New year eve again...

 

I couldn't remember what I did during the new year eve ..... was I watching  the count down in the house or was I on call ?
I read back my blog written on 2006/12/31 http://blog.xuite.net/lywuu.ving/dayinED/9564324..

I was working acutally... and the shift is just the same....

I am sicked - sorethroat with no fever...
The ED was filled up with MVA victims...
I met some rude family- a mother complaint that her drunkard son was irritated by us during the management. The person had drunk a large amount of ? wine or what ever with lot of alcohol in it as he was having a very bad mood. How did I know ? he was grumbling about his bad luck in the ED when his mother arrived....

Group of young boys and girls who took a joy ride down south and fell from their bikes. Some told me not to call their families; they were afraid that their family would be worried displeased...

Well, I am going off 12 more hrs later - by 6pm 2008/1/1, hope I could make it in one piece.....I am tired and it reminds me next year I might want to stay home during the new year eve....

Not my specialty...

 

These 2 piece of  ear shit, ear wax whichI removed from Yun's ears 3 days ago...Well, I tried very hard to stabilized my shaky hand during the process...

 finally she let me do it...she had resisted it many attempts and I had tried ear drops but in vain and I am reluctant to do it...I am so afraid I perforated her ear...

well - it had been there for few "years"...well, I admit I am not a good daddy...

NSP - 2

There are 2 grades of nurses in taiwan - "護理師"(registered nurse) and "護士"( nurse)[I got the translated english terms from the ministy of examination, however I found the terms inappropriate)... There is this nursing class in this vocational school which run for 3 years (equivalent to senior high school). One can sit for nurse examination when graduated from one this class. The post high school education had divided into 2 categories mainly - the 3 years college diploma and 4 years bachelor degree program. Both are eligible to sit for the registered nurse examination. The only different is the entry salary when one work in a hospital. To be a NSP, one would need to hold a nurse license, preferablely registered nurse qualification. The nurse are graded into N1, N2, N3, N4 like the medical resident system. However, one does not get promoted on a yearly basis. A nurse start at the level at N0 and advance according to the CME credit and passing of relevant evaluation. The N3 is a very tough level, the N2 would need to present a paper in a public evaluation session organized by the society of nursing. An NSP should be at least N3 when she is selected. Most of the managerial nursing post also start at this level.

NSP - 1

How do a specialist care 20+ patient without help from resident doctor/medical officer ?

Unlike some big hopsital with trainning post - small hospital could hardly get any medical officer to work with. Even in hospital with 500 beds like my ex-employer has, attracting resident doctor to join is a matter of luck. The trainning post in Taiwan are so available even the prestige university hospital couldn't hire enough resident doctor. Approximate 15 years ago, there was a few hospital which was rich enough to get some prestige specialist to work in but unable to attract resident doctor as no trainning post was available(the hospital was newly setup and pending evalution). What they did was getting nurse to act as para-resident. Those nurses were named as nursing specialist a.k.a NSP. Since then, the job of NSP had started to flourish.  My home univerisity hospital was very against such idea and refused to set up such post. Later as the univeristy hospital expanded and unable to recruit new resident, they gave in and started to hired/trained such nursing personel.

The job/duty of NSP varies, some acted like a true resident, some acted like medical secretary. Frankly said, some of their duties were beyond the legal duty as a nurse. However the lack of medical resident had made the demanding of NSP risen. Last year, the bill of NSP act was passed and the NSP had become legal. The nursing specialist however is unlike those clinical nursing specialist in the US. It is more similiar to nurse practitioner. The requirement is less - unlike their counter part in the US, they don't need a master degree. All they need is a training in a certified training facillity for 6 months and passed a national examination ( MCQ - no oral). There is currently 4 NSPs in our hospital and none of them were certified yet.....none of them work under me, frankly said, I had 5-10 patient at any time and I could handle them with no stress....

a very bad call...

I had this bad call recently...no many patient in the ED after 12 MN. The ward was quiet...I had just admitted a patient to ICU by midnight. A case of hypoglycemia coma due to insulin overdose. He was fully alert after glucose infusing but his brain CT had revealed subarachnoid hemorrhage.

