Stop disgrace us in the service... buckle up your act!
[sorry for the long rambling..]When we the government doctors complaining about our over work, under paid working condition... There are certainly some of us in the fold really don't deserve any pay raise... They can continue to endure in their slackiness instead.
This is not new, it happens very frequently... hope the local A&E ppl notice and change... a big hope.. Have seen many A&E MOs comes and go, earlier year they don't have enough experience (claimed they had only 3 basic posting as houseman before being posted into A&E) now most of them there had completed 5th or even 6th posting what else if it's not the attitute?
Today at almost 6am in the morning, I was informed by my surgical colleague that there's a MVA (Motor Vehicle Accident) victim in the A&E (Accident & Emergency Department) that needs immediate surgery, a laparotomy for intra-abdominal injury. Was also told that this patinet is in severe shock, BP was very poor from unrecordable to very low of about 80 mmHg systolic BP.
I went down to A&E immediately to assist in resuscitation and prepare the pt (patient) for immediate operation.
Meanwhile in A&E, this is what make me most angry. This pt was brought into A&E at about 3am+, initial BP was SBP 80+ and after fuild resuscitation, when up to 140mmHg. A&E seems happy with this and nobody suspect any life threatening condition accept cerebral concussion and open fracture Tib/Fib (the leg bones). The case was to be admitted to surgical ward (for it's cerebral concussion) and refered to ortho for the fractures.
Luckily, my ortho colleague went on to see the patient in the A&E itself rather then later in the surgical ward. What he get in front of him is a very pale young man with BP unrecordable, and to add salt onto the wound, with just a 18G IV line running the IV drips (mind you this was a trauma pt brought in with BP 80+mmHG). Half an hour later the veins would have all collapsed, but luckily he (ortho) and the A&E team manage to insert another 2 branula and started colloid and blood transfusion and begin some sort of resuscitation (a sincere thank you for this ortho guy who are one of the few I respect and feel secure if he is on call).
They called in surgical guy (another friend), he did a DPL and it was possitive, this is when they called me.
I was actually just went to bed for less then half an hour before the call from A&E. Attended to the pt STAT anyway, to help in resuscitation, assess the pt and prepare him for the operation.
Being an anest guy, definitely start with ABC (Airway breathing circulation)...
The A&E team had already intubated the pt and was manually ventilated him with ambu bag and oxygen. However the ET tube is a bit too deep (we adjusted), air entry remarkedly less on the right side, surgical guy help to insert a chest tube (pneumothorax confirmed with gush of air and bubling drainage tube). SO airway and breathing was taken care of.
Circulation was really bad, there was only central pulse palpable, HR 150+ /min. Peripheral pulse not palpable and sPO2 monitor wasn't picking up any wave or reading too. Definitely severe hypovolumic shock. (who was those gave me the funny look when I ask for more IV lines to the pt? really think that the 3 18G is enough for this patient huh??) I ask for more blood to be crossed match and but nobody move... asked again.. atleast 3 times, even the senior MA there on that shift just murmur some thing but no one move again! I have to leave the patient, pick up the phone called the blood bank (luckily got a responsible man one the other side) he'll get more blood ready, pronto. (Blood bank MLT on night, I thank you for a good job done without delay).
At this time OT is ready, I've also informed my consultant on call that I'm bringing this 20 yr old man to OT (I know he has very little chances to survive but it's either we give him our best in the OT (surgical team open up the abdomen and arrest the source or intra-abdominal bleeding while anest team continue resuscitate him on table) or we can leave him in A&E, continue this half hearted resuscitation going no where but sure die, and at the end of the day proclaimed that we had 'done our best', too bad for the pt for he was not stable enough to be operated on! (don't make me spit! your best is not what I have in mind!)
to be continue....
Please tell the whole truth, not just the truth...Few days ago in CCU...
A 70+ years old gentleman, known case of 1st degree heart block with Ischemic Heart Disease admitted from A&E (Department of Accident & Emergency) for MI (heart attack).
On arrival to CCU, patient was found Asystole (heart no longer pumping) secondary to complete heart block, CPR (Cardiopulmonary Resuscitation) and ACLS (Advance Cardiac Life Support) was started promptly and a temporary pacemaker inserted to pace the heart (a device to meke the heart beat in regular rhythm).
