NSP 3 - training course

We had 5 nursing practitioners (NP formerly known as NSP) at the moment. 2 of them serving in the medicine dept, the rest of them in the surgical dept. Their daily routine was assisting doctor at the charting and managing some minor complaint.
2 of them had gone for a training 1 + months ago. 1 from each department. The nursing director did not suppor for them to go for any training scheme. Her excuse was so how an absurb one: the role of nursing practitioner was currently in the legislation hearing process and it is not wise to sent any of them for training as their role might not be helpful to the hospital in the future. It was one of the shortsided speech I heard lately..... Indeed the legislation hearing was not completed yet, however a lot of hospital(I mean big big one - leading medical center grade hospital) had started setting up such post with good pay (1.5x compare to a senior nurse). Their intention is clearly to utilized the NP as para-resident.   

The NP of the medicine dept. MH,  is someone who is dedicated. She had a good boss (WT, chest physician, malaysian) , who is willing to teach. I had worked with her and she is competent at ther job. She had told me that she wanted to go for a training course earlier this year and tried to call up every available training hospital for information. She had finally found a training course in KVGH which started from April. The NP of the surgical dept. MQ was not first on the list (another NP was more senior than her) but she had managed to secure a seat. Her act was really out of the working ethnic as she did not ask for permission from the nursing dept before she summit her application. The nursing director did not give her a good time finding out she had acted on her own. The director had slammed some sarcastic comment and tried every effort from her to go. The senior surgical NP had also tried her best by persuading her surgeon to complaint to the nursing dept. MQ had finally given up , as the seat was difficult to secure, MQ had offered the training seat to be taken by the senior surgical NP. But surprisingly , after making so many noises, the senior surgical NP turned down the offer. So the nursing dept was in a dilemma and finally MQ was given a "go"....

Upon the first rejection of her application, MQhad asked me for a favor if I could help her to push her application through. I as the "only" two doctor without a management position was actually in no position to do so. I did not promised her anything. Months before this incident, I had not only once suggested to our dept supt(admin) that we would be needing a lot of NP, especially after the expansion.  A group of good function NP would secure the patient group as they would the first line during the period when the doctor is not around. The dep. supt (admin) agreed with my opinion but he told me the truth - he had no authority over such topic, but he would try to pass the opinion through.

1 days later, I had the chance while I met our hospital supt. in the lift. I asked him if, "if we could sent more NP for training as there is a training course available lately. ", he hospital supt was surprised as he was not aware of the situation and he told me he would look into the matter. MQ was finally given a permission after a few painful and tearing discussion.

They were out for 1+ months now and they had come back to me asking for some advice. The design of the course is good however the setback was lack of good trainer, part of the course stress over the physical examination and history taking.  Howeve these are what really lack for Taiwan doctors.... few more months to go before they would be back...
Yesterday we had a discussion again during our morning meeting. A new conclusion and vision is made - to recruit more NP and sent them out whenver there is course available. 

It would be good to see someone got a good training and hopefully they would come back and serve us good (AND cut down our work load...). I am fighting for NP in the ED as our current surgical aide had no appropriate qualification.....hopefully we could have our NP in the near future...

bear in fire....

 

I was darn happy when I finished the 24 hrs calls… I could enjoy a 34 hrs off and I felt so happy by just thinking of the spare times… however, the feeling was spoiled….

I was sitting over the desk when CM came, I stood and walked him toward the trolley and passing over the remaining 4 patients. I had completed most of the chart(meaning I had written the discharge medication). There was one problematic patient – a psychiatric patient who came in last night. He came to our ED 12 hrs ago with forehead bleeding. He claimed that he had fallen from his bike. He had a strange tone, high pitch mixed with low one. I did not bother to chat with him as he seems fine.

 But I was wrong, 8 hrs later he was sent into our ED by the 911 rescue team and “2 policemen”. When the police came with the patient – that mean the patient is either a detainee or involved in a crime. I saw the patient and immediately recognized him as the wound look so familiar. I did a quick survey and history taking – the patient claimed that he had drunk some POLITA( loca1 red bull like famous ‘spirit’ booster ) and decided to take a jog and he had mis-stepped his foot onto a drain. He showed me a swollen right foot. After the survey, I walked toward the police and found out that he had gone to the police station along with 100k of cash earlier that day. He claimed that someone had cast a spell on him and he wanted the wired to some BOMOH(malay word for wizard) so that he could be safe . The police had found him laying along the road side moaning for his rt foot injury. He was a little bit irritable, apart from on and off self talking and shouting, he had even kneed down on the floor and started to knock his head over the floor asking for pardon. I ordered a jab of haloperidol and midazolam to calm him down. When we approached him, he had started to struggle claimed that he was so afraid of injection, by this time, police and the EMTs had gone and no one to assist us(just 2 nurses + 1 security and me). To restraining this kinda psychiatric patient, it would take about 7-8 persons to pressed him against the floor and get the injection done. During my service in Klang GH casualty department – the police had brought in a schizophrenia patient who ran amok. It took 3 policemen, 3 MAs, 1 doctor to complete the IM and IV injection. However the midazolam and haloperidol had seem to be an effective regimen which I learnt since my intern days. We were unable to complete the jab and the patient had run over to the betel nut joint opposite our ED. He had called for a cab and left.

15 minutes later, he was sent back to our ED by the rescue 911. Apparently he had hired the cab and headed to the police station. I did not hesitate to ask help from the EMTs but we did not performed all man pressed on patient method – by using violent language, the EMTs had managed to “ask” the patient to co-operate with the treatment. He was sedated and I had a good sleep then as the police promised to get his family later in the morning. I did my usual style of passing over and told them that the patient’s family would be informed later in the morning. I added that if he ever get irritable again, im haldoperidol and iv midazolam could be given. However my “advice” was cut off by CM’s words, “ok, I got it, thank you” before I finished the phrase. I was cursing in my heart as I thought it was my offer to help him. It is very rude to interrupt a Passover in such way. I went back to 175 getting my bag and asked lem if he spoken to CM about the CT issued.

Lem had told me that the radiology department and ED nurses had complaint about CM’s CT request. He had frequently placed 2 CT request in one form. The radiographer would have to do a lot of delete and adding job due to his wrong doing. Nurses had complaint about him and so do the radiographer. Lem told me that they had requested that CM to be informed about his mistake. Lem told me he had informed him in the morning and he had “choke” Lem – “who the hell had told you that ? it is the hospital supt. ?” He was pissed off and walk out.

No wander he was so temperament during the pass over. I was not pleased with the attitude. I thought he was just pouring out his feeling, after all, I had caused him a loss of 40k per month due to my change of shift. But I think more and more conflict in the future would be noted as he is stuck here with 30% less than what he had asked.

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.