never ending learning...

My past few calls were bad - interrupted sleep q1hly either by the wards or by ED patients. I seldom spent time watching TV lately - mostly busy with my program while waiting for data. The currently phase would be finalized by next week. I would have to meet with the nursing superintendent and head of pharmacy again next week. The progress note and passover note part were completed 3 weeks ago. Although some minor modification is neither - both of the them were running smooth. The order entering and prescription printing part are my current focus. The core was completed last week but after a brief discussion with the head of pharmacy, I was forced to re-write part of the script. The head of pharmacy requested and insisted that the 1st day UD dose would need to be stated on the prescription. Eg: IV Tagamet 1 amp Q8H is not enought it shoule be IV Tagemet 1 amp Q8H 1st day UD = 2 dose(if the order is prescrbed after 8 am).

2 tasks more before I could proceed with the test run in ICU. 1. The list of oral drug were not enter into the database. 2. The re-printing of prescription part need to be revised - serial no. needed for each print out prescription to facillitate the reprinting process. Why test run in the ICU ? well, I am one of the ICU attending physician - more easier for me to implement things. The ICU is a closed unit and manuplating is more simple. The most controversial part is the temporary telephone order. The nurse would need to key in the prescription on request via phone. The ICU nurses are more senior and able to carry out this job without problem. The ICU test run would last for 2 weeks and after the run and review. It would be implemented throughout the hospital. Then I shall move on to another project.

I enter a phase which I ever imaging  - writing computer program .Once, I thought becoming a physician is the last thing that I learnt to be.  But now, I knew more surprise I would get if I keep on the hard wark of learning.....

to helmet or not to helmet....

It was tiring morning..... I was post call and I got a phone from the combined ED down south..

"We had a case of head injury with SDH and we wished to transfer him to your ED", the doctor talked to me over the phone with Cantonese slang. (Hong Kong with ROC citizenship...). I agreed to his request as the ICU was quick empty ... I asked him what was the GCS and wheather the patient was intubated and this was the reply :" The GCS is 6 but he is breathing smoothly, so I don't think he need intubation at the moment...".

What a professional answer I got.... this was what the local people down south derserved. A special fund was set up to upgrade the service the ED service - the doctor was paid RM100/hr and these kind of doctor was hired....

The patient arrived 1 hrs later and there was a nasal airway in his nostril. I took a glance at the CT. The hemorrhage was minimal but there was severe midline shift. I told the family, ops was needed and I needed to intubate him stat.

The guy had short neck and small mouth - short than mine...I tried the oral approach and failed. I did a second look and still failed to visualized the vocal cord. I decided to go for the nasal path. I was lucky as the patient was still breathing heavily. I passed the tube successfully during my first trial. Well, he was up to the OT within 40 min . That is the advantage of a small hospital ... fast and efficient of clearing patient from ED.

I obtained the history and found out that the patient had fallen from his bicycle. He had gone to the famous Kenting beach town with his wife and children. They were doing a joy ride in the morning. Unfortunately the person who rent the bicycle did not provide helmet. He had fallen and knocked over his head... The history had reminded me about a news I saw 2 days earlier - a police who took part in a bicycle ride with his chief. The unfortuante policeman was cycling down a slope a loss control. He was riding with full gear but the speed was too fast and he sufferred from intracranial hemorrhage and cost him his life...

Well - better stick to my helmet(my head ...) and Strida(not the efficient but slow is safe...)   - I am doing my ride consistently and I dont want to end up like anyone of them....

Visual Basic Programming

It had been 3 wks since my last blog... well, I was stucked with a project... Few months ago, I was appointed as second chair to the patient safety committee. The was this issue about the passover of doctors requested by the evaluation board. I was learning visual basic then and I took over the responsibility to write a simple program for this passover procedure. The concept was simple - each attending doctor enter the passover note of relevent patient on the computer and the doctor on call log on to the computer and read the passover then print it out and signed it. The concept was adapted from one of the university hospital. Well, just enter, write into file and read it out and print.... Well, the program took me few months to complete and it was very raw ... the was this obsticle keeping our staff to using it - the biodata of pt - > entering the biodata is not a simple task for people who are not good at chinese input....so eventhough it was ready but it was never in use. Until the last attack visit by the local National Insurance Agency officer - the inspector complaint about different handwriting and not so up to date progress note. So I was thinking of writing a Progress Note Program .... this time, I would need to get access to the hospital database. So after a few discussion with the project manager (our hospital computer system is contracted to a software firm), we had worked out a solution. I was reluctant to do in the past because the hospital would be billed for every task done by the firm. 

