Terror of the tongue...

A few of my friends had asked me if I had to choose again would I choose my path as a medicine man again ? My answer definitely a YES It was a chance of a life time to lay my foot on this path. No remorse --- although most of my time, my brain had been thinking of solution for the -pharmacy project. I was lucky to become a physician and had the luxury to do tropical medicine in a less hazard place (such as Africa). I am currently the family physician of my own family - really a luxury . I don't have to sent my children to a ENT for a common cold consultation -- even the H1N1.... I am greatful to the MOH...

But sometimes, you would get a hit over the head, you just can't solve everything......... We had gone for a camping trip during the new year eve 2 months ago. During the stay I had noticed a persistent pain over my right lateral tongue. I could feel the pain intermittently for the past 3-4 months. I had always thought the I had bitten my tongue somewhere in time. But when the pain become persistent, I was worried. I did a good look at the lesion - well, a 1cm cleave like lesion was noted and I could feel a plaque around the lesion. The colour is paler than the surronding on closer observation. It was a darn shocking ... a leukoplakia a.k.a pre-cancerous lesion OR maybe a real true malignant lesion !!!!

I had entered an dilemma and tried to seek the cause - I am a non-smoker, non-betel nut use and I don't drink either. I didn't spend much time to give myself an answer --- caries.

 A long long story - tracing back to my college days, there was this toothache over my rt upper first bicuspid tooth. I had visited the dental clinic and a pulpectomy was planned but I defaulted the treatment(I had DENTOPHOBIA). The pulpectomy hole had become bigger and bigger and I had suffered a few years long of toothache ( the second bicuspid was involved later on and the I had 2 caries instead of 1) This 2 caries had cracked over the time - their sharp edges had consistently rubbed over my tongue.

After a 2 weeks trial of "trying to keep" my tongue as left as possible most of the time but the lesion was till there. I decided to visit the dental department of my university hospital. I saw a young attending dental surgeon - - well, my BP rised up to 230/130 mmHg prior the consultation ( I was very very very very nervous) - the worst case scenario was "cutting" off half of my tongue and a long time speech rehab.... I am definitely not prepared for that !!!

An lady dental intern saw me first but she could barely localized the lesion. That was where I got the "rocket high" once of a life time BP recorded. I proceeded to see the dental surgeon minutes later and he assured me that it was just only an leukoplakia and tooth extraction would prevent the lesion progress..... I sigh and turn down the offer to extract the caries on the spot- I was scheduled for a 24 hrs shift then....

With no struggle I called up William's clinic and scheduled for a tooth extraction 4 days later....William's is a dentist and my senior who practiced not far away from the place I worked. He is very senior to me(he graduated 10 + years before I enter medicine school)... but we had sometime in common - both of us had a practice license back in Malaysia but choose to stay back here in Taiwan...

The tongue lesion had regressed after the extraction and I had walked out from the "self frightening anxiety" syndrome.....I tends to precious my life more - I had the feeling of regainning my life( still far away from a reborn...)

New year,,,

 The new year
session was longer then ever – a total of 9 days counting from the eve. No
special assignment for the ED shift – most of us did what we should – no extra
hours nor major change… I got my weekend off as usual… Most of the staff were
prepared for a major hit of patient waves but I was not … what can you get
during a 24 hrs shift ? 100 – 120 pts ? I am not worried…

What worried me
most was the traffic – I had waited for 900 seconds in front of a traffic light…that
was the worse.

This year the
traffic police did a good job, in fact the traffic was smoother than ever, at
every traffic light an officer was placed. The controls were well coordinated…..

The shift were so
so , saw around 100 + pts per shift, mostly AGE and some trauma.  No burn from fire cracker – the
economic crisis had taught the public a good lesson…

I survived the
shift (2 x 24 hrs QOD) … the ICU was so crowded (lots of complaint from the
nurses of coz…)

As for my bonus - I got what I have expected...an encouragement for me to keep going... well, next months, i got a cut in night shift and I would have to face my 4th challange for the ACLS instructor pretest....

Crisis.... I hope something can be done....

I was appointed as asst chair of patient safety committee when I joined the hospital. My asst superintendent wanted someone who with experience and new idea to lead the team. The commitee major task is to control and manage the extraordinary incidence in the hospital, ranging from patient fell down to drug safety... My assignment was to monitor and counter sign each cases - deciding which case should be brought up and root course analysis (RCA) should be done. During this period, I had become one of the "black badge" in the hospital. When ever I was seen discussing c the matron or other head nurse, the nurses would gossip around that I was complaining and trying to dig shxt out of them...

In a matter a fact, I dislike the job, but I wanted the hospital to become a better place - not only to work, but to all the patient. But the fact was the other way round, you can see violation of standard operation procedure here and there. Workers decide the way the they do their job - SOP is for reference and not comply.

I was a little fed up about the situation and asked for a leave. I finally got it "exchanged" . I resigned as asst chair but remained in the committee and focus on the RCA team.

Recently I had three similiar incidents which ended up differently. It all started from the pharmacy....the pharmacist had "accidentally" and "wrongly" enter a wrong drug name while transcripting the prescription to the pharmacy entry system;a wrong entry would lead to wrongly despensing of such drug to the ward. well, when the system works well, the drug would be double checked in the ward and error would be noted and correction would be done so the patient would not recieve any medication that he is not suppose to have.

