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...

what if... can i change the will of the GREAT ONE.....?

Not a quite night it was…I was “vrooming” here and there … the rescue call station had informed us a case of “penetrating injury” – well, that was it, the details were mostly blurred. We had get use of their style of reporting… I was seeing another patient, when the ambulance arrived. The way the EMT “rusheh” the trolley into the resuscitation area means – very very serious case.

When I placed my foot into the resus area – I saw this…

“Holy SXXT”, I grumbled and started my assessment and my question round. The EMT told me that the patient was a bike rider and skidded. A wood had penetrated his abdomen and he had removed it on site. It was a big wood judging from the size of the wound.

He was comatose when the EMT found him. In our ED the patient was unarousable and only carotid pulse can be felt. The night shift Head nurse had assisted my with the CVP insertion and I got 2 pack of O neg packed RBC stat. The resus was not pleasent as the ED nurses were doing nonsense act(despite of getting large bore in, someone was exposing the patient with her best effort(cutting the very thick jacket...)

Within 15 mins, I had flushed in 2000cc of fluid plus blood via the 1 large bore and CVP --  the patient regained conscious - good sign.... The BP was still unmeasurable and I rushed him to the CT room. I had called up the surgeon and Anesthetist. Well, I think he would make it, it was an risky act, because, the pt might collapsed again and unable to make it to OT, if so , the surgeon and anesthetist would not be happy as they had to rushed from KHH….and further more I had no family to sign the permit. But I thought I need to give him a chance….

Well, we finally got a SBP of 70 mmHg and all those needed were at scene. The pt was sent into OT. However 30 mins later, I saw the OT nurse coming down to the lab and asking for more blood… Well, should be a mess and deep shxt situation. I asked the OT nurse and she told me the IVC was injured, I heart sunk…he is definitely not going to make it….

3 hrs later my surgeon came down and told me what he saw… the wood had penetrated and torn the rectus muscle into pieces and went straight through until it was stopped by the spine – thence the IVC and SMA was ripped off. The intestine look pale as no blood supply was noted . He told me that he would be losing the patient….

I did my best the rest of the night pouring any fluid/blood I could get my hand on into the CVP line….

It was not up to us… the GREAT ONE had determined what is going to happen.. I did not feel well but I think I could closed my eyes tonight piecefully as I had tried . But sometimes I wandered if I should go for a surgical trauma training, so that I could do more. I am seriously thinking about it…..

end of tour...

I had completed my tour of vaccination yesterday.... these were the 2nd stage of the H1N1 vaccination(target were 1st -3rd grade students...). Well, as the wide spread of negative news around by the media, the vaccination rate had been so low (<20%....) The public had been so panic... the media had been so happy to comply with the hysteric act of the public...example of 3 suspected adverse reaction secondary to vaccination...  1. 16y/o high school student who was vaccinated 11/2009 and developed thrombocytopenia in 1/2010 ...unfornately the youth died despite of IVIG management...

2. 8y/o student who developed pethechia and blister over his limbs after 2wks of vaccination...

3. 7y/o boy who developed bil lower leg jerking movement(EPS like jerking) after 2 wks of vaccination...

4.Multiple intrauterine death was noted after mother being vaccinated... The opposition party had mobilized some van going around the rural area, broadcasting about negative effect of vaccination and asking the peoples not to be vaccinated... I could accept their act but there is this key person from the society of O+G who urged those in their first trimester not to be vaccinated and those in the 2nd and 3rd trimester to withold and consider their risk before being vaccinated...I despised his act as what he did was talking without evidence(talk X#$%@%%%)  - at least he did not quote any research.....

As a medicine man, I could only shake my head... The public had wanted an unreasonable guarentte from the govt - a 6 months or long lasting healthy life after vaccination or else ....The public had however forgotten their request of vaccine 4 months ago.

There was this high school student who died of H1N1 lately despite of tamiflu used. The family wanted to sue the hospital and the media report the news like don't know what...Negative negative news... No one appreciate what their was given, remind me of those student who never say thanks after their jab....

The public had fablized the medical profession... they thought if they follow the rules, take the medication they would be immortal..well, unfortantely, only the GREAT ONE could decide....all we can do is assist......condolence to those who had lost their love ones....

vaccine issue....

The issue of H1N1 vaccine was flaming as the local news station had tried their best effort to report single complaint by the public. First was the "needle vertigo" phenomena . One of the news reported had created the terms : it all started when bunch of school kids noted with giddiness and vertigo after the jab. The reporter had used the term and later all the media had started to massively report it ( newspaper and round the clock over the news channel). I had a bad tour of injection due to the report – there was this school with 2 handful of primary school student experiencing vertigo after the vaccination…the student was pre-hypnotized by the news that vertigo was expected after the jab.

