clever patient...

It was 6am in the morning....I had a good night sleep, 3 patients seen (and they all came within the same 30 mins) and no call from the ward after 2am. The patient was a 60+ y/o male sent into ED by the local 911 ambulance. The nurse had told me that the patient claimed that he had an intestine rupture. I looked at the patient behind my desk when the nurse told me that complaint. The patient is bed-ridden and he doesn't look like a "medicine man". "Another clever patient..." I grumbled as I walked toward him.
The history taking was long and unpleasent as the patient is a case of old stroke, bed-ridden and suffered from dysarthria. It tooke me a while before I get a incomplete image of what had happened. He claimed that he had constipation problem and use to enema himself. During the enema he had heard a "pop" sound and severe pain was noted over his lower abdomen. Indeed, he had an distended abdomen c rebound. But I also notieced he had a over filled bladder(up till the umblicus). I ordered a urinary catherization and gave him an NSAID jab. The catherization produced around 500cc of urine and his pain was not relieved. I ordered an abdominal cat scan and managed to get the full story this time. He did not use a glycerine ball nor evac enema(bottle of 118cc of glycerine) for enema instead he slided a hose(yes water hose) connected to a tap and inserted the other end into his anus. "Holy XXX" , he is right,  definitely a rupture in the colon. What amazed me was he had left side weakness and his left upperarm was contracted.

 I gave him 50mg of pethidine and called the surgeon. No free air was seen on the CT scan as I expected. The surgeon came and concurred with my decision. He was sent to OT and Hartman procedure was done.

 
Well, you don't need a scan sometimes - proper history and physical examination concluded your diagnosis. Sometimes I would tell my patient and their family - I take the image because I want to let you see the lesion....most of the time it was waste of money and time but it protect my ass  ....

Uninvited...

It was a quiet night until 2am.. I had been disturbed by call from the wards and the ED. Around 3:30am , there was this family wanted an explaination and I walked out from my call room. The explaination was short and I walked back to the office minutes later. When I opened the door, I had seen a shadow moved inside the toilet. The toilet just at the right end of the room from the room, I could see the toilet door just when I stepped into the office.

The ED office sketch.....

 

I was stunt and waited for a second, before I asked "who is there?" A voice anwser from the toilet and "I came for a pee". "PEE" my ass I grumble. A voice means he is definitely human and not any being that belong to another word. I walked into toward a toile and slice the pie. I saw a person about 175cm tall wearing a cap and blue jacket. He saw me and told me that he couldnt find any toilet and so he came here. I was a little annoyed, "WTF" I grumble. I chased him away in a unhappy tone. He quickly zipped his pants and I walked him out from the room. I sat down and had a quick thought that he might be a thief - but I was too tired. The next day, I shared the incident with Lem, and Lem told me that he was definitely a thief. I went to our engineer department and told the manager what had happened. We traced the surveillance camera. Yes, he is definitely a thief. He had entered the hospital 20 minutes before he walked into the office. He had wandered around and took the lift to 7 floors. The nurse was sitting in the station but did not ask him what he wants when he walked into the ward. Then he wandered around the registration desk and waited for me to come out and see my patient. Fortunately I did not take too long to do so and I walked back in heavy paces. If I had not make any sound when I walked back I might had caught him red handed searching for something -then a fight and someone may get hurt....well, I was lucky, nothing was lost. I had a couple of hundred laying on the table along with my laptop, mobile phone....... well, I was lucky I don't have to confrant him ... or else someone might get hurt....

We had actually hired a security guard 3 months ago. However he was sitting in the ED instead of sitting where he should be. If he had sitted at the security desk and questioned someone who had entered the hospital but did not seek help in th ED, the thief might had walked out straight. But it is not the time to make a big issue about this neglect of duty - boss might think it is useless to hire them and we would be back to dark age again.

Gadgets....

I had added the below gadgets into my arsenal during the past 3 months...

1.Apple macbook pro 15"
- Ving had wanted it badly... so a big big hole in my pocket and a load of point in my credit card account...

2.NXT robot x 2(8527 and 9797 )
- Yuns latest toys.....her dream: sumo robot...currently we were building an alpha rex..

3.Linkstation live 1TB
- wanted to backup my tivo program..I had installed the pytivo server on it and started to BT again..

4.Apple ipod touch
- I converted to my credit card point to costco gold coin and found that I could get an ipod touch for free... so it landed in our house...hell of the device, not only music, but endless hours of fun....

I had very best to avoid apple product in the past- but now, I am thinking of an imac later...

Evidence based

The H1N1 had disturbed most of the public... but I was disturbed lately during a debate in a forum. There was this chinese SJA forum which I discovered lately. One of a forumer (a paramedic I presumed) had posted some irritable message - wearing a mask in public area is a social obligation. I was irritated by his posting. I am one of the raw face tribe in the hospital from the first day stepping into medical field. I think not showing your face to your patient is an impolite act. One should know the look of who is going to treat/harm him - basic manner. I donned my mask whenever it is necessary.

Even after the SARS, I still keep my habbit until lately the H1N1 strike. We were requested to do so when seeing our patient.

The debate in the forum was unpleasent as the forumer started to comment and "adviced" me to see my patient correctly and nicely... I was irritated as all those sentences were unfriendly and filled with comment which was not true. Most of the facts presented by the forumer were so called common sense... just like those uncles chatting loudly over the round marble table in an old coffee shop.

