Nasogastric tube is for drug feeding only....

I had this old lady who was resuscitated from a DOA(death on arrival) situation... The admission diagnosis was Suffocation... I asked Lem how did it happen ? Lem told me she was a victim of stroke and an nasogastric tube was in use. But the family said they feed medication via the tube and "FEED" the lady through mouth. The lady was choked by this papaya !!! I had seen many case that suffered from aspiration pneumonia because family and patient refused nasogastric tube placement for dysphagia due to stroke, but such case was the first one I encountered....

Well -she was still E1VEM1 before I went off yesterday.....

175

175 had been part of my life since 12 years ago....There was once I thought that it had become history...now I am living with it again...

In the hospital, whenever there is a incident that needs the ED doctor - either a patient in ED , or procedures in the ward; 175 would be the answer and solution....

175 is the extension number of the call room. I was introduced to this room the first day I worked in this hospital. I had slept in the room 10 + days per months in the first 2 years. There was period of  6 months when I did 20 night shift per month. It ended when I gone home to served the MOH. When I came back, it was still there with some minor changes - a desk with chair was given.

the room was slightly smaller than the hostel room of Hospital Tengku Ampuan Rahimah. There was 2 double decker beds - there were 4 of us when I started to work there. We were all classmates... No TV nor refrigerator initially. 6 months later, one of the senior management staff came to the room and decided to give us a TV( 14") and a small fridge ( I mean small, the smallest - just like what you see in the motel. ). What could a resident grade doctor demand then? after all it would be good enough if there is a good bed to sunk in during the endless night shifts. The cleaner would come in daily to mob the floor with chlorine-added water. The condition become worst when I left. The management started to bring in more locums and no one care about the condition. There were a lots of staffs  - bags, overall coats, jackets, drinks , we don't know who left it and no one bother to dispose them...
When I came back from Malaysia  the 175 was in a greater mess .... but I could live with it as a bed, a TV and a fridge was enough for the stressful night...

175 was still there on my 2nd come back - but this time I had a desk in the attending physician office . But most of the time I would hang around in the 175 as Lem ( my classmate cum colleague. he had made head of ED then) was there and we could chat and watch TV together.

Recently we had a Surgeon reported for duty and the doctor's office is too small to add another table. The deputy hospital had asked politely if I could vacant my desk - I gladly complied as I did not spend much time there. Lem was also being asked to move out from the hostel(It was a building in the same row as my previous old residence) to vacant a room for the surgeon (he hardly sleep there so no harm..). So to compensate both of us - the hospital service manager had offered to refurnish the 175, he had given a lots of his innovation during the requesting session - at least Lem was the Head of Department ....

A thorough cleaning was promised and some  new furnitures. We tried to clean up most of the unwanted staff... and the cleaner came and did a good sweep. But the serviceman told me that no new furniture is being ordered and only the mattress would be replaced. Well - crap shit....all those staff discuss before were not being implemented. I was feeling upset and that night during my call, I had told the night shift nurses about the incident. One of the nurses suggested that we should have a sofa than...

I ended up drawing a design chart that night and passed over to Lem in the morning - he gladly agree with the setting and told me to carryon. The chart was passed over to the service manager and forwarded to the management then.... Few days later, there was a new change in 175 -> the upper decks of the beds were removed and we got a sofa. There was a locker for each of us ....when the rennovation was done the service manager said that we should make a signboard outside the room to warn there other staff  (the ambulance drivers and surgical assistants) to stay away....He said that strong word should be used. But I gave him another suggestion...and he accepted it...

Now the 175 is no more a call room - > it had become the ED physician's Office. Truely, it look like a office now - 2 bed with good matress , a sofa , a desk and internet connection. And also we had a bigger fridge...On call life in the hospital had never be so good before....

the young and the old

the accident happened in an early friday morning...

a bike rider had rammed a old lady...