At 2:30am, the combined ED from the south call( the ED, I had part time before while I was working in my ex-hospital...). A nurse at the other end of line. I was told that the male patient had an intracranial bleed and presented to their ED with Glassgow coma scale(GCS) of 7/15. They asked me if I could take over the case. I saw the admission board. I had already + 3 beds in my ICU but still 1 ventilator left(minus the one in ED). I said ok and advice them to intubate the patient as his GCS was only 7/15. I got this answer," well, the patient was better after his arrive and we don't think he need intubation now...". Another standard crap-shit answer- I did not insist any further, after all is their call as the patient was currently under their care. Asking a nurse to do a referral over the phone is a very rude thing, but that is what they have done most of the time...

By 3:00am, the patient arrived and he was moved to the active resuscitation area. I saw the brain CT scan - rt putaminal hemorrhage with minimal mid-line shift. The blood clot esmitated around 50cc. However my nurse told me the patient's GCS was only E1V1M2 and he was not intubated. The family did not came along with the ambulance. The nurse told me they drove and would arrive later. I intubated the patient stat and sent him for another scan. No mannitol was given, only some steroid and fluid in the combined ED. My nurse started to curse .... I pacified them while waiting for the further CT scan. Well, intubation for my team is kacang putih( eating peanut , i.e piece of cake), but for those staff in the combined ED down south - it might be a very stressful procedure. Lack of training and on hand experience made their situation worst. I been there before.... nothing to blame and covering their ass is our job : afterall those case landed in our hospital would increase our bussiness. If they are competent and capable those patient might not have to transfer or stabilized and transferred further up north to Kaohsiung.

The follow up scan was worst. The bleeding had increased and the midline shift was more prominent. The younger son had arrived then. I explained about the patient's grave condition to the family. I told him, surgery was needed for this kind of bleeding but even if the surgery is done successfully and the patient survive the surgery; they could be facing a vegetative patient. The younger son said he had could not make any decision and his elder brother was coming from Kaohsiung. I told him, before they made any decision, I would proceed with my current management but the patient is definitely going to die if no ops is done. The patient was sent to ICU and by the time he reached ICU, I got this call again from the combined ED. This time the doctor talked to me over the phone. He told me that he had a patient presented with SOB and diagnosed as acute pulmonary edema. He had given her a furosemide injection and put in a Foley catheter. He said she was better and wish to sent her over. At this moment, I had only 1 ventilator in the ED left. I hessitated for 1 seconds and told him ok. I accepted the patient. My nurse asked me about the case and was worried with my decision. I told my nurse, I never trust their diagnosis, we should see what was coming to hit us and decide. There were a few times, when we  turned down such referral, they still sent the patient over to us - because the patients were too ill to make it to Kaohsiung.

 I saw the ICH patient in ICU minutes later and his pupil had fully dilated. I informed the condition to my neurosurgeon and he told me if the patient's son agree for ops he would come over. Later, His elder son came and I told him about the situation. He said that they would consider the option and would told me later about their decision.

By 3:40am, the SOB patient had arrived. She  was noted with mod SOB. She was a esophagus cancer victim s/p radiotherapy with gastrostomy done. I saw no physical sign which support the diagnosis of acute pulmonary edema when I examined her. The picture looked more like pneumonia to me. I grinned when I read the referral note - the doctor had given her furosemide but also infuse her with NS 1000cc !!!! Such a controvesial management....
The x-ray confirmed my diagnosis and she was sent to ICU. I did not intubat her as she was better on oxygen mask use.

At this moment, the ICH patient's elder son had told me that they wanted an operation. I called my neurosurgeon and informed him about the decision. 10 minutes later, the elder son came to me again said that they wanted a transfer. He said that the second son is currently working in Chang Gung Memorial hospital( one of the biggest hospital in Kaohsiung)  and wished to transfer there for ops. I gladly complied and called my neurosurgeon again. He was on his way then and told me not to worry about the change of decision. When I called the relevant hospital and was told no ICU bed was available. The ED physician had also spoken personnally that they should not go over as the patient would not recieved proper treatment.(fromt he conversation, I found that the second son was not working in CGMH after all, he work in one of the sister company only..).  After 10-15 mins of making phone call, the elder son had come to me and told me that they still want to try their chance there. I settled everything and was just about to take a nap, the nurse told me that the son had again changed his mind -  they wanted to go over to another big hospital in Kaohsiung. Again, I called the hospital and was told that no ICU bed was available as well. I informed the family and when the family was about to ask me to try for another hospital, I told them that our hospital was capable to manage such patient and I was not going to continue with the wild goose chase. If they wanted to transfer, they need to asked for ICU bed themself. They finally went to CGMH and tried their luck there. I doubt any ops would be done as no NSICU was available. The patient is gonna die as his BP was dropping before he left our hospital. The patient's son does not care actually - if they just wanted to make the event look nice: they had tried their best taking their father to a very big hospital....
Well, I hit the bed around 6:00am after I made a morning call for Ving and Yun....there was only 5 patient from 12am to 6am and I did not sleep....

fading job...anyone ?

