almost had it ... part 2

I was better in the morning...
my SpO2 had returned to 99-100% and I had felt better....I discharged on the next day due to 2 reasons:

- there was a night ED shift waiting for me...
- I had felt better..

so I discharged by noon and did my call...

There were severe things that were notable...

1. the ward room was too small - I had a twin sharing room... but it was still consider very small..

2. I am a attending physician in the hospital and I don't have the priviledeg to get a single room - yet another fair and square and justice dilemma - the hospital is almost full and you just cant ask patient to without a proper reason...

3.There was no clock in the room - very unconvienent

4. The vital sign check was not that routine...

5. Never do enchaned CT in a patient with shortness of breath - very very dangerous - trust me , I experienced that.
When the nurse inject the contrast medium (I had ordered a 2nd gen non-ionic medicum), I told her to inject me with subcutaneous epinephrine first before she bagged me ... and you know what ? she asked me why ? ????? and what the FFFFFFFxxxxxKKKKKKK, one of the crucial steps of managing anaphylactic shock - I knew if she follow the ABC, I would have get the epinephrine jab hrs later when someone recalls it.......luckily I it did not happened. But I got this palpitation during the procedure - imaging the effect of aminophylline + neb + contrast medium.... I almost had it again...stupid stupid move to do CT at that time - but I was so worry that I had any gastric disorder...

6.It was a good way to loss weight - 3kg in 2 days...

7.Sanitized the toilet thoroughly before you sit on it... I got this UTI on D2...crap and strain sensation over my bladder.

8. 6 injection over my upper limbs...
I got the 1st one over left hand dorsal site - removed when I thought I was better
the 2nd one was the Arterial blood gas over the antecubital area- luckily 1 jab..
the 3rd was over the left intern vein(cephalic)( missed !!! and I had got good vein )...
the 4th over right dorsal hand - 1 shot
the 6th was over left intern vein( yes...left side again) and ruptured!!!
the 6th is over rt antecutibal area a 20G for IV contrast medium..
well, 6 pricks in 2 days....what a record for me...

right antecubital	rt metacarpal arez
left antecubital	left cephalic vein

well.... I went home and got a not that good sleep and ...there was still part 3......

almost had it ... part 1

I had my 1st asthma attack during my induksi (a.k.a govt servant induction course) 8 years ago. Since then I had on and off attack. Most of it resolved with a sipped of inhaler....but this time - I had the worst ever... I almost had "it"...

I was supposed to do a 6pm-6pm shift. But unfortunately the health insurance office inspection had forced me to come earlier. I started to work by 8 am instead. The morning was ok. By noon, one of the nurse had given me a mango ...then I had my lunch...At 3pm, I was feeling a little bit tightness over the chest. I took a neb of combivent(ipratropium and salbutamol) and it had partially resolved. In the evening, when I took over the ED shift, I was feeling really unwell. I did an oximetry check , my SpO2 was still hanging around 98-99%. The condition got worst when I eaten my dinner. The abd distension sensation had almost " drown me" ... really, I felt that I can't breath !!!!
I went back to the ED, took a neb with the O2 flow. My symptom was partially relieved again - my SpO2 was 97%-98% then. I decided not to stayed in the call room (175). I shifted to the conference room upstairs and rested in the physician office.

Few hours later, I had shortness attack again. I was worried- I am obese and my cholesterol was borderline. I did an EKG 12L with cardiac enzyme and it all returned normal. I did a chest xary and nothing special was noted.  I took loading dose of prednisolone 30mg orally ant did not get better. I then a shot of Methyprednisolone 40mg and after few hours I was feeling better....but still only parital relieved.

I was too tired and took a 1 hr nap between 3-4am. I woke up and did a SpO2 it was 97%...but I feeling severe dyspneic. I went to ICU and asked one of the senior nurse to take a arterial blood gas for me. Since my SpO2 was satisfactory, I was thinking of something more severe : ? acidosis - diabetic induced or maybe HHNK....? ..

I had needle phobia - I really hate being pricked but I need to face and confirmed my thought . Luckily they got it by 1 trial - but the shocking thing came next...the paO2 was only 55mmHg and O2 sat was 88%!!!! although the SpO2 over oximetry was 97%....I knew that I need to go on O2 use.....If I had a patient with such ABG data in the ED, I would have admitted him to ICU...but I was the one doing calls - I can't quit, the second line oncall doctor is a surgeon, he couldn't fully covered the ED...so I need to go on..and I would have to put myself on O2 use...