The old lady was almost 80 and she had poor eyesight, poor hearing - her job : kalung guni (refer http://en.wikipedia.org/wiki/Karung_guni)...she was later sent into our ED by the local rescue ambulance. She was alert on arrival, holding her rt lower leg and yelling at how pain she was...her right face was severe swollen and she look terrible...her BP was stable and I did the usual assessment. There was definitely a facial bone fracture and probably some intracranial bleed. Chest and abdomen was clear and the lower leg closed fracture could wait...but the face swelling worried me; she was very thin ~ 30kg max, and the skin was so lax and the space between the skin and bone are spacios. If the swelling/hematoma expands, the airway might be compromised and I would need to intubate her...I told the family on my first explaination about her condition.
Although she had no neurological deficit, the brain CT confirmed my suspiscion of intracranial bleed - some SAH and frontal ICH - nothing much needed. But her BP crushed ( SBP was 70mmHg) on returning to my resus area. I was thinking of demerol effect, but I had given her only 25mg intramuscularly. I did a second assessment and yet no suggestion of any chest nor abdomen contusion. I flushed in some fluid and the BP return to satisfiable level. But I was cautious and did a chest and abdomen CT. The CT was clear and I sent her up to ICU as the family agreed to be treated in our hospital. The families were local peoples and the old lady had a major trauma 3 years ago (pelvic fracture and ICH) and recovered well after treatment in our hospital.
The BP was not good on arrival in the ED. The SBP was again 70+ mmHg. I inserted a CVP via the rt side of neck. The swelling of neck was noted now. The CVP level was -2 cmH2O and I ordered a fluid challenge and proceeded to the weekly morning meeting.
It was not long before I was called back to ICU to intubate her. The nurses were ambubagging her and got into the position stat. I glanced at the monitor before I did my trial. The HR was 50/min...she was crushing alright. The swelling had extended to her neck - airway compression had happned. I regreted that I did not intubate her earleier. The following process was more shocking. I had difficulty to get a good view as the facial swelling had made the mouth opening part difficult. Then I noticed freshed blood had flooded her mouth. After suction I could still get a good look at the vocal cord. There a swelling under the epiglottis. "Damn !", I yelled in my heart - 2nd time I regret that I did not intubat her earlier. I did a second look and waited. She was still gasping and the instant she sipped her air, I noticed the opening of vocal cord and successfully put the tube in...Now, the question : where the heck the blood come from ? I did a thorough check this time - there were multiple laceration in the mouth - the tongue base, the upper and lower gums...The BP was unmeasurable at the time. I ordered a lot units of blood...The BP was so bad and I don't think it would be appropriate to sent her to OT. I decided to do it ine the ICU.
I summoned the surgical assistant and 2 nurses(one of the OT) and we did it in at the side. The surgery took about 1 hours and we finally patch up all the wound. But blood was still pouring from the nose...
I finally make up the story : the old lady had swallowed all the blood until she went into hypovolemic shock. She was comatose finally after all this was doneo, although I got a good BP then...I went off by noon.
Before I took my supper that night, I called the ICU and found that her BP was again unmeasurable and nothing was done. I ordered more blood and went to sleep. If was an off day for me but I called the ICU and found that her BP was stablized again after the blood transfusion. The bleeding from the nose was less but she was still comatose.
I saw her again at noon on Monday. Her BP was stable but no urine was noted. The worst had happened. She had acute renal failure after the shock episode. She was comatose still. Her BP started to crushed again since that day and we lost her last night...

The young bike rider was sent to ED later after the old lady was sent to ICU. A young man who bared a backpack with a tennis raquet in it. He had 2 earing over his rt ear. Petrol smell over him. He had some abrasion wound and contusion but nothing serious. I treated him and adviced him to called up his parents. He refused initially but later called his mother after we insisted. The conversation did not go well - the young man hung up and told us that his mother refuse to come...The way he told his mother about the incident was rude - he said he had an accident and knocked someone, but refuse to give any further detail.  We later sent him to the toilet to washed away the gasoline. He left his phone in the ED and it rang. I answered the phone and it was his mother on the other end of the line. The mother was calmed and I told her what had happened and asked her to come over as the old lady was in a critical condition(she was not intubated then....). The young man later returned to the ED and rested on one of the bed. The nurses chatted with him and found out that he was a 4th year English faculty undergraduate; he was planned to the Annual Spring Shout Festiva Concert in Kenting....He asked me what was the statue of the patient - usually  I would told the person who knocked the victim - against the ethics. I would told them that I could not reveal the detail but if he wanted to know more he can stand among the families and listen to what I said. I told that the old lady was in critical condition(what a crap, one should be in critical condition to be admitted to  ICU !). He then mumbled to himself - I hope I could just attend another Annual Spring Shout Festiva Concert before I am jailed...all of us in the ED shaked our head after hearing his words...My thought was - it was a 3 days off (Fri to Sun) and he should have go back to gather with his parents instead of attending this concert....When I told Ving about this incident - I got shock again; Ving said the young man thinking is positive - freedom is what he is seeking....I think I am really old . I felt a little deserted - not belonging to this generation anymore, none of the feature on that young man I wanted to be present on my children. I wanted them to be "good" - lots of people asked me about teaching my children English but I would politely tell them that I am not in a rush. Maybe later I said. But deeply I felt that I had come so far to this soil and it happens to be one of the origin of chinese studies. A good master of chinese would let them learn the core of chinese ethics and hopefully for my children would grow up and become one of the model people I look up to...

