now and later....

It was a busy week follow by a 24 hrs weekend call... well, a little bit exhausted as the day shift in ICU was quite busy. CM had improved a bit as he had successfully intubated a few patient...The last few calls were bad - q1hrly call by the ward and ED.

I stopped by the ICU today to see a patient. CM joined me later and asked me what I usually do when I do ICU shift ? It was a darn sarcastic question - 1/3 of his pay came from shift he didn't know what should be done ? I told him that I would round the patients and review their order. Order renewal should be done twice per week. And I showed him how to use the prescribing system. He was not in patient and lack of concentration as far as I observed. Not paying full attention and did thing recklessly. I had told him that there was this virtual pt mode where he could practice, but he went straight and took a patient and renewed it before me. A great deal of mistake which I corrected him during the process. But at least I warned him that he should be careful as he might need to rebuild the whole order if he screwed up - I greatly advice him to try the virtual mode.

Thinking of the bright side, if he could learn then I could leave in grace. I am wrapping up my program and hoping it would conclud by the end of the year. Then I could focus on the job search. I had learnt that there is a trainning post for infectionist 70km away. It is currently my 1st choice...

con man....

It had been a months since we had our new colleague…well, he is truly a questionable person…..He had completed his general surgical and orthopedic training in 2 infamous hospital. Yet his had “houseman” grade skill…. At first we thought he was weak in internal medicine field. But later we found out he was doing darn badly even with orthopedic. He had done 3 orthopedic surgeries and without the surgical aide help, he would have trapped himself on the table, but still he dare to show his post ops checked xray to our boss claiming that how good he was….

The final showdown appeared 2 days ago. When our boss told the deputy superintendent(admin)that he is going for a 2 weeks vacation back to Myammar. The dep. Supt had however poured out what he had heard over the past 1 months and boss called a emergency meeting. Lem was summoned and asked if CM was suitable. Well, Lem gave a pretty objective point of view stating that he is above par when dealing with simple ED patient. But his life saving skill was definitely below average. After the reviewing all the negative remark regarding CM. Boss had called him up for a discussion and surprisingly he had offered for a resign when boss confronted him regarding his skill. He had actually told boss how good he was during the interview. But the resign comes with a condition – he had asked if the hospital could give him 2-3 months times for him to get another job…. But our boss was indeed a soft hearted person(it is really a pleasure to work for him…) he had told CM that he is barred from any further surgery but if he is willing to learn and would turned up anytime(even on his off time) to learn, he could still work here.

When I heard this story I had finally linked up the fragmented puzzle about this guy. According to our dept supt. His had worked in many handful of hospitals for the past 4-5 years. It is not hard to figure out his tactics. He had first bluffed himself to secure a job – he would said he is so good at every skill, he would say he had worked in XXX hospital paeds dept and XXX hospital ED for what period….He asked for a pretty handsome pay and very demanding about hostel condition, he would insist that he can do what ever possible shifts (to get the maximum pay).Darn, when he saw his shift this months, he even walked into the dept supt officer and asked for more shifts....and when boss challanged how good he was with the 3 tube skill(ETT, CVP ,chest tube), he claimed that he had lost the feeling but still assured boss that he is good at chest tube insertion. (Lem commented that from his way of doing other clinical procedure, he is sure CM could not even memorized the step of doing so..)

When negative complaint started to flood the management, he would ask for a resign and bagged to stay back for a little while so that he could “bluff” his way to another unlucky hospital. He could still get paid 200+k RM per annum in such way. This is another way being a con man....Ｉwandered if he is truely the person (or someone had masquaraded...) ...

 I think he is now unable to secure any job in the northern part and central part of Taiwan, but there is still the east and south to rover around. Well, I am prepared to go back to my 8 -9 night shifts/months life within the next few months….

someone "new" to the field....

Ong went on his US trip to visit her daughter again…my shift was supposed to be better as we had a new colleague joining us…however I was no less better – still 8 night shift ( mon -2 but sat +2)…darn and 2 more Sunday day shift, all I could do was cursed….

