yesterday). Yes! Would you do this PLEASE? I could have hugged him when he said ok. I carried on with the other resuscitation. Sadly after 20 minutes there still wasn't any output, and I suddenly realized that he was actually a surgical patient (and they have enough doctors there already), so I quietly went back to the ward for the more pertinent ward round. (Later I learnt that the patient died).

My MO, registrar and specialists started appearing in the ward. Darn! Haven't finish updating the charts yet. And why are there 3 specialists in the ward today (maybe it's Chinese New Year eve)? Nevermind. More importantly, why why are there only 1 MO and 1 HO in the ward today? When there are 7 patients to discharge and at least 3 central lines to put in? Luckily there wasn't too many referrals, phone calls and scans. My MO and I fell silent when our specialist said he wanted bronchoscopy for one of the patients TODAY. We could only nod without any promise as requesting (begging) for one itself is a mountain of a task, whatsmore one TODAY. Alas our charming specialist said he would call the respiratory physician himself for the bronchoscopy, and we rejoiced in our heart. After ward round, it was just work work work. No time for lunch. Carry on working. Taking out femoral cath is one of my least favourite jobs as I waste so much time (up to half an hour) on compression, and I have 3 of them today! And to go to radiology to get perm cath date and later off to request for CT brain. I hate going down to radiology lately as well because they keep me there for ages and then will tell me that the scan is not indicated and will not do it. Pharmacists let me down today. First it was a Bactrim dose - I doublechecked twice with a pharmacist from the Drug Information Service and yet she gave me the wrong information 4x, until another pharmacist called me up to clarify the dose at 6pm. Luckily the medication wasn't served yet. One of our patients needed to be discharged with an injection, and we called up the pharmacist to come and teach the injection technique several times already, but still at 6pm no one came. Alas, the staff nurse had to demonstrate the injection to the patient. Whilst with my patient after taking off the femoral, I overheard a grumpy old man complaining about why he still cannot go home. Sorry uncle that you are late for you reunion dinner but discharges are on the list of my jobs, after scans, femorals, referrals, prescribing etc etc. Alas, a nice registrar helped sort out that discharge for me. Could have hugged her also.

Sigh sigh. Cheer up Yen! and don't fall asleep. Alas, I finished for the day and passed over. Home for reunion dinner and the start of my two weeks break and the end of my medical posting!

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Not so nice part of work II

It pains me to write this but it's important to reflect. Here it continues.

I clerked him in. He was admitted through the respiratory clinic for a few days of fever and cough and was relatively stable apart from the lowish blood pressure. Pneumonia is pretty bread and butter stuff for us in medicine. The previous doctor seen him has given him lots of IV fluid to help with the BP. But when I saw him, his lungs were full of fluid suggesting overload and renal function was bad, so I stopped it. He was able to tell me that he was admitted because of the worsening diabetic foot ulcers. I spotted what looked like DVT, went down to radiology to request for US doppler to confirm it, but evil radiologist refused to do it (even after I asked twice). During day time the primary team (my MO, reg and specialist) saw him and still very undecided about whether we should give fluid or not. The nephro MO said he looked damm dry and ran 2 pints of fluid through, and the BP picked up. However, when we inserted a CVP line in, the central venous pressure was through the roof (20cm H20, normally between 8-12) and ABG showed worsening metabolic acidosis. He needed dialysis. In the meantimes, he deteriorated - could see it in front of my eyes - gasping, colour draining off, BP not picking up, every blood I took subsequently showed worsening. That night before was a bad call - I spent 4 hrs waiting around in HKL just to transfer a stable patient (we had to accompany the patient from our hospital, pass over at the emergency department, wait for ortho to come down to review the patient, then send to x-ray and push the patient to the ward ourselves). When I arrived back at my hospital, there were 7 new admission waiting for me to clerk. I did not sleep and was able to squeeze only 10 minutes for myself to freshen up quickly in the morning. I only finished my last clerking at 7:30am. In hindsight probably should have thought about inotropes, inserting a CVL and inform my MO earlier. The ward was extremely busy as we were post-active that day with 8 new admissions and everyone was really stressed up (I hate days like that especially when post-call) I could sense that coherent thinking was on the low. I had to deal with another of our patient lodged in another ward downstairs with haematuria and ?intracranial bleed (also one I've clerked in last night and forgot to realize that new confusion might = ICB and did not off the anticogulant) - so had to go down to radiology again to request for an urgent CT brain, just after I've been down to radiology for nearly an hour pleading for several US doppler and CTA brain (it's ok, I told myself, it's only consequence of my own action). You can imagine that how the rest of the old patients and even the new admissions who are reasonably stable might feel left out on days like these. Anyway, alas, this pneumonia man was transferred to HDW and subsequently deteriorated and died from presumed multiorgan failure from H1N1 infection. I feel personally responsible and that's not a good feeling.

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Not so nice part work

My job is sometimes so exhausting physically, emotionally and intellectually that I feel like walking off for so many times. I have posted something nice, now something of the opposite.