However that were not the case for all of the incidences I mentioned. In one of the cases, a fourth generation cephalosporin was wrongly entered as a second generation cephalosporin.... a stat dose was ordered and the pharmacy had entered it correctly and a stat dose of such drug was sent to the ward and this nurse A had given the stat dose. However the regular 4th gen ceph was wrongly entered to the system and on D2, a 2nd gen ceph was despensed to the patient. On D2 this nurse A had however violated the SOP: she did not perform a double check before given the drug; she had to checked the drug with the dispensing sheet( it was transcripted from the medical order sheet(this sheet was printed c clear capital letter)) and she had ignored/or maybe forget that the packaging was different from the drug she given to her patient last night. She had injected the patient with the 2nd gen ceph.

And then the evening shift nurse and then the morning shift nurse and then .....had given the drug without properly checking the label of the drug and the order sheet . (there were 21 "and then" in total: yes 21/3 = 7 days!!!!) During this 7 days no staff had discovered the error - the drugname on the UNIT DOSE sheet, the order sheet and the drug label was totally different. On D7, the drug was renewed and a new prescription was sent down, this time the entry was correct and the 4th gen ceph was sent to the ward. The nurse (not A) of coz, had discovered that a different drug was given and they had tried to file a complaint to complaint the pharmacy of wrongly dispensing drug. And later the truth was revealed.....well, no one seems to care after the incidence...

Well, the patient did got better - he was given a double dose of 2nd gen ceph ... lucky he got better and did not suffered from any other damage.

 "TOO ERR is human, to forgive is DIVINE" ---- but this is far beyond forgiveness....the chances of having another incidence is 1/536870912 in other hospital but with the current staffing, I think it is 1/2.......

The RCA report will be my responsiblility, but before I seen the investigation report and conclude my report, I knew the conclusion - negligence.

But why these staffs dare to do so? this is another management problem: in the past only finger countable(to be exact 1 hand) staff were reprimanded for what they did - most of the time, oral warning was done....and also only handfull of staff were being praised .... that was the main reason...

TIRED -- I told Lem, I am prepared to resign .... no sense of security working with those staff...

SICKED department....still, GODS ruled....

The patient survived untill D3….His MAP was around 55 mmHg at a medium dose of dopamine…. There were 2 incidences which irritated me …

On D2 the patient’s condition was still bad – MAP ~ 0-30mmHg and tachycardic…

The patient sustained an open fracture over his left hand, the surgeons had planned to repair it after the laparotomy but it was not perform as the patient’s condition was too ill. On D2, while I was doing rounds in the ICU, I had seen him and asked the orthopedic surgeon to see him and at least do a simple debridement at the bedside. While the surgeon was preparing to do so…. The nursing specialist of the surgeon walked in to the ICU and advised the surgeon in a high tone –“ No need to do so, just wash up, the patient is going to die anytime today…” I almost lost control and wanted to walk toward her and give her a good slam…well, she is really an aXXhXle as far as I concerned. Her boss had covered her well, she is a dare daring person, she is always late on our case conference. She buy her lunch at 11:45am at the food store. You could hear her grumbled how busy she was when she had only almost handful of patients under their service.…She hardly renewed order for their ICU patient , you could see patient with order that dated 10 days ago(order should be renewed at least once per week )…. Arrogant and knowledge poor person who keep writing patient had bad digestion and poor bowel movement but never bother to manage the patient’s hypokalemia….

3 hrs later after the irritating words, I got a call again from the ICU…. The patient had removed his endotracheal tube. “WTF,” I mumbled on my way to the ICU. I saw the patient again struggling under restrain at a MAP of 10 mmHg. I asked the nurses what happened, and the nurse told me that the patient had removed his endotracheal tube while they were performing the rolling over position change. I asked,” Wasn’t the patient under restrain ?” the nurse in charge told met that they thought the patient was “flaccid” as the BP was so low…. “Flaccid” my aXs, never violate the SOP(standard operating procedure) was the rule of engagement working. I shook my head and ordered some propofol while taking my position. The intubation was smooth and I waited for the mouth bite while the nurses were trying to fix the ETT. I asked for the bite but no one had seem to care about my pledge. And during my 3^rd request, the nurse in charge told me in a high tone(in a sense of telling me the TRUTH) that the patient is suffering from air hunger and don’t need a bite as he was opening his mouth all the time gasping for air…I almost roar but tell them in a very serious tone – “ then no bite for him and THERE WILL BE NO BITE for this patient FOR THE REST OF HIS STAY….”

 

The next day, someone told me that the patient was given 2 bites as he started to bite the ETT hours later….

 

This nursing department is SICKED as far as I concerned… the nurses had dared to violate the SOP under their discretion(which proved to be fatal in some of the situation…), I had prayed well for the patients.....what the heck happened ? simple we had a nursing director who was so “Lemah Lembut”(weak and soft) that no nurses would be punished /demoted for their fault… the head nurse of ICU had gone for a long leave and the acting head nurse is a BIG(in size I mean ) BULLY who is another arrogant lady who was .,..

 

PS: pt was transferred on D3 and died in another hospital - he did not make it for his second ops...