Well, our new colleague is an orthopedic surgeon, ex-hong kong citizen turn US citizen, Taiwan medical grad. Some introduced him to our boss. Prior to his arrival, boss had described him having 6 months of ED experience. Lem and I had exchanged opinion about this guy and we agreed that we were last of the breed…. And we were right…

Our new colleague(CM) first shift was a night shift and Lem had requested him to report earlier. Boss had led him around and after a tour in the ED, boss had brought him to ICU for me to brief him. During the briefing, I had noticed 2 controversial point …

 Point 1 – He do know how to insert a central line He had indirect admit that he doesn’t… when I told him that for shock patient, a central line would be needed prior to start the dopamine drip. He had asked , “ so do the surgical aide insert the CVP ?” well, a question indirectly informed us that I hope someone insert it for me… I told him NO and the doctor would need to do it…

Point 2- he is good at intubation Before I sent boss and him off, I told him that we don’t have any relaxin(succinylcholine)in the ICU, propofol(diprivan) would be the first choice as it had some muscle relaxant effect. Boss had asked him, “ do you know relaxin/succinylcholine.?” He answered in a confident tone – Back in XXX hospital, we used to use it …. Well, in the ED only 3 persons use relaxin prior to intubation – boss, me and the anesthetist … darn dangerous drug as the patient would not be breathing by himself if the drug is given…. I used it occasionally as I don’t want to break someone teeth and I am prepared to do a tracheostomy / cricothyroidectomy if I can’t tube the patient…. Well, seems we found our 4th man, I told myself… I happily went home that day as it had been a long time I hadn’t sleep in own bed on a Monday night…

The next day, I came and I asked the ICU night shift leader how was the shift… she shaken her head and told me that she didn’t want to comment any…I told her that if it is something regarding the CM, she ought to give us some feedback so we could prevent any further damage….. She finally agreed to voice out… they had 3 intubation last night. The first one was a TB patient in the ward with sudden onset of hemoptysis.The patient had suffocated and CM had took a long time intubated the patient . The 2nd one was an ED patient who was noted with OHCA(out of hospital cardiac arrest). He had tried 3 times intubating the patient and finally gave up and asked our surgical aide to do so... our surgical aide intubated the patient on his first trial(his last intubation was 10+ yrs ago…). The 3rd one was an ICU patient which fused the ICU night shift leader’s patient…he was unsure of the ETT position kept retracting the ETT (until 18cm) and the even asked the nurses to confirmed the position for him…

I shook my head when I heard that – I remembered our deputy superintendent asked us to “make way” and “let go” of our shift for CM (so that he could work 260+hrs /months and make a handsome living…) …

Later on…he started to show his “weakness” – he was unable to locate a femoral vein during CVP insertion , cannot insert a chest tube…and he doesn’t act like a surgeon… he had prepared a suture set by clamping a needle on a mosquito clamp (supposed to be a needle holder) and passed it over to Lem; Lem almost pricked himself when he tried to suture…….He had lacked the skills to work in an ED – ETT intubation, CVP insertiong, Chest tube insertion…..he mastered none is not familiar with any of them…intern grade to be exact…

He had diagnosed a appendicitis which had pain over right middle quadrant- a definitely laughter as he is almost board certified general surgeon....

He had prescribed baktar 1# bid to UTI patient…

Lots of spelling mistake – suptum, corase crackle…

what do we have ? an intern ?

For the past few weeks – he had stepped almost on all of the medical attending… everyone had complaint to boss… boss had come to us and asked us to lead/guide him… but I doubt we could, if he stays , the ED staff would be the most beneficiary from it as shifts would be shared , however, it is difficult to teach someone who just watch TVB drama in the 175 whenever there is no patient…..I would have read up a lot if I am at his level……god, he getting the same paid per hour as I do...

attitude decide everything... you might lack of knowledege, lack of skill but with a correct and positive attitude, everything would be fine...

 

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...