patients.....

I had bad attack after the bike ride last Friday .... After the clinic session, I went home and felt very tired... The afternoon nap did some help but I had this shortness of breath again in the night... Ving drove me back to the hospital and I took the O2 tank home. The O2 tank re-energized me... but the rest of the weekend was not stable... I did not stopped my prednisolone and continue it to D10... By Wednesday I was better and I stopped my prednisolone use. I did a ride again - but with cautious. I did 3km over 20 min... The fatigue sensation was there but better. No more attack requiring any neb use. I did my 4km ride today and hopefully no more attack....

I had to give up the 3km run in Taipei... a sorry for Yun but she could understand it....

Well, a great experience for me ... .I am glad I am trained as a physician. Eventhough there were helpless moment during the attack but I knew what was the extend and what would come next - imaging a public who knew nothing about asthma.... the stress was not only on the patient , but on the families as well.

Lesson learned : " Be a patient and learn to care more for your patient.....  "

almost had it - part 4

What did I had ?
 
The symptom was so severe that I almost got admitted to the ICU...  The tachypnea was worsen partially due to my obesity ... time to lose weight....

Looking back to the course of disease, I think something had triggered the attack and it was not only a pure exerbation. I might had an viral infection that triggered it. The recovering was dramatic and I am back to my normal self now.

For the past few years, I had on and off attack during the winter and at one time, the symptom was so bad that I had shortness of breath on climbing stairs. But the symptom was better after the winter. This episode of attack was out of my expectation. I did not see it coming and was hit very badly. But I still believe that it was karma - time to pay and I am lucky that the price was not that high...

A narrow escape for me - I valued every smooth breath I take now.... the sensation of enjoying every breath is so good....

I had tappered off most of the drug and currently on long term inhaled steroid use only... I had this developed peptic ulcer due to oral steroid use and I stopped them yesterday.

I did a 6km ride today and tolerated it well; I use inhaler prior to the ride just to prevent any exercise induced asthma attack. The fatigue of body ( ? due to hypoxia) was still noted, just like a hang over after a heavy drinking night...

My challange come next week - the 3km run with Yun in Taipei ... Yes, it was planned 1 months ago and at one moment, I think I couldn't make it but now, back to preparation ....

Almost had it - part 3....

The sleep was bad.... chest tigthness and tachypnea....I was confused as I had never had similiar attack before. I was only slightly improved and I not really better. It was Friday and my round to the land of the lion govt clinic...

The "land of lion" govt clinic is located down south 40 km away from the southern tip of Taiwan. The clinic is currently under construction and the clinic is temporariy relocated to the local library. No air con was installed and it was good damn hot that day... My symptom had worsen again after a while, I took a couple of inhaler but it only relieved for a few minutes.... I need to take a few sigh from time to time to relieve my shortness of breath.

I finally reached home by noon and did not feel better. I told Ving that I might need to get re-admitted later that afternoon. Ving was very very worried... I was in a dilemma then - some O2 use may eased my discomfort but admission would panicked Ving... By now, I had reliazed that I had tappered my steroid too fast... I had only use methyprednisolone 40mg q8h for 2 days and changed to oral dose of 20mg tid on D3....Way to fast, during an acute attack - 1mg/kg is recommended and I am 90+kg : a use of at least 30-40 mg tid is needed....plus I did not use any oral ventolin nor theophylline tab... I gave in by 8pm.... I took a drive to the hospital - I saw the panicked and terrified look on Ving's face, when I told her I need to get admitted ... she offered to drive me but I denied - it was too late for her to drive such a to and fro distance....
I reaced the hospital by 9pm and got admitted... The chest physician was running the night clinic and he admitted me... he hit me with everything ... IV methyprednisolone, oral aminophylline and ventolin plus regular neb....
I slept better that night - thanz to the O2 use...but I did not get better. I was still breathless and need to sigh on and off to get some new air.
All the side effect of noted
 Headache and flushing - aminophylline + ventolin
 Mouth dryness - ventolin
 Dizziness - antihistamine
 Gastric discomfort - steroid
 Palpitation - aminophylline + ventolin

I just laid on the bed and put on my O2 whenever I sleep.... Ving came with the kid on D2 and brought me some food .... Once a while ( for mintues to hours), I could feel that I could breath smoothly and I thought I was better, but it was just for a while.
By D3(Sunday) - I was better and I discharged myself in the evening. Better means improved but not fully recovered. By this time - I started to wander about my condition - would I recover fully or I would have to go on prn O2 or lifelong oral tab ????? I just can't bare to think about my condition in the future...all I considered was - can I do the shift on Monday ?

I decided to do the shift ... at least I could use O2 when needed...and I was restless and having poor sleep due to the oral medication...

I wandered around the hospital with unsteady gait and inserted 2 CVPs with my trembling hand.... and put on my O2 nasal prong whenever I lay on the sofa of 175...

Amazingly the SOB sensation went off and I was almost well when I get off by 6pm Tuesday .... it didn't happen like a snap but I felt almost normal when I reached home....

I knew I had my life back and had an near escape from the gate of HELL....

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....