Good knows how many minutes the patient has been in asystole before he arrived at CCU. Although ACLS was started and we manage to 'kick-start' the heart again with CPR and pacing, mantaining a good BP, the patient remains unconscious, opening eyes to call but with blank stare and not obeying commands.
He sustain hypoxic brain damage, he is not going to have any quality life after this.
His BP is stable, gases exchange is good on very minimum ventilator setting but still needs intermitten CPAP/SIMV switch. I would like to tracheostomy him.
The problem arrised from here... In my hospital, we dun't have cardiologist. CCU is incharge by medical team and support by Anaesthetic team. Medical team painted a good picture to patients family member on patient's prognosis based on stable heart with pacing, they would refer patient to state hospital with cardiology service for permanent pacemaker.
Cardiologist agree to take over if patient is out of ventilator support.
So the balls is in our hand, the anest team. medical told family that patient's heart is 'stable' and waiting for anest team to extubate patient. They also said patient can survive if cadiologist take over for permanent pacing.
Wow... come on man! Yes, they are telling the truth (that the patient 'can survive' with permanent pacemaker, and can send patient to the hospital with cardiologist once patient is out of ventilator). The Big BUT is, they are not telling the WHOLE TRUTH!
Patient's GCS remains 6/15. He is not going to have any quality life after this. It will be continuous suffer for him and the family if we can discharge him home after this.
I sincerely felt that medical team had unnecessory gave false hope to the family. We should informed the reallity and the whole truth... Let them understand the whole situation and make an informed decision.
2 days after the admission, I was oncall again and was greeted with family who are eager to know when can we send the patient to otherhopital for permanent pacing... And those initial few days, patient can't even tolerate CPAP. I had to nail the hard reallity and broke the bad news to the family, regarding the bad overall prognosis.
Arrh... Just another sad case to share with you guys... venting out my frustration...
Puasa month associated injury
Well, it's Rhamadan again and wish all my muslim friends selamat berpuasa.
Today, I'll present to you what I called Puasa month associated injury. Every year, we'd seen this type of injury during puasa month over and over again. Yesterday, we had 2 such cases in back to back.
Crush injury of hands by sugar cane machine.
Many peoples are making extra money during the Rhamadan by selling foods in make-shift stalls. Sugar cane juice is one of the favorite.
The 1st case was a young school boy helping his father at the stall. His hand and fingers should be able to function normally again later.
Since he is just a young boy and it's late at night, I anaesthetised him with GA and a LMA.
The next case wasn't that fortunate. He is a middle age man. Take a look at his x-ray.
I'm not putting up the hand photo affraid some of u guys out there might not drink sugar cane juice anymore.
I called him to OT early and gave him a brachial plexus block with the surgeon 'fixing' the kid up. When the proceed with his case, I gave him Midazolam for sedation. I kept him quite sedated, he don't have any
erotic dreams. He must be a holy man too, in between his snooring, only words that we heard from him was some citation of Prayers.
I was worried was he in pain? But he wasn't. This morning when I see him in the ward, ask him does he aware of what's going on in OT? He said he was only about 20% conscious during the surgery, on and off he can hear us talking but he was not in pain.
I do wish him well, hope he can learn to use his 'new' hand with only his thumb and palm left.
Where is my on call allowences?
My friend GASMAN wrote about
empty promises by the Malaysian Government back in July 2005 to it's doctors in public service.
Months passed by since then, and we have a confirmation that the call claims are indeed increased to the new rate. I've received my June call claims. But that's all I've got so far. It is already mid Oct 2005 and I haven't been getting my on call allowences of July, August and September 2005.
Is our government running out of cash so soon this year? Previously, it was the last 2 or 3 months that we can't get the allowences in time but this year as early as July??
Seems to me that Pak Lah is not doing a very good job as Finance Minister (or any other post he is holding) Remember his on-going fight with corruptions?? Some might ask what fight?? It's already more then 2 years he ask us to work with him but not for him... I was impressed then, but very dissapointed now.
I became Spotty! (Pityriasis Rosea)
Damn! Lots of rashes and lots of scratching before I finally get the diagnosis right...
More then a week or so ago, I suddenly developed few rashes on my body. These later become more and more serious. the 1st 2 days it looks like some eczema (I do have sensitive skin that easily developed rashes), so I didn't really bother about it.
