dnr, homecoming and why not ?

The patient was a 55 y/o aborigine lady. She was a case of lung cancer with brain metastasis. She was placed at I3 when I saw her in the ICU. She was admitted to the ICU for SOB and was quite ok when I saw her. Her condition was unstable with episode of dyspnea from time to time. However she had noted with abd distension one morning when I did the round. Her abdomen was very distended with diffuse tenderness. Clinically , ileus was impressed and KUB was ordered. The KUB confirmed my thought and both WT and I had agreed that she had ileus which might be due to ischemic bowel syndrome. The underlying causes were obvious as she is a case of cancer and had been bed-ridden for sometimes. A surgical consult was done. I had the impression that DNAR was signed but the nurses told me that the family wanted to do whatever we could. I was reluctant to comply so but since I am not her attending physician, I had to comply with the medical plan. 2 hrs before I left, her BP had started to crushed and acidosis was noted over the arterial blood gas. Her dyspnea had worsen and hypoxia was noted in addition to the acidosis. I intubated her under sedation and inserted a jugular central line.

It is a hard decision for me….. I expect her to leave with all the tubes. But sometimes, I could be wrong, there was this lady with lung cancer which admitted for pneumonia and the family had decided to go all out even though I had explained the prognosis. She was lucky and she was discharged later. However with the peritonitis condition, I double this lady would make it…..

In Taiwan, DNAR order is clearly defined and guarded by the law. DNAR order would have to be sign by 2 specialists and only eligible to cancer patients and those with disease which is fatal in the near future… to breath out one last breath in his/her own house is very important for Chinese. There is this Chinese custom that those who “die” outside cannot set the altar in the house and could only set up the altar outside the house (so as the coffin)….It doesn’t look nice and many of the family would request us to informed them to “bring” the patient home when the time is up (just before patient going to die: the actual way of saying it : “retained the last breath and sent home”  …)… that was definitely impossible as we are not god….but however there is still some alternate ways to do so…

1.   Go home and really “swallow the last breath”(Chinese way of speaking it – should be exact: breath out the last air”) – this need a little bit of luck. Usually the patient is hypotensive(on 20ug/kg/min of dopamine with acidosis and sodium bicarbonate drip) and intubated. When the MAP is below 40mmHg, it would be quite safe to do so as the patient would pass away in a very short while when everything is removed.  However sometimes things just doesn’t go that way – sometimes, the patient would drag on for a few hours and the families were unable to tolerate the scenario and sent the patient back to ED…timing is so important.

2.   But sometime, accident do happen and patient just passed away suddenly and we still hook the patient to the ventilator and tell the families, they could bring the patient home with the ETT and ambugging, in a way that , the patient is still having his/her last breath...some dirty move but of the families would still be grateful if we had planned to do so….

 

Just life and death…. And if everyone could be happy(I mean including the patient), then why not ?

Darkside ... suicide

I had come to work after a good 8 hrs sleep… well not that tired actually as I had even shot my way through one of the small chapter of “Darkside Chronicle” before hitting the bed.

Well, a good start today and I had finished my job by 2pm. It is my 1^st day of getting back to Monday night shift. A little bit resist but I had gained a 34 hrs break after the Monday night shift and I hope it would be a good bargain. Sometimes I tell myself, it is so good to secure a job….

I had a few suicide case who ended up in the ICU lately. They were placed in the ICU as it was the safest place to prevent them from another attempt. Most of them use charcoal burning as their medium to heavan(or maybe hell). Charcoal burning had been the cheapest and least painful way to die. The newspaper had reported these methods widely over the past few years. Well, I had read a report that some of those who were saved would become paraplegia in the future as the hypoxia process would damage the peripheral nerve as well.

I believed the economic had been revived but only for the riches – those poor are still struggling to get out from the swamp of poverty they sunk few years ago. Most of them had economic problem and marital problem. However the was one who stabbed her abdomen just because she had an argument with her love one. Well, lots of excuse but I think none of them is acceptable.  I wandered if really those zombie from the “Resident Evil
 stormed our life, how many peoples would have the guts to commit suicide before they were bitten ?