I found out a few facts during the debate. Most of the public were frighthened by the government and they had no ability to verify what they read/saw/ heard.... My training had given me the skill of picking knowledge based on evidence but unfortunately there are a lot of peoples who don't... that was what my brother told me months ago. He told me detailing is one of the key to a person success.

However this evidence base stuff had sometimes make me look like a person without principle - when the guideline change, I changed..... had to live with it..it had become part of my life...

episode running...

We were back to square one next months.... O is going for his break again after 45 days of work. The gap was 30 days (better than indefinitely). Lem had shown me that roster and asked me to fill in what ever shifts that I could handle. I adopted a few and still there are 5 holes left to filled. Everything would be up to boss ...
Well, we were actually disturbed lately. Boss had informed that there is a board certified emergency physician interested to join us. The doctor was introduced by one of our head nurse. I chatted with the head nurse( is my nature to dig around...) and found out the below facts:

1. he is currently working in a small hospital nearby

2.his work is heavy - did most the night call

3.he wanted a change of job...

4.he is a filipino medical grad

We waited for a few days and someone had told us that - it was a misunderstanding... this guy didn't even hold a practice license...phased out immediately of coz.

10+ years ago, our hospital had stopped to placed doctor without a license working in ED... now the situation is even worse : any doctor working in our setting need to registered our hospital as his /her alternate working hospital with the local health authority.

Unlike the Malaysia, the practicing certificate here is not renew annualy. The so call practising license is renewed every 7 years. The renewal criteria include adequate CME points....There is a list in the local health bureau which specific where we practised. If we wanted to work locum elsewhere, we need to add an alternating practising site. Alteration of the list would need an agreement from the primary working hospital/clinic. We were strict about this regulation so we had problem to attract doctor for locum nowadays. Getting permission to work locum elsewhere is difficult....

Few days later, boss had told Lem that a surgial chief resident from a teaching hospital had decided to join us and  grab some big cash. He had asked Lem to re-arranged the shift so that this guy could share our load with a reasonable shift( that mean he does not come to join us and work only during weekend nor night shift). We tried to "squeezed" some daytime shift for him. However we were in doubt why did  surgical resident give up his training ...

But no news from boss since that day - both of us had agreed that it is just another faulty granade. This so called surgical chief resident grade doctor is someone without a practising license stranded in a teaching hospital. Teaching hospital are allowed to hire medical grad without license as "trainee resident". There are still load of such medical grad striving in some local hospital. This doctor may had  thought small hospital like us doesn't mind to hire doctor without license and came to approach our boss....

Well, looks like we have to clench our teeth and survive the next 30 days...

1st class service...

I had this alcoholic CWC disturbing me lately in the ED. He is a case of alcoholic liver cirrhosis who unable to get rid of his bad habbit. CWC is a person on social welface list. He enjoyed many priviledges. He doesn't need to pay for the registration fee, he is not entitled to the 10% payment of admission and his meal is pay for during admission.
What he did was begging for admission. He came to our ED and begging every single one of us to admit him to the ward. In the ward, he could sleep nicely (or get through his alcohol induced drowsy state) on a nice clean bed. Wake up and enjoy a good nice meal. Take a big gulp of rice wine in the fully air-conditioned room. When he is awake he would disappear elsewhere to get some money and continue his drunkard life.
He usually get admitted and would be discharged automatically on D2 and mostly D3 when the nurse found no trace of him around the hospital hours later.
He came on the few days ago and complaint about generalized discomfort and asking for admission. I told him I would take after him nicely. I explained to him that I would be in charge of all the patients of the hospital from evening to the next morning. So I would give him 1st class service. I would provide him with a 1 to 1 nursing care and he could chose to take the negative pressure isolating room or the ED room. He showed me an unbelievable look and was wordless. Despite my explaination that he would enjoyed the 1st class service in our hospital(that is no admission to the ward) he still hoping that I would admit him later and complied to my invitation to take a drip. After 1 hrs of laying and begging on the bed , he finally gave up and walked off....
I hope this would be the last time he tried to harrass me in the ED.... I would still provide the so called 1st class service for this kind of KNNECB scum bag(waste of the tax I paid...) and hope they would enjoy it...

 

Lucky people ....

I was lucky...there was no outbreak in the hospital. I could finally relax my crampy crossed finger. I was lucky - the child was placed in a air-conditioned room over night with 3 other peoples. Those who had contacted with the child was free of symptom until now. Well, pandemic it is however thanks to medical care - there is only 11 deads until today morning. More than half of the patients had chronic disease. There was this pregnant lady (20+ weeker) with respiratory failure(lung invasion). She was put on ECMO and survived through the critical period. However she lost her baby. ECMO have been last resort for those critical ill with cardiopulmonary collapsed. However it was not the magic wand of fairy. I had been through a lecture by one of the pioneer of ECMO in this country - Prof K of NTU. He had presented us with a load of patient survived with severe complication(gangrenous change of limbs with amputation). I had noticed there are intensivists who used double ECMO nowadays. Well, life is so precious here compare to my homeland. I saw flood refugee eating buffet style meal in the camp, those homeless were well treated.

By 2 more months, there is vaccine for us...I am still worried only 3 of us in the family are eligibled for the vaccination. Ving is not in the group. Well, would try my best to get her a jab...we are lucky, if I am back in Malaysia, I am the only one who could get a jab...

Outbreak it is and stand we will......