Later more and more negative news came out. One of the most prominent was a child of a O+G specialist. The child had suffered from rashes 1 days after the injection and his condition had deteriorated later and gone into septic shock. The cause of death was sepsis. Specialist from the department of health had speculated that the child died of sepsis cause by immune defect. The father had called up some rep and held a few press conferences accusing the govt of releasing vaccine which was not fully tested. They had blamed the death of their beloved child on the vaccine. I pity the family however despised their act. The accuse they made was based on nothing. The vaccine was packed into 40 doses per ampule, that means another 39 students had taken the injection. If the vaccine itself is the cause, there must be some reaction noted among the rest of the students who received the same ampule of vaccine. That however brought the issue back to the processing of giving the injection – issue of aspirating and injecting(in my opinion, this was the most likely cause). However there would be no evidence to prove so….so back to the square zero --- sepsis . Anyone could get a sepsis just like that, a small wound or some unclean food…

After this incidence , patient who died or developed illness( stroke, weakness…sepsis…) few days(or maybe weeks later) after the injection started to complain to the media that they were also victim and wanted the govt to grant them an explaination(or maybe compensation )….

Is the vaccine safe ? All I could said was a local doggie team magazine had reported few months ago that some of the eggs used to produce the local vaccine were not up to the standard(not sterilized enough ….)

I felt relief as xian and yun did not have to undertake the vaccine as they was infected and cured….

bitten

It was a last day of the "cold front" night - supposed to be a peaceful night - at least the "small night" shift(4pm-12MN) was... I had a 999(a.k.a code blue) and I managed to get a ROSC after 15min of effort...A CVP was inserted as hypotension was noted. After the CVP, I went back into the blanket and wished for a good night shift the rest of the night. But by wish lasted for only 10 min - > "ETT cuff leak noted with bed I X, might need a re-intubation...". I gladly complied and went back to ICU. The patient was struggling as the nurse tried to remove the ETT - no a good sign : "S n R" (struggle and resistance)...
I ordered a propofol - if muscle relaxant was ordered, the nurse would have to take a long time(ran to ED ... it was the hospital policy to keep it in ED and OR only) and  propofol seem to be a  good choice at the moment - and I was wrong....

  I waited for the patient to calm and introduced the blade... the patient suddenly awaken and started his "S n R" tour. He had caries and lost half of the tooth and the blade had sunken into one of the gap and my right index finger was bitten following the sink.... Luckly no wound was done but I had a bruise over my index finger's nail bed....

darn ... 3rd time since I got my license, reminded me to insist for muscle relaxant next time....

Best employee award again...

It had been 1 year and the election was on…Unlike the other hospital I work in. The best employee award was generated by election. The staffs vote for the best nursing personnel and the best employee…
Well, as the last year award holder, I was barred from being voted for the next 2 years. The nursing list was not surprised as the winner came from big unit(means unit with more than 10 staffs). These unit can “request” their member to vote for specific person in the unit….
The best employee winners went to some ‘rover’ … those who roved around the hospital…
The polite rover would attract enough vote as other staff would have a good impression on them...(I am a rover as well, I roved around in the night...)

well, a little bit unfair and much more to be improved, But I still felt that every winner deserved the award as they really work hard..

bone problem...

I had tried very hard to keep myself update on my job, however sometimes, I had doubt…. Thank god, someone had invented something called the internet.

We had this osteomyelitis case who was referred to a medical center for further management. There was a great chance for the patient to get the disease as she had rammed her bike into a drain and the bone was soaked in the drain for sometimes before she was dragged out. A simple trauma case who undergone surgery in our setting...

It should have been ok eventhough osteomyelitis developed. However we had pushed ourselves to the current ground. Proper communication was not done pre-ops - no one had explained the risk to the family. When the wound broke down and pus was pouring out from it the family was still hoping for a forever remedy - the family was polite : I just don't care how you all fix the problem, just healed the pt.... 

 The implant was removed and however a plate was re-planted on the second debridement. And weeks after discharge, pus was noted from the scar again...Well, this time, the patient was referred to a bigger hospital up north ... and more shoking news came later -osteolytic lesion was noted (so rapid...) . We reviewed our film and found that no xray was repeated on the latest admission...well, the worst is not another suit as one of the close relative of the patient was a ex-convict ( man-slaughter....)...

For a moment I was a little bit shock when I heard the whole story as it was not the 1^st time for the attending doctor to do so…(the last pt expired after a severe noscosmial infection) .

I had a discussion with Lem and we had re-confirmed over the net that the concept of removing the implant in an osteomyelitis situation was appropriate.

It is impolite to criticize our colleague…but I still felt someone should talk to him…..