Fire in the hole...

It had been my 3^rd week into the new roster – Life was much better as I spent so much time in the house. I was able to focus on my job; instead of manage the patient through telephone, I could able to see the patient personally. The feeling is good being responsible again. Expecting to go of in a not the tired state is crucial.

The adjustment was not fair though, as 3 of us did not get the same adjustment. It was the choice of the management and I couldn’t fight for my colleague at the time. It is definitely a delayed “fire in the hole” situation in the near future.

I am still considering a training post- I projected my view further : where would I be in the future ? I could think better in my current state....hopefully I could come up with one....

bitten...

It was a busy night, I had my dinner at 10:30 ->mutton fried rice.. Catch some sleep with q1h call. The Respiratory care ward nurse called me at 6:06 am telling me that there was a leak cuff and the patient was desaturating. I splashed my face with some cool water and took the lift(even though it was 3^rd floor but I was too tired). As I entered the ward and took a quick glance at the patient; I decided to reintubate her stat. The nurses showed me that introducer and asked me if I need it. I was still in my twilight zone and told her that I would do a direct one(simple reason – the tube is definitely not in the trachea as the patient was desaturating). When I removed the tube, I found that the patient was clenching her mouth very tightly and I was unable to introduce the blade, I started to wander if I had made a wrong judgement/decision at the time. I ordered 3cc of diprivan and proceeded with the trial by forcing the blade into the mouth. The attempts had leaded to bleeding of the gum and I found that there was a lot of granulation tissue around the gum.

I almost fainted when the nurse came back with the milky colour syringe in her hand but she also had a veno-cath in her hand. That means the patient had no parenteral line. Wow, now I had 2 problems, airway and venous assess……My fault as I had taken for granted that all patient laying in the respiratory care ward had a line. Well, blood had kept flowing out from the patient mouth while I bagged the patient…. I had to make a call of inserting a central line or try intubation… One of the nurses had run to the station and prepared for the central line insertion and I decided to take a chance to intubate again. I could barely insert the blade through the silt of tetanus-like clenching teeth but managed to get it. The best I could do was lifting the jaw up and exposing a window of slightly larger than 50sen coin. I saw the epiglottis though and decided to give a try…. I passed the tube into the mouth and did a slight adjustment of the curve(bad practice as you would have to contact the tube with the oral mucosa) – curving it into a U shape. I sighed when I noticed fogging in the tube as I passed the tube along. I had a feeling that my right index finger was bitten as I felt pain during the trial (bitten of coz…) and I was right, I noticed some blood in the glove and there was a shallow wound over the middle phalange upon examination. Well, the rest was simple – securing the tube, inserting a central line and packing the bleeding of the gum after sedating the patient.

The nurses had told me that the patient was lucky that I was on call or else the scenario would take extra times and messy… I grinned and told them that the patient times was not up yet, but deep in side me- I considered it was an act of god through my hand….. Had my skill become better ? I don’t think so but I think faith is the key to the success….

bitten...

It was a busy night, I had my dinner at 10:30 ->mutton fried rice.. Catch some sleep with q1h call from the ward. The Respiratory care ward nurse called me at 6:06 am telling me that there was a leak cuff and the patient was desaturating. I splashed my face with some cool water and took the lift(even though it was 3^rd floor but I was too tired). As I entered the ward and took a quick glance at the patient; I decided to reintubate her stat. The nurses showed me that introducer and asked me if I need it. I was still in my twilight zone and told her that I would do a direct one(simple reason – the tube is definitely not in the trachea as the patient was desaturating). When I removed the tube, I found that the patient was clenching her mouth very tightly and I was unable to introduce the blade, I started to wander if I had made a wrong judgement/decision at the time. I ordered 3cc of diprivan and proceeded with the trial by forcing the blade into the mouth. The attempts had leaded to bleeding of the gum and I found that there was a lot of granulation tissue around the gum.

I almost fainted when the nurse came back with the milky colour syringe in her hand but she also had a veno-cath in her hand. That means the patient had no parenteral line. Wow, now I had 2 problems, airway and venous assess……My fault as I had taken for granted that all patient laying in the respiratory care ward had a line. Well, blood had kept flowing out from the patient mouth while I bagged the patient…. I had to make a call of inserting a central line or try intubation… One of the nurses had run to the station and prepared for the central line insertion and I decided to take a chance to intubate again. I could barely insert the blade through the silt of tetanus-like clenching teeth but managed to get it. The best I could do was lifting the jaw up and exposing a window of slightly larger than 50sen coin. I saw the epiglottis though and decided to give a try…. I passed the tube into the mouth and did a slight adjustment of the curve(bad practice as you would have to contact the tube with the oral mucosa) – curving it into a U shape. I sighed when I noticed fogging in the tube as I passed the tube along. I had a feeling that my right index finger was bitten as I felt pain during the trial (bitten of coz…) and I was right, I noticed some blood in the glove and there was a shallow wound over the middle phalange upon examination. I did not bother with the tetanus injection as I got shot 5 years ago but true reason was I darn hate neddle....Well, the rest was simple – securing the tube, inserting a central line and packing the bleeding of the gum after sedating the patient.

The nurses had told me that the patient was lucky that I was on call or else the scenario would take extra times and messy… I grinned and told them that the patient times was not up yet, but deep in side me- I considered it was an act of god through my hand….. Had my skill become better ? I don’t think so but I think faith is the key to the success….

grace... truly amazing....