 

gun shot..

I had just walked down from the ward and wandering around the ED entrance. I saw this car parked in front of the ED and one of the nurse was standing beside the car with the trolley. I walked toward the car and was a called by another nurse to be prepared in the resuscitation room - she told me there victim was a gun shot patient...
I gloved up and waited. The patient was still breathing when he entered. I felt the carotid pulse but the BP was unmeasurable. There were 2 wound - left chest and left upper quadrant fo abdomen - the heart and spleen area.... I asked the registration staff to inform the police and summoned the ambulance driver - I was gonna transferred him once I got all those tubes and lines in. We had no cardiothoracic surgeon and our general surgeon would be reporting 1 week later. All I could do is get a BP and sent him out stat. One of the 3 persons who sent him in had sticked his head in and asked me how his condition. I told him it was bad and asked him what had happend. He replied he dont know and quickly walk out from our hospital. The patient had standard look for a samseng/san qik la(3,7 chap ).  Well, I think he was one of the importants/high rank - tattoo all over his body and was neatly done...

those 2 hole was the gun shot wound 0.8cm ..... I confirmed spleen rupture with abd sono..

Since the patient was still breathing and complaining about shortness of breath. I decided to get the chest tube in first. There were 3 nurses assisting me but they look panic - no team work at all. I was grumbling but nothing to shout. The chest tube was inserted smoothly but still unable to get the BP . Only 1 line was inserted and the blood I ordered had not arrived. The EKG leads was not patched yet and the patient was showing me the white part of his eyes. I had to intubate him stat and start CPR. After the intubation, there was still 1 line only on the patient - he was a IVDU( with needle mark here and there...). So the CVP was inserted and by now I got my blood... it had been 18 mins since I lay my hand on him... Now the blood was up and Plasma expander flushing through the CVP like pipe water.. But still no BP...There was this same kinda of peoples poking their head out from the curtain from time to time. By 20 mins, I walked out and got his relative - mother, and told her that the patient was hit over the heart and I am losing him but I would try my best for another 10-20 mins.
I called it at 35 mins. There was a big crowd outside the ED. The polices, the family, guys from the same clan... I continue to see other patients waiting in the ED.
I was lucky - no reporter came...
the police requested to keep all the tube and lines - to facilitate the coroner with the autopsy...the patient was finally sent out 40 mins later.
My call that day was uneventful and I got a fair night sleep...
The next day, one of the local nurse told me that the victim was son to the head of local gangster, Mr. E. I knew this Mr. E, but I did not see him last night. Well, our works manager (a local who also PR person ) told me later that most of the local gangster came last night...it was a serious matter, should be some severe misunderstanding and dispute. There might be further incident in the future...
Well, I was lucky that night, I heard that some of the doctors were threated by the relatives during such resus situation : guns was pointed at the doctor head, requesting them to save the patient....

stable and unstbale..