 After 6 weeks of effort - the program is currently online.... The Nursing Specialist would benefit from it and hopefully some of the doctors would like it......The passover program was integrated to this program and currently on its 2nd days of test run...... I mastered several skill during the process - mapping drive, cutting a long sentence into different line and accessing database. I am learning as an apperentice programmer and trying to evolve...The health department had started to pushed the concept of "paperless" hospital but it is currently governed by the electronic medical record act - 11 hospital had entered the project but I doubt we should follow.... there is one requirement which is strict - each record enter would need to be transferred to the mainframe of health department - electronically signed and stamped with a date and time then sent back to the local hospital computer before it is saved. That means once the progress note/ order sheet/ nursing note / imaging or whatever could not be altered later..... well, which I dont think is executable at the moment.... My next project is currently the order entry system ... I had a deathline of 2 weeks and I intend to make it...

There are lots of books regarding basic of VB2005 but only few of its talked about advance technique, most of the time, I would need to browse the net to found a solution...

Proper passover

I was doing my rounds in the ward and got a phone call from my ortho colleague K - urgent call to the ICU...

The nurse was preparing O2 for the patient at the bedside. I positioned myself to the bed top and started to bagged her. I spot the oximetry reading was 80% when I reached the bedside. I knew the case - the nurse in the ward had called me last night - the family was complaining in a bad manner about a bruise over rt forearm....

The patient is a 70 y/o female who sufferred from a femur fracture and undergone surgery few days ago. She had also suffered from some brain tumor and undergone surgery few years back. Both her son were drunkard and a lady was hired to care for her in the ward. The son would come to the ward on and off under the influence of alcohol questioning the nurses this and that. Most of the time, the sons would calm down after explaination by doctors. The bruise was noted after removal of a venocath. I explained to the son and calmed him down. The patient had c/o abd pain and I attended to that. A frank epigastric pain with normal EKG. She was troubleb by such problem since post ops. A small dose of pethidine would make her sleep all the day and some respiratory depression was noted. So NSAID was given instead but after couple of shot she had this epigastric pain and peptic ulcer was impressed.

I gave her a low dose of pethidine and some cimetidine.... no more calls about her that night...
And now, she was laying in front of me waiting for her intubation... K told me that she look drowsy and gasping for air was noted in the morning so he rushed her to the ICU stat.... She was confused and not fully comatose. She was biting and took me some strengthed to open her mouth. I managed to intubate her in 1 trial and sedated her with some propofol...

The SpO2 was quickily elevated to 100% after a few bagging... that ruled out pulmomary embolism but the heart rate worried me... it was 180-200/min on the monitor since I lay my eyes on it... the BP had crushed to 60/40mmHg after the intubation. I double checked the tube and the patient and nothing suspicious. By the time the hospital director and cardiologist was beside the patient. I proceeded with a internal jugular CVP and the reading was 12cmH20 - her skin turgor was poor though...

An EKG 12L was done and ischemia was noted. The rhythm was atrial fibrillation with rapid ventricular response. I decided to shock her as the BP was still lowish even after dopamine use. The cardiologist concurred with my decision and proceeded with the cardioversion starting with 30J(biphasic,sync). No response after the 1st shock and the current was increased to 50J (she was obese...). The 2nd shock resulted in asystole and chest compression was commenced.This was the 1st time I had an asystole after a sync cardioversion.... We managed to kicked back the heart within 1 mins and we got a call from the lab.... the sugar was 34mg% only.... what the @#$%^^&&***,(it had been 30min since I started to managed her...)  I mummbled while ordering 4amp of 50% of GW.....  she regained conscious after the sugar injection but her vital sign did not stabilized. She started to have fever and we had started her on dobutamine and steroid... Now, multifactorial leading to her failure... When I probed back to the history ... a sugar check was done in earlier that day in the morning which revealed 69mg% : the lady caring her had offered to feed her but she had only eaten some and vomited moments later - this event was not reported to the doctor nor managed further after the vomiting.... one of the crucial point. No proper passoever about the sugar reading was done during the passover to the ICU nurse....her hypoglycemia maybe due to poor feeding and finally worsen by sepsis....

She was still there this morning during my rounds - we treated her as septic shock with EGDT regimen. Her BP was ok and now the urine ... only 300cc for the past 22hrs...

Lesson of the day - sugar check !!!!!!!

patients.....

I had bad attack after the bike ride last Friday .... After the clinic session, I went home and felt very tired... The afternoon nap did some help but I had this shortness of breath again in the night... Ving drove me back to the hospital and I took the O2 tank home. The O2 tank re-energized me... but the rest of the weekend was not stable... I did not stopped my prednisolone and continue it to D10... By Wednesday I was better and I stopped my prednisolone use. I did a ride again - but with cautious. I did 3km over 20 min... The fatigue sensation was there but better. No more attack requiring any neb use. I did my 4km ride today and hopefully no more attack....

