Category Archives: Med Talk

C.P.R.

Don’t think I will ever forget what happened today. I actually had a pretty decent shift today, busy but not overwhelming. But what happened today would not be easily forgotten.

I had TWO patients died on me, literally before me today.

One had a code blue.

Immediately brisk walk to the lift. Saw the ICU registrar sprinting across the corridor. Shit….. My registrar and I started sprinting too, up two floors, and to patient’s side

Unresponsive patient.

I know this patient.

I saw her yesterday. I admitted her.

Asystole.

CPR.

Next thing I know, I was by her side, hands firmly on her 97 y/o frail body, elbows locked, pumping with the weight of my upper body, panting and counting. I’ve never performed a CPR on a real patient.

I’ve always wondered when would be the first time doing it.

I wondered no further.

I recalled seeing her yesterday. Speaking at length with her. It was a simple gastroenteritis. I am pretty sure. Did I miss something? Could be something I have overlooked? No, I was pretty thorough. I am pretty sure. Or am I? Would I have to stand before the coroner after this?

I was snapped back into reality when one of the nurses pulled me back from the CPR.

“Enough! I will hit you if you ever do that to my grandmother! It’s cruel!”

Someone then announced, “Time of death……”

Then the reality started to sink in. She’s gone.

“You alright, Xiao?”
“I am fine. A little bit shaken.”
“Don’t worry. You might be thinking whether you’ve missed anything. I am pretty sure we didn’t.”
“I am not too worried. I am pretty sure I was very thorough,” me putting up a strong front.
“I am confident you did, Xiao. ”

I wanted to say that was the first time I’ve performed CPR on a patient. And this was a patient whom I knew very well.

Unfortunately, she didn’t make it. God bless her soul. May her rest in peace.

The images of her frail body buckling intermittently under the strength of my hands, the weight of my body and heart, I don’t think I will ever forget.

Who would forget the first patient you performed CPR on?

Arrivederci.

End of Internship :D

My internship would officially end today on paper. 17th January 2010, the date my internship contract with my current employer, was due to end.

Looking back at my internship, I’ve learned and grown a lot for the last one year. There was a time when I was a fresh graduate out of medical school, where I questioned myself whether I was fit to be a doctor, much less an excellent which I thought I would be. I was offered a job, in place of someone who pulled out of the game, not necessarily because of my ability and CV,  thrown into the deep end at one of the most notorious hospitals in this part of the world.

I survived. I came good. I then became even better:)

I was one who was always up for a challenge,but not for a physical fight though. To be honest, I vaguely remembered my first day of internship for a 6 weeks rotation in the Emergency Department of a small hospital in Gippsland. It was not because I was traumatised, that came later, but it was because the first day was very smooth sailing. That’s the only day of honeymoon period. The 3 weeks that came later really left me questioning my ability as a budding doctor. Harsh comments from consultant, senior nurses questioning your decision. Twice I sobbed at night, doubtful of myself, doubtful of my ability, worried unnecessarily for my patients. But I came good. They wanted me to be better. I wanted to be better too! Perhaps, it was the shooting guard mentality built in me, “If you misses, keep shooting! That’s the only way a shooter would score! ”

I learnt the system there. I learnt to suture, digital block , ring block, read X-ray for fractures, and etc. The harsh comments I got from the various consultants dwindled almost to zero. I learnt how to think, how to decide, and what to do when I am stumped. The experience did give me a quiet confidence that lasted through the year.

The rest of the year did feel like a breeze to me. Talk about baptism by fire at the start. It wasn’t until my 4th rotation, in Colorectal unit, that I realised I’ve grown so much. I was running 30-35 patients on my unit list as the solo intern, majority of the time. It was tough, stressful but I loved my job even more then. The surgical registrars were very impressed at my work in the ward, handling the patients in the wards while they were scrubbed in most of the time in the OT. The downside, I have limited time in OT, I didn’t mind that much, but the few times I was there, I was the primary assistant for a few major surgeries.