There is a case conference every week in our hospital. Unlike those big big hospital which hold their respective department meeting/conferecent, we could only hold this combined case conference due to lack of doctors . The case conference usually follow with administration meeting. Last week, our deputy hospital director(admin) had told us that they planned to intake one of the part timer(who did locum for us during the weekend) to our team. In most of the rural hospital, doctors are reluctant to do night shift - especially ED shift. The law had required hospital with 100+ beds to have a 24 hrs operation ED. ED shift are stressful - paeds, surgery and medical....sometimes some O+G emergency may show up. In some hospital(as in ours), the ED doctor will need to cover the wards as well. A stressful job indeed. The pay is considered handsome in the rural area as one would be paid RM 100(non-taxable)/hr. A shift is around 12 to 14 hrs, so one would walk away with RM 1200-1400 per shift.But in the city, the pay is less and 1 night shift is around RM 500-800. A resident under trainning earn around RM 9k to 15k depending of the hospital they are working. A good side income indeed if those resident willing to do these locums. But as most of the training hospitals are situated in the city and the residents are supposed to report by 7:30am for morning meeting thence it would be difficult for them to do these locums in rural area and rushed back to their primary trainning hospital. Another factor which affect the availability of locum night shift ED doctors was trainning. Before the PGY1(post graduate year 1 ) training ERA, graduates start their specialty training as soon as they leave school - lack of exposure, now it is improving but not satisfactory yet though...the ED training was too short in Taiwan - 3 years only, I recalled weeks ago, there was this senior ED physician(professor grade ?) who replied a letter in the forum of the "Apple Daily"- He claimed that the ED physician training was 5-6 years and asked the public to trust their skill; all I wanted to say is 5-6 years my AXX...the bigger the hospital the more focus of its training in medical and surgery(not in the respective department but in ED itself) with the paediatrician and O+Glogist seen their relevant patients in this kinda of hospital ...to make the situation worst - such rural hospital would require night shift doctor to cover their wards as well...few were interested in such job in the past and now only some left... Those who moonlighting about this job could be classified into : 1. Residents who were very short of money 2. "Rover" - denied specialty training/examination : work in clinic/very small hosptial in the day light and doing night shift here and there .. 3.Specialist who was once in the 1st category but later unwilling to give up such skill and moonlighting once a while to see if he could still do it o 4.Specialist who was once in the 1st category and just returning favor / or don't know how to say no to their ex-night shift's hospital management. 5.Medical graduate without practicing license... They would need courage and extraordinary physical and mental endurance as deprivation of sleep is the major stress factor apart from the variety of patients. At the present moment, the resident pay is considered good compared to other occupation so only a handful of doctor wanted to join category 1. Those in catergory 2 are less nowaday and fading from the health care chain - do not have a wrong idea: these group of doctors usually make a very handsome income. Only a few left in category 3-4 as they came from category 1. The 5th category has the least member as the local health department has strictly enforcing the medical act. Just like Malaysia system, notifying the local health department while doing locum is a must and violating the rule maybe fined both the local health department and the general health insurance scheme. Notification should be done by the primary employer and the locum organization jointly so approval from your employer is needed to do locum here and there. All this restriction had made the locum bussiness worst. The part timer mentioned above is a "rover"... the management had asked me if I could adjust my current shift and I complied partially to their request....I was looking forward to it actually although my income may become less, but I might get rid of some night shifts. Unfortunately today, our offer was rejected and we were back to square 1... I am hoping one day, I could do only 1 night shift per week, my white hair is increasing in a great speed for the past 2 years....

the system.....

I don't like others interfere with my patient nor my treatment plan; but sometimes I can't resist them ..... Today the hospital the head of development section(HODS) had come to our resting room while I was having a chat with my colleague L....
He asked L if 2 of the patients could be transferred to ICU as the ICU a little bit empty..... The HODS is not a doctor but an administrative staff, why did he requested so ? ---> it is all about this hospital bussiness....