 

I was lucky as I did not have to resus any 1+1 suicide case yet. A 1+1 means an adult suicide with his/her minor. Life is hard and I just don’t know how to help them……

30 hrs of day and night...

I saw the movie 30 nigths few days ago during my night shift - a good one (remind me of the WII title - chop till you drop). But I was lucky as it was only a 30hrs shift instead of 30 nights.....

 

CM had gone for his annual “colon” check and I have to start working from noon. The night was good and I am awake here waiting to go off…

 

It would be a major change next week… Our head of MIS is back and he had agreed to get a NAS (Network attached storage) device. Well, I would have to prepare my program for it. I would have to replace the current drive string to a common public variable and later re-direct the path to this new device.

A long , boring and scary job for me. I am really afraid that I would accidentally delete something or change the command leading to major failure. But still, have to keep up the good faith…

I had tried myself over the buffalo NAS after the initial discussion and surprisingly it was as easy as it claimed over the internet. The NAS, which is a linux-based machine is so simple to manage its user. I had copied a mapped drive code elsewhere from the net 1+ yrs ago and it proved to be good mapping the drive with username and password…. So I am prep for the big day sometime next week. I just had to replace the path….

It had been 29 hrs since I start take over the shift and I survived. Well…it would be a 12 hrs rest and another 24hrs shift before I could enjoy a 34 hrs off……the drive to home is definitely a great struggle but luckily I had Fireball’s Torquay and John Barry’s 007 theme rocking all the way with me till home…

Registrar , senior registrar .....or maybe consultant

I had this SMS lately from my colleague cum senior Han. It was about recognition of KMUH degree by the Singapore Medical Council. They are calling for a dinner conference next Thursday. The SMC is inviting those with qualification of 3^rd year resident and above to attend the conference. I did a search over google and got a good picture of the plot...

When I went back to Malaysia, the SMC had only conditionally recognized those from NTU but now they had recognized 2 universities – the NTU and CGU.

 

The SMC is inviting those with specialist qualification to fill the post as registrar(working under supervision as our specialist qualification is not recognized.) Registrar is sort of like a chief resident - consult, supervision of junior medical officer and also NIGHT CALLS !… well, a simple conclusion is:  they want to find KULI(hard labor).

 

A very attracting offer if I am still single. But if I take up such offer, I would have to stay in an apartment instead of a terrace , and my children have to study together and compete with those singlish speaking kids….. well, I could not accept both…although working back in a English speaking environment is so attractive……but still, I think I would attend the dinner….

never enough....staff

 

Located 100+km from the southern tip of Taiwan, it is not easy for us to hire staff. I spent around 2+ yrs to get a full time general surgeon. As for nursing staff, the situation is no where better. Most of the wards short of 1-2 staff averagely.

The key to the shortage of nursing staff is the pay. Our pay is considered as par around this part of the county.

 A par means we could only get whatever other people reject. Indeed most of the new staff was either 1^st timer to the job or basically under average. The time for them to have proper attitude and proper working skill was so long that it is intolerable, and so of them never evovled....

 

Imaging that there was one time we had 3 ICU nurses who was over 100kg. I am fat myself but for ICU nurse with that kind of size, it would be difficult for them to move about. Well, both 3 of them were transferred to ward after 3 months.

 

Recently the ED nurses were so short that Lem started to grumbled. He is rather a nice guy and to get to his nerve it would really take a good effort. 1/3 of our staffs were below average either in attitude or skill. I would directly point out their fault when I noticed it but Lem does not act like me. As the head of dept. he is consider a nice person.

Once, the deputy supt had had a discussion with me and we agree that the nursing staff would really need a raise and we should start to kick out whoever that is unfit. A raise would attract more applicant and we could choose. According to our observation, the plan is definitely gonna work as there were so many mistake/violation of SOP done in the past. Some of the mistake was so non-forgivable from my point of view. But what can we do, you pay what you get what.