Well….after a 2+ months silence…finally catch the feeling back to blogging.. It was one of my toughest period but still manage to get past the darkest hour… I had seen lies, deception, undergone depression and was truly lost. But at the end of the day, Lord had shown it mercy and guided me through the valley of death(no kidding…. I was blind and found), maybe one day I could share the story but not at the moment…

 

Well, starting from this week, my shift had been greatly reduced…Mon-Tue shift is now 20/24(depends on Lem). Wednesday – only night shift(18-8,14 hrs !!!). But I had to do alternate weekend call(Sat-Sun 24/30 hrs) – nothing to complaint as I had currently doing it for the past few months. I all started 3 weeks ago; I had initiated a daring negotiation which seems to be an impossible mission --- but I got what I expected… my pocket did not get lighter despite the cut of working hours.. in this kinda of hours, where most of my peers were enduring a cut, I considered myself as lucky….

Well, more time to spend with the family and better rest...

post intubation tetanus jab....

A short break follow by a stressful week….I had been back to Malaysia for my holidays(to be exact, I did not have a good rest…) and came back 2X fatigue than ever. A few events had occurred but the track was not affected. Everything was working fine... It was long but not physically stressful shift; after 20hrs in the blue working suit, a nurse in the respiratory ward had called me….A patient’s endotracheal tube seem to slogged off and I told her that I would come up and had a look.

Indeed, there was noise from the tube and I thought the nurse was right. One of the nurses took out a long stylet and asked me if I wanted to replace the tube with it…I was in a good mood than and told her that a 50% chance I would pass the tube into the oesophagus if I did it with the long stylet. I told her I would do a direct intubation. She ran to the station and prepared a tube for me. From 10m away, I saw her passing a “brown” stylet into the tube. Well, I grumbled to myself, ”since when we had this brown stylet?, MS golden plum should have informed me and Lem earlier[we were the major ‘intubator’….]…” (Ms golden plum is our purchaser cum store keeper). The intubation was smooth and when I removed the stylet, I was shocked when I saw the stylet...…..

 

 

 

Well, it was “rusted”….lucky I was as it did not “break” during the removal or else I would need to call the chest physician for bronchoscopic removal…

close up look....
 

Well, I had later informed the matron and acting head nurse later called me up and explained that the stylet was in that state when the store keeper given the tube to them….Well, I told her that I would look the matter up and pay a visit to Ms golden plum and she told me that the ward had applied the stylet 2 yrs ago…really Crap and Meat SXXT….I had shared this incident with Ong and this was this joke of the week response, “ Well, a jab of tetanus toxoid will be enough after the intubation…”

 

tough ride..

CM had left us and we had our roster out… so many LUBANG(hole, in malay) left over, Lem had did the roster and filled out whatever we can. The rest is up to boss and he managed to fill up the vacant. It is a tough ride, for everyone. A 24 hrs is truly not acceptable and healthy, I had to do 2 weekend shift but nothing to complain as I had a long vacation ( is 8 days long ?), I had left over 2 shift for them.

The worst is the coming august when Lem and Ong had to go off. The were 4 days of overlapping and it would be tough challenge.. no obligation for me to cover them up but I did tell Lem that I am gonna do 1 weekend only next months – enough for the “lending a hand” story. It had been more than 1 year doing a favor and the management had taken the favor as granted and placing me routinely on 2 weekend call. Well, there were ED physician who come to us for application with a rocket high pay request. (almost 2x what we are getting…) No way the management going to accept the terms, but our working environment is truly more demanding than others – Apart form ED, we had to cover the ward/ICU, only 1 doctor at a time and the nearest hospital(my ex-) night shift come with a acquiescence 3 hrs sleep and it is 20 km nearer to KHH… I I am not sure , very tired about the present situation – hope for a change in the near future…

Staying in but not admitted...

There was this 8 y/o girl who suffered from fever. No cough nor running nose was noted initially. She was seen by her family physician and ? common cold was impressed. Syrup acetaminophen was prescribed. Her fever had worsen and prn voltaren use was warranted to ease the fever. 4 days later non productive cough was noted and her fever was still stationary with no improvement. On Day 5, decrease air entry was noted over her rt lower chest and she was brought to ED where a chest xray was taken. The chest xray revealed right lower lobe lobar pneumonia and she was admitted. Parenteral augmentin and oral erythromycin was prescribed; fever had subsided on D2 and she was discharged well on D7. A simple history but a stress for me….Yun was the patient.

I had accompanied her in the hospital during and after my calls for the past 1 week. Yun had been admitted multiple times since her birth. Roseola, viral fever, bacterial tonsillitis, febrile convulsion…. And now pneumonia. I had no explanation – just a act of god, some people never get admitted but some suffered from wave and wave of disease. Yun was a healthy girl in general, but fever was a nightmare for all of us. Her fever was so difficult to control in the past. Acetaminophen(full dose of 15mg/kg) q6h and voltaren supp q6hrly. We really had a hard time with Yun as she got admitted on a yearly basis, most of the time was before her birthday. Well, she had overcome her major fear during the admission, she learnt to drink grinded pill with yogurt during this admission. A great leap for her as her body resisted of taking any medication except syrup…. Well, nice to see your child taking their step one at a time (or maybe a great leap)…

I had some thought during the stays in the hospital. The hospital had too much space to improve. The room was not cleaned properly before we enter. There was this blood stain over the curtain extended straight up to the wall and ceiling. I had to tell the head nurse before she sent the cleaner to take off the curtain and take a good clean over the wall. However the new curtain was never installed before the discharge. The fridge was not clean, ice perk over the cold storage making it not cold. The dust bin was not cleaned at a regular interval… I think something should be done – after all service is one the key factor to attract people. I considered the medical industries had no different than the hotel service. Comfort and hospitality(after all we are really a hospital…) is key to success….

As a attending physician in the hospital, I think it is a basic ethic to get admitted to the home hospital if care is available. Our fellow cardiologist had chosen to get admitted to our own hospital during his last admission – he could have stayed elsewhere nearer his house, he even had to share a room with another patient as no single room was available…