Pre-empt

In the business of child health, a mentor once taught us that we must always be ahead of the babies and children. From the moment they come in, we should already be able to anticipate the course of the illness, complication and recovery, and pre-emptively sort them out. We do not wait until the problem arises, then go into a panic mode and make rushed decisions. 

In the district hospital that I used to work in, this ethos is well understood by the whole team. From the outset, if the doctor or nurse who first saw the child have any concern, whether it is a diagnostic dilemma or that the child did not look so good, we would talk to each other about it. We may alert the parents and the rest of the team about the concern or put on extra monitoring in a place easily noticed, and make sure that a senior personnel is to see the child before nightfall. When I first started in Paediatrics, I was an anxious ball and would become agitated over every tiny anomaly which I did not expect to find. But I am grateful that even as a junior member of the team, my concerns were usually taken seriously. Hence we are able to prevent lots of unanticipated problems. 

This is very different in the adult wards, especially the medical wards. It is extremely common to have several deaths in a day, more than half of those were unexpected, resulting in several 'crash calls' in a day (or night). 'Crash call' is a panic button that summons a team of doctors and nurses to come immediately, and is to be pushed only when a patient deteriorates critically suddenly. 'Crash call' in the UK hospitals are quite well run because the members of the team have been exposed to different scenarios simulated beforehand in training. But, over here, it is more like a circus of confused people arriving, no leader, no effective communication, only grumble and criticism at this most inappropriate timing. Needless to say, the patient outcome is usually poor. 

One of my colleague who used to work in the adult medical department, had recently join Paediatrics, and was asked to present on a case of a child who deteriorated during the early hours in the morning during his oncall duty. 

'The child was admitted at 3pm, with a chief complain of fever, altered behaviour for 3 days and 1 episode of seizure which lasted for 20 minutes'. On arrival his GCS was 11 out of 15 but haemodynamically stable. He was reviewed by the specialist at 5pm and started on antibiotic and anticonvulsive treatment. Night review was done at 7pm and the child's condition was the same. At 4am the staff nurse was called by the mum as the child had suddenly became unresponsive. On my review, the GCS was 3 out of 15, hypotensive and bradycardic. He was intubated and sent to ICU.'

The boss was clearly unhappy. 

'In medicine, there is no such thing as 'suddenly collapsed', 'suddenly deteriorated', 'suddenly became unresponsive'. I do not want to ever hear those words again. The child was last seen at 7pm, What happened between 7pm and 4am? The child was at the acute bed with continuous monitoring. What did the observation show? What was the level of consciousness in the interim?'

My colleague were unable to answer. GCS was not recorded and observations were not documented clearly during the interval 9 hours. For the child to deteriorate to the point at 4am, there would have been some signs that the body was compensating, and all the members of staff on duty that night have failed to pick them up. From this example, we all got the message and went on to improve patient care by working on this very basic principle of medicine for every single child that came through the doors.

I requested for transfer to this tertiary referral centre to further my training in Paediatrics. To my dismay, such basics are even more poorly done here. There is a systemic problem of too many staff, too many teams, too many leaders, too many egoistic heads, as well as a system of office politics and culture that have been ingrained in this institute for many decades that are not easily corrected. The Paediatrics department is huge and the sub-departments who are supposed to provide support are not always easy to talk to. I see more of the bad habits of adult medicine surfacing, for example kicking patients like a ball from one sub-specialty to another, or from one ward to another, to avoid the responsibility of being the primary team. Every workplace has its strengths and weaknesses, and it is working with the systemic limitation that upsets me because I cannot give the best to my patients.

However, as another of my mentor who has worked in this dinosaur institute for many years said: 'Aim to save one patient at a time'. I am a tiny minion and I have conceded that I cannot change the system. So I am using the principles of good practice that I have learnt to look after the few patients I see. And so far, I have been able to prevent a few patients from failling into the state of 'suddenly collapse' by starting antibiotics early, fluid resuscitating early, starting inotropes early, referring to ICU early. 

One of the parents once told me he would like his son to be admitted to ICU because he felt the doctors there are better. In his son's previous hospital stay, he had experienced watching the ICU doctors rushing to the ward in an emergency, intubating the child, performing chest compressions, inserting various lines to save the child. He felt that the ward doctors were inferior as these jobs are not their routine. This is the trouble with people watching too many dramas on TV, who sensationalises this heroic image of being a doctor. 

Please. Every doctor is able to help in any emergency situation, but to what extent? If only one can feel what a doctor feels during those surprise 'patient collapsed' situation: rushing to the scene, internally your heart is palpitating away, you feel a little dizzy from hyperventilating, your hands become cold and your brain starts to freeze; externally it is a havoc, no one knows what is going on, who is who in the team, who is this patient, where equipments are kept and who has done what. Besides, once a patient succumbs to the point needing CPR, much irreversible damage has been done. The patient stands little chance being treated in this extremely uncontrolled environment. It improves though, the profession has started to realise the importance of teamwork and effective communication in such high stake scenarios (but this awareness has yet arrive here, I am afraid).

Who you really want is a doctor who is able to prevent you from falling into that state. Problems are always easier to tackle when recognised earlier. There is completely no need for 5 doctors rushing to stick huge needles all over the patient instituting invasive treatment when one injection of antibiotic given 5 hours ago could have prevented all these. 

An unknown hero is the real hero. But a good doctors do not care, he or she just want to be able to sleep well at night. 

Do the basics well. Being able to pre-empt problems is one of them. 

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