 

However it would be a hard move as the nurse dept had been a welfare dept for quite a long time. The tolerance was so high that no one was fired/demoted due to mistake in the past.

Recently 2 head nurses was demoted – 1 due to some “black mail” attacking her being unfair , the other due to poor performance leading to failure during an evaluation. It is a good start, but still a long long way to go.

 

chane again....and ? how long

Since CM joined us, I was able to spend more time in the ICU. I was very frustrated with the nursing staff. Their performances were really out of my expectation. The nurses do not know amikacin is an aminoglycoside and have no idea that it would worsen the renal function. Only a hand full of them knew how fast you could drip the dilantin into a patient, and no one knew EKG monitoring was needed during the drip.

 I had told the head nurse that it was intolerable. The deputy head nurse had even questioned my order for not inserting a Foley catheter for a patient with urine retention(I did a drainage instead). The deputy head nurse had used the word “pig head” to describe me and I was very unpleased with it.

Head nurse JL was a nice person. She is good at preparing document and running admin but is not good at managing her staff. Due to salary reason we are facing shortage of senior nurses. The head nurse had agreed that we start a training program and retrained the staff.

Loading had become more but we really see some improvement.Unfortunately I was called by boss and deputy supt (admin), they had asked me politely if I could take back Monday night shift. I had expected the request and was not surprise when they asked me. I gladly complied but was not happy when they told me I need to do 6pm to 6pm(mon->tue). I was not happy with the decision as I had told them earlier that I don’t want to do any more evening to evening 24 hrs shift. I usually wake up by 6am and take a nap of 1-2 hrs during the afternoon. It would be more stress for me if the shift start by evening. After all I don’t get use to prep myself for night shift by sleeping the whole afternoon.

 When Lem told me that he would be taking the shift arrangement, I told him that I don’t want any 6-6 shift and asked him to see what he can do. He gladly complied with my request and I got  8am-8am shift instead. I got a small break during the mid-week as I am off from Tue 8am till Wed 6pm. I was happy again but wander how long would it last.

CM had lost 40-50k as the Monday night shifts were stripped off. I wandered how long he would tolerate as his pay was 100k lower than he was expected.

lost .....

I spend the whole day outside…govt specialist clinic (darn good one with only 1patient/3hrs) then the lube - > tyre change and finally home. My mobile phone’s battery was drained dry and when I got a plug to recharged it , I got this SMS from my brother - --- “granny had passed away and dad and mom is going back Malaysia tomorrow..”

Not a shock for me , my granny(mother side) was so old. She was in a dementia state and regressed greatly for the past few years. Last year, I had chosen to put up a night in my uncle’s house and had a good look at her. I thought I could see her a few more times before the time arrive.....

She was a nice lady, manned a coffee shop with my granfather . The coffee shop was located in Chuah;small town near Bukit Pelanduk, Negeri Sembilan. Yeap, the origin of Nipah virus (however they had shifted out from the shop many years earlier before the outbreak).

After my grandfather had passed away, my aunts had started to bring her around the world. I remembered she had gone to Europe and various place until her knee osteoarthritis worsen. She could only walk for a short distance since then.

She doesn’t speak Chinese but we could communicate with Cantonese. Me and few of my cousind had often played card game(name 4 colour, UNO like game) with her during my younger days.

Our financial situation was bad and from time to time, she would tugged RM50 to me and brother during our visit to her house. Not much but still it was a great help.

When her bil knee OA worsen, I had suggested to my parents that she might need a total knee replacement so that she could work properly again. However, my parents had asked me not to interfere with the medical condition of my granny as my uncle had shown “concern” about if she might be wheel chair bound after the ops. I kept silence and did not fight that for her.

However one of my uncle(with the help of his wife of coz), did a great job of looking after her. She was taken care properly when I saw her last year.

She was a tradition lady and a cheering person as far as I recall.

I called up my dad last night and asked him to informed me about the date of funeral services when he got back to Malaysia . Although, I am the “outer rim” grandson(inner rim means father side), I would like to attend her funeral service if time allow….a little sad I am…but still LIFE GOES ON….