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...

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….