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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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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