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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