In the past when the General Insurance Scheme(GIS) just started - its budget was unlimited. All the hospitals treat their patient and claimed the fee from the GIS office. The GIS office then select some of the records and examined it in a very detail manner. If any drug/examination is inappropiate the GIS office would fine the hospital according to the ratio of the selection - if 1 records was selected from every 200 records then the fine = fee of inappropiate examination x 200. The hospital could appeal though but it would take months for the final decision to be made. At that time, if 3rd generation antibiotic was prescribed in  a small hospital there was always a 50:50 chance it would be deemed as inappropiate and appeal was needed to justified it's usage. So the small hospitall would tend to transferred critical patient to major hospital. And more transfer means the hospital was more incompetent thus jeopardising their name. The bigger hospital however enjoyed some better treatment - less fine and less appeal. Under this scheme, some of the smaller hospital could barely survived and shut down - this include some urban area and thos people who lived around would face the lack of medical resource as they had only 1 hospital around their area. The bigger hospital had developed into creature and consumed most of the budget. The GIS office has sufferred a great loss and the loss were filled by the government treasury. Finally the government decided to put an end and the GIS started the budget system....some sort like the British scheme. Each hospital were allocated a budget every quarter - if you get whatever you did as long as you don't exceed the limit, and if you did more than the budget you won't recieved more. So the hospital would like to do slightly over the target but not underdo it....
Due to the above scheme the hospital hired this HODS to push the bussiness a little bit....And from time to time, he would monitor our in out and "managed" our patient... I am just an employee: I need to comply to this strategy...

Anyway, I had this patient  X who was not the critical but unstable was "requested" to the ICU as there were 2 empty patient..later another patient had some complication during a pigtail insertion for pleural effusion was sent into the ICU... By evening, there was this 80+ y/o female who presented to our ED for generalized discomfort who I noted with a full bladder on examination. A cathether was introduced and urinary tract infection with leukocytosis was noted. I admitted the patient to ward and on the way up - the lab informed me that her BUN was 165 mg/dl and Cr 14.1mg/dl respectively...I hailed the patient in front of the lift and sent her to ICU instead. No sign of hyperkalemia and pulmonary edema was noted. I had a discussion with the attending nephrologist and no emergency hemodialysis indicated.
While I was writing order in the ICU, one of the nurse grumbled,"see, why transfered patient X(my patient - which was requested....) to ICU, see now we are +1...". I got a little pissed off...I told the nurse, " well, our HODS did not know this patient coming and he don't know that I would admit another 4 patients into this ICU for the next 8 hrs..."(just kidding in a sarcastic way, where could I find 4 critical patient ? actually what I wanted to say was the HODS is not god and neither me...)   +1 bed means more loading, but need not grumble, I dislike such situation as well....Only 1 word I would said- Lazy and attack of mouth itchness syndrome....I blame no one but this system : It took good care of the local people but the local people never appreciate it....

just when you think you know all....

We had this 60+ y/o uremic patient few days ago...He had been hemodialysed for a few years. He was also a known case of Diabtes mellitus and recieving control with insulin. Few weeks ago, a small wound over his left hand was noted and he had been doing routine dressing in our hosptial. His wound had worsen and he was admitted later. On D2 of admission, his BP crushed and gangrenous change was noted over his left hand extending toward his forearm. I was just about to go off by 11:50am, and the orthopedic surgeon called me and asked me if I could put in a central line for him... I tried and failed over 2 site - the rt int jug and rt femoral. As he was going to OT urgently for an amputation - he was sent into OT stat after 2 trial. I got the vein but was unable to introduce the guide wire during my trial. The guidewire went in half way and could not advanced. I seldom came across such condition - femoral vein and internal jugular vein are both big vessel - I cant explain such condition.... The patient went into arrest in the OT while waiting for his amputation, he was intubated and resuscitated after few minutes of CPR. He recieved an Below elbow amputation and sent into ICU for care. The CVP was inserted by the anesthesiologist.... The next day, he was planned for hemodialysis and as his AV shunt was done over his left upperarm, he was unable to used his AV shunt - a double lumen catheter was needed. Our nephrologist needed to put in a double lumen catheter - he had chosen the rt femoral vein approach which I had failed 1 days ago. He tried and met the same problem. Twice he had got the vein but just unable to introduce the guide wire. He than requested a heparin + NS in an 20cc syringe and flushed the venocath before he introduce the guide wire for the 3rd time - well, he succeeded - he told me the vein is ok but due to coagulopathy, sometimes the clot will formed instantly when the guide wire was introduced...so heparin would do the trick.... Although I had done so many central line - I learnt something that day...