I went to the ED, locate a empty bed, pulled the curtain and use O2 nc 2l/min. My headache, fatigue, muscle ache went off gradually - I got a good rest of 1.5 hrs before I was disturbed by another ED patient...

By morning, I was feeling better. I was thinking of getting off earlier and told my deputy superintendent. I still had my IV lock on my hand and was thinking of getting another methyprednisolone jab before I went home. But I forget .... and I went home with some oral medication.
I reached home by 9:30am and took my bath. It was 10am when I taken my medication. But I had this shortness of breath attack again - and it was intolerable and Ving was frightened by me...
She offered to sent me to the hospital and got admitted. I resisted a little bit but gave in - I need O2 to recovered from the fatigue of the on call and I was scheduled for another call the next day...

Ving drove me to the hospital and I walked into the ED....The nephrologist was doing my ED shift and he knew what my intention was when I stepped into the ED with the big backpack..... Under the "courtesy" of my senior - I did my own admission and wrote the order. My attending physician was our chest physician( Malaysian as well, he was new ...), he told me to write what ever order I want , he said I should be able to manage....
I really wanted to have a single room but unfortunately the hospital is almost full and I had to share the room with another patient. The worst was - my room mate was a patient I admitted last night. He had a cut over his dorsal surface of his hand and sustained a tendon severence... It was an embarrassed experience getting into my room - multiple explaination to my colleague why I had become a patient... not mentioned the grinned and strange look by my room mate. Actually, I didn't care a shit - all I wanted was an O2 and a good sleep...

I slept for 3 hrs before I was disturbed again by some visitor...I had felt better but my symptom did not fully subsided....

I was confused at that moment - would I recovered or admitted to ICU and I+V (intubated and ventilated !????)

inspection

Life was much easier lately in the hospital - in patient was less....

The local National Health Insurance Agency (NHIA) office had started their hospital inspection rounds. They go from one hospital to another and checking about in patient detail. Some hospitals were caught red handed doing illegal claims and their contract with the agency was terminated (that means they could not get payment from the agency for any admission).

  Well, there are lots of way of doing "claims":

1.Warded patient slept in the house at night
- the patient go home to sleep in their own bed (or elsewhere...)
the policy of the NHIA  : a patient is allowed leave for 4 hrs everyday and should sleep in the hospital during night.
Patient who left the hospital and sleep elsewhere is considered stable and does not required in-patient treatment.

2.Prolonged stay
- patient stayed for a longer period than expected...
there are always some patients who got admitted and stayed for a long time just for insurance purposes...and some requested a longer stay for other purposes - such as law suit...

3.Incomplete medical records
- daily progress note is required to show that the attending doctor is doing rounds. It is ok from Mon to Sat ... but Sundays ? lots of hospitals do not do any routine rounds but they still claim in patient consultation fee from the NHIA.

Our hospital had discharged lots of patient lately and  rumors said the inspection team is currently near our area....

Bully

I came back to work after the 4 days trapped with my children...
very very tired day of coz....Ving came back late and we slept late. I managed to finished my paper work and rounds and took over the evening round...

Later that night, I had this young female who came with her mother. Her mother told us that the patient was assaulted by her husband. I took a glance at the chart on the LCD  - she was only 20 .  They had a small arguement - she tried to use her husband computer and her husband had grabbed her upperarm and slammed her down to the floor. She complaint of dizziness and nausea but no sign of concussion. I did a CT scan for her.. well, I am always cautious with assault case - a little bit misused of CT but an accidentally missed would cost me a 5-7 years law suit. It is not the matter of money nor jail term I might face. There is medico-legal insurance and eventhough with case of malpractice leading to death - no doctor had actually served their term eventhough they were found guilty. All of them recieved suspension of sentences. But the being subpoena is a pain in the ass, especially after multiple appeal and the case landed in the supreme court. Being subpoena once to twice per months is something usual. Living in southern part of Taiwan make the condition worst.

Well, the CT revealed occipital subarachnoid hemorrhage and I admitted her. Well, I actually encouraged the patient to lodged a report as this was not a first time she was hit. The mother told me that son-in-law looked kind and innocent when he asked for permission to married the daughter.... Well, the baby is now 5 months old and the daughter was hit twice. What a crap, I think the male was fedup with the girl and doesn't want to take care of the baby. I think he wanted to get a divorce without paying any alimony....