The NUMs were very happy too whenever I was on the ward. One of them even gave me a voucher for a coffee at the end of my rotation. I couldn’t help but smile at her simple yet massive gesture. The night resident would always check the schedule to see that I was on for the day, so he would know whether he would be in for a rough night. He would heave a sigh of relief whenever I was on. Before I realised it, I was getting recognition for my hard work. Awesome…..

My last rotation in Respiratory unit was a fun one. The team was awesome. I had an excellent working relationship with both the AT and the registrar. I spent most of my time with ET, the registrar. I enjoyed the fact that he allowed me plenty of freedom to do what I want, guiding me rather than ordering me around. It did feel, at times like two medical registrars or residents working in the same team. He treated me as almost his equal rather than as a registrar-intern relationship. He even occasionally put in cannulas for me, without even me asking! Whenever I cleared my work in the ward, I would head down to ED to help him with admission in the ED. Admissions were so smooth and fun.

Spent the last few weeks covering various odd jobs in the hospital. Everywhere I went, I could tell they love me to be there. I am going to miss this hospital, regardless of its notoriety.

All in all,nternship had been really fun, though humbling in the beginning, just like what I thought it would be and so much more 🙂

Officially, I am a medical resident from tomorrow onwards.

Arrivederci.

A for Ace

Today is the last day of my third internship rotation. Moving on from Gen Med A into Colorectal next week.

Ironically, now, I wish for my Gen Med rotation to be extended. Primarily because of, the awesome registrar that our unit currently has. Not only I think he’s a fantastic and dedicated medical registrar, the three of us in the Gen Med A work very well together. Teamwork. Clock-work teamwork for the last three weeks. Delivering care just like the way I prefer. Sensible clinical decision and unhurried by the bed pressures.

Unfortunately, I only have the chance to work with Dr. JW for one week. The other two weeks, I was working the gen med cover job. However, that one week was probably the highlight of my Gen Med rotation. I would remember it for a few reasons. The events during that one week, the things that we did, had definitely caught the attention of many in the hospital. It was also the first time I participate actively in a MET call.

I’d put my recollection into words here, to be remembered for years to come.

“I tell you what, Xiao. We gotta head home on time today and hopefully I can take my afternoon off today.”

It was a Thursday morning, a day that Dr. JW and I were expecting a relatively relaxing day. We’ve been slogging since Monday, working with some of the more complicated patients but all the referals’d been made and had plans outlined for all of them. We’d never have seen it to be the day where anything that can go wrong, would go wrong.

Our first patient of the day was a gentleman in his 70s, coming in with unstable BSL for management. We were planning to “sell” the patient to Endocrinology team for transfer of care, considering that we did not identify any other issues that would be sorted out under the General Medical unit, besides the poorly controlled sugar level, with episodes of hypoglycemia. That’s why we skipped our normal routine and started our ward round with him. I shall address the patient as Bill here.

We walked into the patient’s cubicle to find patient was fast asleep. JW went on to try to rouse the patient while I went through the history to know the events overnight, if any. I promptly told JW that patient developed a hypoglycemia the previous evening with altered GCS and BSL of 2.1 and managed promptly with 50% dextrose by the covering doctor. Otherwise, no other significant happenings overnight.

The alarms bells in our heads started ringing when the patient was not rousable. He was fine the day before. A check of the vital signs revealed no readable BP, tachycardia, afebrile and normal saturation. Manual BP revealed no BP as well. In the next few seconds, my registrar and I went to work. Reflexively, I went to palpate the carotids and radial pulses, while JW auscultated Bill’s chest. Carotids present, radials absent while JW was reassured temporarily by the presence of heart and breathing sounds.

JW called A MET. We needed more hands.

It would be minutes before the ICU hands came. In the minutes, I’d have delegated various jobs to the nurses.

“I need a bag of ice. I need extra bredmas. Get me the portable phone, need to call X-ray. Get the IV trolleys here. Get the ECG.”

I belted out orders,crisp and clear, as if I’ve been through this a dozen times before, but in reality, I have not. I tend to evaporate into the thin air, whenever a MET was called because, most of the times, there were more than enough experienced hands on board, and interns were not normally required at all.