It was not a good day to start...I saw 2 ambluance parked at the ED entrance while I was walking into the hospital..Through the ED glass window, I saw our nephrologist performing physical examination on one of the trauma patient...well, not a good sign, that means some major trauma had occured.
I was informed earlier in the morning that one of my patient had noted with respiratory failure and he was intubated. The ICU was +2 beds at the time. I proceeded to the ICU and started my routine. The patient had had a noscomial pneumonia and septic shock. He was given Tienem and I think he would not make it throught the night. I informed the family and took a round in the ICU. The drowning child was stationary however not much improvement on his neurogical condition. No ARDS and pulmonary edema was noted though. The rest of the patient was unstable and most of them were hooked onto ventilator and no way I could sent them out.
Later, the ED informed us that 2 polytrauma patients were currrently in the OT and would be transferred to ICU later.
I look they imaging studies of both patient and knew that I would not have a good call that night. The female patient had a splenic rupture with left hemopneumothorax. The male patient had a blunt abdomen contusion and scheduled for a exploration laparotomy eventhough the CT was negative of ascites. I asked around and found out that it was a motor vehicle accident. The car with 3 passenger had lost control and rammed the hillside. The backseat passenger had suffered from lower limbs fracture and also being operated in the OT. L ( my classmate cum colleague) told me that the female was in severely shock state on arrival. Appearantly the EMT had mis-triage at the scene. The male patient(also driver) was stucked in the car and moaning in pain but the female who was in shock condition was too weak to moan. So the EMTs sent the one who moan louder first. The female was sent over 20 minutes later with BP of 60/30mmHg on arrival. She was given 16 u(1 unit ~ 250cc ) of pRBC in the ED[plus some plasma and hispander as well].
Later in the evening, the female patient was sent to the ICU and the surgeon had told us that splenectomy was done but tear over the omentum and splenic artery was noted. Retroperitoneum hematoma was noted. The surgeon said he had done his best - he expect oozing and he felt that the patient might still bleed to death.....The last platelet count noted was 68000 before she was sent to ICU. I ordered some platelet for transfusion. The Vital sign was stable when she was passed over. 1 hour later, the BP started to crushed again and heart rate risen to 140/min. The drain(peritoneum) had poured out some 200cc of fresh blood. I began to worried about DIC at the time. I ordered some more plasma and pRBCs....She was stable few hours later after the platelet was transfused.
The male was better, no internal bleeding and simple repair of tear over the small bowel was done. The patient was extubated and pending transferred to ward when the family arrive.
Only 1 family came. The 3 casualties were family. The younger child came and he told me that he was unable to look after 2 patients in 2 different room(the hospital was almost fully occupied and couldn't placed both of them in the same room). So the father was placed in the ICU.
I thought everything would be fine as I did my final round by midnight.
However there was this wife who was brought into the ED by her husband claiming that the wife had attempted suicide. The husband claimed that she had drunk some insecticide. The wife denied initially but later admitted that she just had a small sip and spitted it out as she was trying to frighten her husband after a quarrel. Well, I retained her and asked the husband to get me the bottle... Hours later, the husband showed up with a bottle - Organophospate ... The pupil was still ok but I believed absorption througth the oral mucosa could be fatal as well and insisted she stayed back and observed till morning. I was right, her symptom although mild appeared later. I managed accordingly and just while I was going to sleep. Another patient was sent in by the police. A male was found in a car parked at the roadside. He was confused and 2 bottle was found besides him - rice wine and a bottle label insecticide : pyrethroid. He was drowsy due to the alcohol and vomited like don't know what. The SpO2 was not stable wandering from 90-95%....No more bed in the ICU and I "persuaded" the family for a transferred. The family requested this KCXXHospital. I called them up and the ED physician replied me in a unpolite tone," no more bed and please don't sent them over...". It was the last month of this quarter, most the hospital had used up all their allocated budget - more case means more lost....I finally got another medical center which willing to take over the case.

pyethroid	Organophosphate

Just while I was laying down for a nap. The ICU informed me that the SpO2 of the father with blunt abdomen trauma was crushing and the ABG was compatible with the readings. I remembered the chest xray and CT was ok for the patient.....I rushed to the ICU and saw the patient - he was alert but sleepy. Coarse crakle was noted and I decided to intubate him; the SpO2 was 70% only~!!!!.. My heart sunk when I saw the suction substasnce after the ETT was placed - it was coffee ground as what came out from the NGT. He had an aspiration. The CXR after the intubation had confirmed my diagnosis. Now the stable patient become unstable....
I was comatose for the next 1+ hours disturbed by various call from the ward - some of them really drove me crazy : 
       " the XXX bed patient with gastric outlet obstruction had pulled his (left internal jugular) just now accidentally.."
       " well, anymore fluid to run in ?"
       "nope, we shall start his infusion tomorrow morning..."
       "ok, I would re-insert it in the morning..."
   it was 5:00am when this conversation occured. I was too tired to throw the 6 letter word start with KNN...

The ICU called me again by 6am. Another patient who was admitted for recurrent CVA had noted with crushed of BP and dropped of SpO2. I went up and saw a BP of 66/20mmHg and SpO2 of 70% on Nasal canula. I intubated him stat and inserted a CVP....another aspiration pneumonia....

By this time, 2 of the stable patient had become unstable ( recurrent CVA and BAT father), the most unstable one (mesentery tear and splenic rupture) had been stabilized...

Well, my eyes was almost shut during the Thursday morning meeting session....

Paeds CVP

I hate paediatric since D1 of medical school... back in my schooling day I need to assist my Mom with the babysitting job. Our financial condition was not good those days, my mom babysitted a few children - max was 3 (or maybe 4, long long time ago and I just couldnt remembered ) at a time. Baby sitting those kids was a stressful job for me. I need to "entertain them" - calm them and don't let them cry....well, I told myself - no paediatric for me...

But eventhough I did not join the paediatric department, but I still have to see kids...I tried my best though and I like those kid who was calm and interect with me in a good manner. However I still hate doing procedure on paeds patients - all those staff since so small/tiny...with my fat and short finger, I think I might just hurt them with those tools...