One fine day when I was oncall, it suddenly became full blown!
It looks like this (not my pic):
Scary isn't it? Mine is even worst! My wife was very worried that it is infectious that I might infected the whole family. By that time, I don't think is is something infectious, and I knew it wasn't just allergy eczema, but what the heck is it?? I have no idea, non of my colleague has any clue too...
Went on to the internet did quite a lot of reading and narrowed down my differential diagnosis. However, to be certain, on my post-call day, I went to see a GP with a diploma in skin (hint: he was a skin MO in Pg). Well, he is fast and straight to the point. Spot diagnosis! It's
Pityriasis Rosea.
So now I'm on steroid cream PRN basis, was on Hydrocort on the 1st 2 days when I flare up thinking it was some kind of allergy reaction. And I've just started Oral Erythromycin eventhough there's only one study shows it's effectiveness.
Looks like I have to be 'Spotty' for few more weeks as it is usually self limiting benign, acute condition.
While I was doing my reading on internet, came upon this interesting story of <
The Pityriasis Rosea Blues> by Matt Lebofsky. Thought of just share it with you all for a light reading.
...The nurse led me to an examination room and... Her expression turned from complete and utter apathy to total giddy surprise. "Oh, wow!" she said. "Oh, wow!" she repeated... And as she disappeared my mind reeled with all the possible horrible outcomes of my affliction...
In BBC News lately,
An Italian study shows having clowns in the operating room can ease anxiety - at least among child patients.
Clowns from the Theodora Foundation are active in 89 hospitals around the world, including eight in the UK.
These
Patch Adam wannabe is said been successfully distracted children aged five to 12 years while they were put under anaesthesia for surgery.
Distraction helps, yes. But having a clown in the OT is over doing it! They are many many other ways to distract a child before we put him/her under (the anaesthesia).
Does anybody out there really wants a clown by your or your children's side in the OT before and after the surgery??
Tell me your view please.
Anesthesia can give rise to sex illusion
We heard about this bizzare but real phenomenon, but has anyone experienced it or their patients experienced it locally? I did my litle 'research'...
I asked my patients did they dream when they are under anaesthesia? When they are in light anaesthesia for procedures like ERPOC etc which I use Propofol for induction and sometimes the only agent without inhalation gas as in TIVA.
Most of this patients being NBM (Nil by mouth) since the night before, they'll tell me they dream about eating or foods... but occationally, there will be some of them who gave me a sheepish smile and flushing on their face... That's the end of it, I never push for an answer, but I suspect those are the incidences that they might be experienceing some kind of erotic hallucinations. Luckily there wasn't any complaints or law suits.
Anybody know of an confirmed incidence?
The other well known drug that can cause sexual hallucination is Ketamine which I was told, is quite easily available in the street.
There is even a
paper published in PubMed for this associate with used of Propofol.
Local U's master programmes open for application now.
Wish all the best to all the would be candidates.
Click
here for online application.
What do I get from Budget 2006?
Well, I was on call on the Budget day. The radio in my Operation Room (OR) tune into budget speach at 15:30hr. Everyone, including the patient on table was listening and anticipating goodies from Pak Lah.
Looking at our current economy status, I personally think that the small goodies that we are receiving is 'good enough'. Although of coz there will never be enough when it comes to goodies... the more the marrier, but it's reasonably 'good enough'.
So for me, still a Pegawai Perubatan U41, I'll get rm150/month of COLA, and rm300/month from civil service fixed allowance (ITKA) which was rm170/month. A total of rm280 richer per month. That's not bad at all for a 'kaki-tangan kerajaan' who get anual increaments of rm80/month!
And for the 1 month bonus, I'd never thought there'll be 2months anyway. So I'm happy as long as Pak Lah didn't said 'lets show that we care, face the difficult time by cutting our bonus!' ;P
What's next? The RM5,000 tax relief for professional courses may help too.
Everytime they increase the 'sin' tax, I'll hope to get more healthier patients, less AEBA, less COAD patients, but that's just a big hope.. ppl will just complaints that life getting tougher but they will continue to smoke and drink!
So' I don't think I'll see more healthier patient nor less asthmatics or COADs or even MI following the increase of 'sin' tax. May be I'll see more snatch theif induced injury!
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