Since I've started working, several patients under my care have died. Some were expected (and we issue NAR - Not for Active Resuscitation before whenever possible) and some weren't. Several patients have come back to hospital after discharge.

The first one was about a very confused man with no relative no friend, sent in by the neighbour because he hasn't come out of the house for a week and they broke in and found him unconscious. He was very disorientated and we treated him empirically for pneumonia based on the very raised inflammatory markers and some vague shadowing in the chest x-ray. He responded well to antibiotics and IV hydration and was much more lucid after a week. However, he was unable to walk and still speaking rather unclearly when we were ready to discharge him, and eventhough we have found him a temporary placement so some people can look after him while he get back on to his feet, he refused to go there and insisted on going back to his own home. I felt that the safest option was for him to go to the placement (or else he will die at home as he was unable to look after himself and would not be able to get food) my physiotherapist and my registrar agreed that we should just declare him incompetent and force him to go to the nursing home. But the social workers who arranged his placement and the psychiatry MO who has seen him disagreed that a person of a sound mind who understood the risk and consequences of his action should be forced against his will. This was the only thing holding back his discharge. My reg said since I am the one who looks after him and knows him the most, I should decide but I just couldn't, and my reg was going to ask my specialist to decide. Next morning I come to work, the nurses told me that he has died overnight. Was it anything that I have or haven't done? Some nurses weren't concerned because he was alone, has no relatives. But doesn't that mean that he should be treated differently as the patient next time him who has children and grandchildren who visit him day and night? I was shocked and sad my his death. I am still wondering why.

More sad cases to come.

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I think I have a bit of brain

I like general medicine because we use our brain to work out problems. Surgeons always say they are not in medicine because they are not clever enough. That's partially true. The physician's brain needs to think systematically yet in multiple layers in different directions in order to know what's actually happening to give the right treatment (as oppose to surgery, where the question is usually just to cut or not to cut). I don't want to be perceived always complaining, so will tell you something nice about the two spot-on diagnosis I made.

The first one was about a young man who came in when I was oncall. He had 2 weeks of very bad headache and 2 episodes of seizure. The diagnosis made by the ED medical MO was '1. first seizure for investigation ?epilepsy; 2. ?migraine'. When I asked him about the headache, fair enough it was vague, but there was a hint of the classical 'hit on the back of the head' and 'worst headache in my life' story. Neurological examination was unremarkable apart from a left sided ptosis, which itself was a good clue towards a posterior circulation aneurysm. Then I saw the CT brain (which no one had reviewed and not reported yet) - there were white stuff around the area where subarachnoid haemorrhage frequently occurred. I've seen quite a few of those scans when I was doing neurosurgery in Manchester but I forgot the name - later remembered - it's called the sylvian fissure. So my diagnosis was 'TRO Subarachnoid Haemorrhage'. Overnight, he was seen by the specialist oncall and we referred to neurosurgery and they all agreed. By morning, the formal CT brain report has come out and it confirmed my diagnosis of SAH. I was so happy eventhough it means that the patient is no longer a medical case and would be transferred off to neurosurgery.

The second one was about a man was a new elderly patient in my ward. He has just been discharged 7 days ago to a nursing home and sent in overnight because of poor oral intake and less talkative. When I see presenting complain like this my heart always sink, because often no clear diagnosis is made and the diagnosis would invariably be something like pneumonia (due to some 'hazziness' on CXR) or UTI (based on 1+ leucocyte on dipstick). Admission clerking was rather pathetic - vague, no clear history from reliable source. I phoned up the carer from the nursing home to find out what exactly happened. It turned out that over the last week, he has been vomiting after every single meal and eventually not eating at all, and also been passing black loose stool for a week. I also noticed that Hb dropped from 15 to 11 in one week. On examination, there was tenderness on the epigastrium and PR showed malaena. So, worked out that the patient actually has upper GI bleed. Seems like a long grandmother story but all the talking, examining, thinking and solution happened perhaps over 5 minutes. So again, was pleased with myself because I made a diagnosis that at least 3 doctors (more senior than me) missed.

I'm not sure about other hospital, but in my hospital, patient from the ED are first seen by the ED doctors, then reviewed by medical MO in the ED, sometimes seen by medical registrar and specialist before being formally clerked in by the house officer on-call. Then, we are supposed to inform our MO oncall to review the patient's we've clerked. So, house officer can be rather complacent about doing a full history and examination as they have been seen by all the senior people already. That's just safety nets put in place so the patient gets the best care possible during the critical first 24h of admission but I don't think that's good for our training. For me, it's not that I don't want to do proper clerking to everyone of my patients when I'm oncall, it's just circumstance. Firstly, I am exhausted - by the time I clerk in the new patient (usually well after midnight) I would have been awake and on my feet for 18 hours already. Old notes would not have arrived, there's not likely to be relatives around to take collateral history and I have another 10 IV lines and 4 new patients to look forward to seeing (waving good bye to my sleep). I only wish that I am able to have time and mental space to think and review all my patients this thoroughly. This can be achieved by having 1 more HO to cover passive calls or having the day before or after on-call off. But I think I am just dreaming and will do my best in the mean time.

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