The youngest I intubated was those newborn who aspirated meconium stained liquor. Well, not a problem as I could see which hole I am inserting the tube. But CVPs ....the smallest I did was 6 years ago...I used an adult set ...

During my last call, there was this drowning  2 y/o child ( 1year 10month to be exact) who was brought into ED. The team did a great job manage to get a ROSC(return of spontaneous circulation) within 5 minutes. The child was sent up to ICU later. After the passover and the nurse informed me that the only IV line was leaking. The nurse "adviced" me to put in a CVP. I was reluctant to do but thinking that a CVP would save the child from a lot of puncture in the near future ( blood could be drawn via the line and saving those blood taking prick..). The nurse brought me the paeds CVP set and I swallon a big gulp of saliva - everything seems so small...
well, I used my usual method and I missed on the rt side. I told the nurse to prepare another set and tried on the left side. I had a flashed back about a scene of ED while waiting the nurse to get another set from the storeroom. The episode was about a conversation between Dr Peter Benton( he was R3 at the time) and a paediatric surgeon. Benton admired about the skill of the paeds surgeon and asked her how she did a central line without difficulty, she told Benton that she knew how the vessel runs... I took a deep breath and palpate the vessel before I cleansed and draped. I mark the artery over the inguinal area( I dare not try neck as the child was gasping on the ventilator...) with a marker pen. Then I cleansed and draped. I did a trial by puncturing just next to the line and I got it in 1 trial. The rest of the procedure was easy and I completed it within minutes. I was supposed to be happy but was unable to cheer up as I felt I am losing the child..

I did a ABG after the puncture and it revealed severe CO2 retention...I presumed he was drowned for quite some time before he was rescued. I had a conversation with the family later - they let the child play around in the yard and later found him lost. After a search they found him floating on his back in their neighbour fish bed...well, reckless and neglience parents. Reminds me to keep my children around my sight...

I told the family the baby is gonna die ,most probably on the same during the explaination session....Surprisingly they did not ask for a transfer. Most of the family would try their luck in a bigger hospital.

 I did everything I could, steroid, antibiotic etc...I did my last round at 12 MN and he was improving - the FiO2 was lower from 100% to 70% and the child had opened his eyes but his limbs was still in decerebrate posture.... I had a good night sleep, only a few calls and interuppted my sleep. I saw the child again next morning and he was better. Today he was still in our ICU, he had pneumonia but no ARDS...

I hope he recover.....

domestic disturbance...

I had this assault case 2 days ago ...
It was 8+ pm when the ambulance brought in a family. 4 persons came in with the ambulance - Father , mother and 2 daughters. The elder daughter was the victim - she was slapped and hit over the head by his father. I examined the girl and found the girl had cerebral concussion. She told me that the assaulter was her father. I arranged a CT scan and interviewed the mother for the further information. It was a simple matter, the father wanted to borrow the daughter's hand phone and she denied. The father was walking in and out from the ED and mumbling about he had raised the daughter for 18 years and he only slapped her likely over the face. But lightly my ASSS...the upperlips was severe swollen and bruise. There was a hematoma over her vertex. The police came later after the scan. The police had a conversation with the family. You know what, one the police adviced the daughter not to lodge a report as it would make the poor relation between the daugther and father worse. It was not the 1st time the father hit the daughter...I whispered the 4 letter word started with F while hearing the conversation...
When the police left, I approached the mother and told her about the further management plan. I adviced them to lodge the report and told them I would admit her and get help from the social service to help them tomorrow...
Before the patient was sent up, the father came to the ED desk and asked us what was the condition of the daughter. I told him that his daugther suffered from cerebral concussion and I would like to admit her for further observation. He burst out and stressed again that he slapped the daughter's face lightly only and there was no way that any cerebral concussion could happen. He then asked for a transfer. In the past I would gladly concurred with such decision, but this time, I turned down his request. Eventhough he was the sole guardian(the couple had divorced and the father had the custody of the kids..), I still had the right to place the child under my care and responsibility as he was the assaulter. I then asked my nurse to call the police. The police came fast and asked the father to leave. They even threatened him that they would lock him up if he go near the hospital again. The father left with a pissed off face...

2 hrs later, the ward nurse called me that the father had gone to the ward and asked the nurse to arrange for a transfer. I summoned the police and went up to the ward to calm him first. He still querry my diagnosis and insisting a transfer. I told him that I would not transfer her stat but would assist them for a transfer tomorrow morning. But the father still insist...The police finally came and escorted him back to the station...I did not see him again that night...

Never never hit your children....that was the lesson I learnt that night...