I had to give up the 3km run in Taipei... a sorry for Yun but she could understand it....

Well, a great experience for me ... .I am glad I am trained as a physician. Eventhough there were helpless moment during the attack but I knew what was the extend and what would come next - imaging a public who knew nothing about asthma.... the stress was not only on the patient , but on the families as well.

Lesson learned : " Be a patient and learn to care more for your patient.....  "

almost had it - part 4

What did I had ?
 
The symptom was so severe that I almost got admitted to the ICU...  The tachypnea was worsen partially due to my obesity ... time to lose weight....

Looking back to the course of disease, I think something had triggered the attack and it was not only a pure exerbation. I might had an viral infection that triggered it. The recovering was dramatic and I am back to my normal self now.

For the past few years, I had on and off attack during the winter and at one time, the symptom was so bad that I had shortness of breath on climbing stairs. But the symptom was better after the winter. This episode of attack was out of my expectation. I did not see it coming and was hit very badly. But I still believe that it was karma - time to pay and I am lucky that the price was not that high...

A narrow escape for me - I valued every smooth breath I take now.... the sensation of enjoying every breath is so good....

I had tappered off most of the drug and currently on long term inhaled steroid use only... I had this developed peptic ulcer due to oral steroid use and I stopped them yesterday.

I did a 6km ride today and tolerated it well; I use inhaler prior to the ride just to prevent any exercise induced asthma attack. The fatigue of body ( ? due to hypoxia) was still noted, just like a hang over after a heavy drinking night...

My challange come next week - the 3km run with Yun in Taipei ... Yes, it was planned 1 months ago and at one moment, I think I couldn't make it but now, back to preparation ....

Almost had it - part 3....

The sleep was bad.... chest tigthness and tachypnea....I was confused as I had never had similiar attack before. I was only slightly improved and I not really better. It was Friday and my round to the land of the lion govt clinic...

The "land of lion" govt clinic is located down south 40 km away from the southern tip of Taiwan. The clinic is currently under construction and the clinic is temporariy relocated to the local library. No air con was installed and it was good damn hot that day... My symptom had worsen again after a while, I took a couple of inhaler but it only relieved for a few minutes.... I need to take a few sigh from time to time to relieve my shortness of breath.

I finally reached home by noon and did not feel better. I told Ving that I might need to get re-admitted later that afternoon. Ving was very very worried... I was in a dilemma then - some O2 use may eased my discomfort but admission would panicked Ving... By now, I had reliazed that I had tappered my steroid too fast... I had only use methyprednisolone 40mg q8h for 2 days and changed to oral dose of 20mg tid on D3....Way to fast, during an acute attack - 1mg/kg is recommended and I am 90+kg : a use of at least 30-40 mg tid is needed....plus I did not use any oral ventolin nor theophylline tab... I gave in by 8pm.... I took a drive to the hospital - I saw the panicked and terrified look on Ving's face, when I told her I need to get admitted ... she offered to drive me but I denied - it was too late for her to drive such a to and fro distance....
I reaced the hospital by 9pm and got admitted... The chest physician was running the night clinic and he admitted me... he hit me with everything ... IV methyprednisolone, oral aminophylline and ventolin plus regular neb....
I slept better that night - thanz to the O2 use...but I did not get better. I was still breathless and need to sigh on and off to get some new air.
All the side effect of noted
 Headache and flushing - aminophylline + ventolin
 Mouth dryness - ventolin
 Dizziness - antihistamine
 Gastric discomfort - steroid
 Palpitation - aminophylline + ventolin

I just laid on the bed and put on my O2 whenever I sleep.... Ving came with the kid on D2 and brought me some food .... Once a while ( for mintues to hours), I could feel that I could breath smoothly and I thought I was better, but it was just for a while.
By D3(Sunday) - I was better and I discharged myself in the evening. Better means improved but not fully recovered. By this time - I started to wander about my condition - would I recover fully or I would have to go on prn O2 or lifelong oral tab ????? I just can't bare to think about my condition in the future...all I considered was - can I do the shift on Monday ?

I decided to do the shift ... at least I could use O2 when needed...and I was restless and having poor sleep due to the oral medication...

I wandered around the hospital with unsteady gait and inserted 2 CVPs with my trembling hand.... and put on my O2 nasal prong whenever I lay on the sofa of 175...

Amazingly the SOB sensation went off and I was almost well when I get off by 6pm Tuesday .... it didn't happen like a snap but I felt almost normal when I reached home....

I knew I had my life back and had an near escape from the gate of HELL....