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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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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Throwing in the towel

Yesterday was one of the worst days since I have started working.

 

On call the night before was not particularly heavy. But one of the new patients had a seizure requiring urgent CT brain, and another was vomiting and bleeding fresh blood (with other issues like extremely difficult vein and relatives who refused to let me poke her to save her lives. Acutely ill patients like this takes up a lot of my time and energy, leaving less for the rest of the jobs. As well as that, I had to deal with two of my usual patients in my ward – one wanted to discharge himself and another wanted me to write letter of a summary of his condition for financial help (which was not urgent in my book, can wait). Also at the beginning of the oncall, no one could contact the other HO – so I ended up doing several jobs for him as well. I did finally get a chance to have my dinner at 3:30am. My last 3 admissions arrived after 5am. Usually if I am still having lots of unsettled jobs by 6am I start to panic because it is my experience that if I don’t start my usual ward job by 6:30am, everything will be delayed in the day. After clerking the last patient at 7am, high dependency (HDW) started calling to ask me to take blood. I only finished the new patient clerking by 7am. Imagine the shock when they tell me that I have to take blood from all of the patients there. HDW patients’ bloods are not easy to take as they are usually very sick. I was still doing bloods there at 8am. Really really stressed up then thinking that I still have to shower, morning bloods at wad warga and 2 hours late for my ward work, and I just couldn’t hold back my tears and snouts while actually poking a needle in the patient. Luckily Debbie and the medical students were super efficient that morning to have finished all the bloods by the time I arrived. Such is the usual arrangement that the oncall person has to do the morning bloods for HDW and wad warga (as well as CCU, CRW sometimes) as they don’t have house officer there and I feel really being taken advantage of. Do they not realize on normal days we have to start our regular morning blood taking as early as 6:30am to avoid running behind?   

 

Prof was in a bad mood yesterday. Everyone got some bullets from her, from the medical student right up to the registrar. Even I was unusually alert (normally I am half asleep in rounds post-call). So many new patients. My registrar was amazing and helped me out and didn’t take forever to review the patients. One of the patients was from Debbie’s side – so many things not done – so I had to pick up the pieces and answer when prof and the other specialist demanded to know why things were not done. Usually my MO follows round on my side but she left half way today – so I had to be totally in charged of all the jobs for the patients on my side.   

 

Half way during the round, a nurse from the other ward called me. In a very fierce tone, she demanded to know why had I not prescribed the medication for a patient admitted last night. Really? When she told me the name, it didn’t even ring a bell. I left the ward round and went down to that ward anyway. The specialist in that ward started questioning why have I not clerked the patient, and the nurse started asking if I’ve not clerked the patient who was it who wrote in the notes? Looked at the notes – no one clerked the patient; in fact the nurse did not inform me that patient had been admitted. They called the nurse on duty the night before – indeed she admitted to have forgotten to call the on-call doctor to clerk the patient in. OK. Scolded for nothing of my fault, but nevermind. I hate nurses in this ward.   

During round also, the patient from the night before who wanted the letter for social welfare became really angry and shouting around saying that I have not given him what he wanted. The registrar kindly sorted out the problem for me, and the patient apologized (all very civilized after), but still didn’t stop me from feeling very incompetent and that all was my fault. 

 

Then in the evening I was doing a discharge at the other ward, Debbie called me and spoke to me and Mandarin, asking if I have made a referral to gastro, which I did, and said the MO told me to come back here immediately because he was very angry. I rolled my eyes. OK OK I made a late referral. Nevermind there was a 2 hour Friday prayer break, nevermind that I was given passed around 3 people before being passed to the right gastro person for referral, nevermind that I had 1000 other more urgent jobs to do including helping Debbie with an extremely difficult blooding taking, nevermind that whenever I tried to do referrals nurses or some other people would snatch the patient file away from me, nevermind that the phone is constantly being used. It’s my wrong. Always. Stressed out, I cried again. I told the nurses my eyes were red only because I was tired.     

 

Looking after 12 patients (from yesterday 16) may sound easy. Sometimes, but usually not. There are always so ill that they shouldn’t have been in the general ward. A patient on BIPAP (breathing support) needs bloods every few hours. There was once when three doctors were spending 3 hours inserting an IV on one patient. Do you know how much work could have been done by 3 doctors in 3 hours for the rest of the 27 patients? As houseman we are the ones responsible for the unpleasant job for poking people, and I just get so much complaints and abuse every time I approach some of these patients. It is not me who want to poke, I am nothing but a slave. And because I am around all the time, relative comes to me to discuss about the patient just when I am rushing to finish through all my discharges. And nurses would call you to ask about insulin doses, prescribe drugs, do IV lines, see acutely ill patient etc etc. I know it is important to know the progress of the patient for the relative and attend to ill patients, but it is even more important that I get through my 7 discharges this evening without interruption.  

 

So yesterday was a really bad day. I went home at 11pm (40 continuous working hour in hospital) and still there were 4 referrals not done, one phone enquiry not done, many forms not filled in, 2 blood cultures not taken etc etc. Patients are staying in hospital unnecessarily long because the houseman is too incompetent to sort out all the jobs in time – and I do deserve to be told off sometimes. Making referrals and requesting for radiological scans especially, we needed to be very clear of the patient history and progress, and know exactly why we are referring a patient and have the necessary investigation – trouble is I don’t always know. The workload is so heavy that I needed to work at bullet pace. There is no time to think or discuss why things are happening or needed to be done, no time to read or check things up. That’s why I’m still so blur with regards to the management of common medical conditions. I have been working for 6 weeks now and I am still so unorganized – I really doubt that I would ever be up for the job.

 

It is nice when my senior says things like ‘Of course she’s good, she’s my houseman’. Yesterday a sister said ‘O… you are Dr Tan. One of the senior doctors said you are very good’, and I told her ‘OK. But I don’t really care.’ Now I have started not to believe people when they tell me I am doing a good job or anything like that. I don’t want to be complacent even for a bit. Can’t afford to because I know I am not.

 

Now my parents are also angry at me because I am leaving home earlier and earlier and going back home later and later everyday. And they get upset if I tell them that I haven’t been to the toilet all day or haven’t eaten anything all day (especially when oncall, can go by without lunch, dinner, breakfast and lunch on the next day). So, I avoid telling them anything of this sort now. It is physically and emotionally draining to be parents of houseman.

 

Stages of bereavement: Denial – Anger –Bargaining – Depression – Acceptance  

I am still at the denial stage.

 

Finally learnt how to apply for leave yesterday. Might get a day off or two soon.

 

 

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