I had always wanted to learn martial art during my high school day - but my parents barely made a living - joing a taekwando club would be a burden ... When I went to college, I joined the aikido club- bcoz the fee was cheap. My master was(and is) the highest rank holder in the southern part of Taiwan. In one of the session, he told us that never never hit a female, male is stronger and aikido is a very powerful martial art. I consider hitting a female as an act of bully and I despise those who did that. Poor family education and lack of civil teaching in the school had lead to such act - hopefully and new govt would come up with a new policy and make the education environment better....

ICU - back to square one...

I had been unable to coup with myjob lately....

One of the nursing specialist had resigned. She was previously assigned to assist me on my progress note...she had gotten a job working in a govt clinic down south. Unlike the Malaysia govt. service, most of the nurse joined the service when they had just graduated from nursing home...here, the post of nurse in govt. service are very rare and one would need to pull string to get into...easy job and relaz...Well, so I need to managed those notes myself...in the end , I had less time to cover the ICU.

I told the ICU head nurse lately that we are back to square one. I am unable to covered them fully and they would have to refer to respective attending surgeon/physician for their case. However the whole hospital is couping to the nurse shortage and those who intended to leave had left, so everybody had gotten use to the situation...

We had a substitue nursing specialist though. But she is new to the job - she was my ex-colleague in my previous ED - ED nurse. She had left the hospital due to some personal reason...she is doing ok and I hope she could hang on to the job...

I missed my job this few days - Ving had gone back to Malaysia...I am left with the two kiddo for the past 3 days 3 night- a more stressful job eventhough I got to sleep in the night....

Polices....

I had this bad encounter again with the police...

there was this Death on arrival patient - the family had found him in prone position and there was this small stool(the wood one and no the shit one...) under his jaw.[his neck was hyperextended of coz..]. the neck was stiff and he was sent to our ED for resus. Although rigor mortis was noted, I intubated him without difficulty - the neck was in hyperextension posture and the vocal cord can be seen easily...I did the resus as routine. The arterial(or maybe the venous) blood gas was acidotic (pH 6.7) with pCO2 of 110+...well, I break the news to the family after 20 mins of effort. It should be 30mins ... but since no law nor regulation had officially written down it should be 30mins and the ED was flooded with trauma - I  had 4 trauma patient pending their xray being review...so I call it after 20 mins.
The police came later and took some photo. When the polices were about to leave, one of the police asked me for a medical record summary....an unusual request - for DOA patient, we usualy issued a medical certificate (standard format which state the diagnosis and some description about the condition/management.) in 3 copies. The DOA patient would be sent to the local morturay(private of coz) and iced...The prosecutor would inspect the corpse with the coroner and signed the death certificate. Both the coroner and prosecutor would go down to relevant medical institution to look at the medical records if in doubt. If murder is suspected, an official warrant would be issued and proper copies should be forwarded to the prosecutor officer for further examination. I had never issued any medical summary for such purposes. I told the police politely that the admin office was closed and such summary could be processed in the morning. He then "told" the family to come to us the next day for such document. I had never encounter such request in the past - My conclusion - the police wants to closed the case fast ! - the patient was an amphetamine abuser and he had history of other drug abuse, but he had this handicaped certificate. A fall in the house due to his handicaped condition could made it look like a trauma incident and save the time for proper autopsy.

I don't think it was proper to comply to the police - unlike the Malaysia system , the police would decides if the vicitm need any autopsy; In Taiwan ,the prosecutor would decide - and the decision sometimes would be decide by the family attitude....If none of the family had any doubt the victim was being murdered, sometimes the prosecutor would close the case...

Anyway, the medical summary was issued the next day by one of our doctor...

ghost ....

although I am a man of science, I still believe in this spirit, ghost ... that belong to the 4th dimension. We had this ED nurse who can "see dirty things". "Dirty things" means ghost or spirit.... she said she developed the ability when she was pregnant. Whenever we did a CPR and lost a patient - I would ask her if she could saw the patient and she would told me where was the spirit - either standing in the resus room or outside the corridor.

We had this gun shot patient months ago and she was the one who did the resus with me. The patient was still alive and we lost him. Last week, she told me that she had dream - the dream, the patient's brother visited her house and told her that he and the patient thanks the ED team for the effort of saving the patient. When I heard this, I felt creepy - the patient's brother passed away years ago due to an MVA - I knew that before hand. The nurse then sent the patient's brother out from her house and saw the patient standing outside and waving to her in a friendly way...I failed to save him and yet he was still thankful with what we did....

Well, it is a job....