Meanwhile, JW put the patient on supplementary oxygen, checked the carotids again and quickly went through the history to look for possible precipitating causes. I palpated patient’s femorals and reported to JW.

“Whatever we are dealing with now, the good news I think we still have a systolic BP of 70 mmHg.” Which was something I happened to have read yesterday. With that, I thought that the intraabdominal organs particularly the kidneys were still being perfused but that was only the beginning of our troubles.

The ICU registrar then hurried in. She looked a little bit flustered, probably not expecting a MET to be called so early in the day. She received a brief handover from JW who thought that we were most likely to be dealing with a septic shock ,while I get the portable X-ray organised. We need to get fluid into Bill fast. JW and I tried unsuccessfully to put large bore cannulas in. JW managed to get a 20G in though and got the fluid running. Bloods were sent.

A stat dose of vasopressin (?Aremin) was then given. The ICU registrar dejectedly told us that there was no ICU bed available in the hospital. She seemed unsure what to do next for the patient considering Bill would definitely need an ICU bed for further management. She was woken up from her seconds of deep thoughts before another MET call was called over the P.A. system. JW sensed her hesistancy and suggested that it would be best that she went for the other MET call and he could probably handle Bill himself. JW after all, aspired to be an intensivist and recently concluded his ICU rotation. In truth, JW might be more experienced than her in critical care, considering the registrars only recently moved onto their respective rotations.

“What now, JW?”

“WTF is this! We need an ICU bed. At the very least, we need a bed, a monitored bed. He would need a CVC and it can’t be done in this ward. Farking hell!” JW’s not in his most friendly mood at that moment.

“You want a monitored bed? I have a suggestion. I learnt during my covering shift that the Coronary Care Unit next door doubles up as our HDU in this hospital. Probably not as good as ICU bed that you need here, but they are monitored bed and should buy us some time for an ICU bed.”

“All right. I will speak to the CCU in-charge.” Off he went, swearing and muttering to himself, probably to vent off his anger before trying to speak nicely to the CCU in-charge. The CCU staffs wouldn’t be happy at our request, but we just gotta what we gotta do.

I went back to the patient and attempted ABG and cannulas again. With no radial or brachial pulses present, I was hunting blindly and unsuccessfully for the ABGs. I had no luck with the cannulas as well. I swore silently to myself at my incompetency. X-ray was taken. IDC was inserted.

JW came back to the patient five minutes later with an even blacker face than before. Looks like the suggestion did not go too well with the CCU staffs, but we got what we wanted – a monitored bed.

Bill was then transferred to CCU. JW got on the phone and tried to get the consultant’s assistance. We’ve got a covering consultant for the day but he was unable to make it to the hospital till later in the day. The ICU registrar was caught up with the other MET call. That just turned JW’s face blacker by the minutes.

However, he was still nice enough to give me some words of encourgement. “You did very well, Xiao. I am very impressed with what you did in there just now. I am going to run this very sick patient as an ICU registrar. Can you move on with the ward round yourself? I will catch up with you later.”

I smiled at what he just said to me. He just meant that I would run the round as a medical registrar today. I was pretty excited, rather than intimidated. I might not be at the level of a medical registrar like JW, but I was pretty confident I could handle the patients in the wards safely and sensibly. I was shouldering the work of a registrar and an intern. In between my ward rounds, I put in cannulas, made referrals, made phone calls to nursing home for collateral history, rewrite drugs charts while discharging patient, writing up plans etc.

I caught up with JW a few hours later. He was still busy with poor Bill, arranging for a transfer to a private hospital’s ICU bed. That was about the only bright spot of our very bad day that patient had private insurance cover for him to be eligible for transfer to private ICU.  JW was very happy with what I did on that day and what we did as a team.

JW clocked out soon after Bill was transferred. I clocked out at 7 p.m with a very satisfying smile on my face, knowing that I have accomplished something very well.

The next day, our unit became the story of the day, for what we had accomplished the day before, turning some heads in the upper echelons as well.

At the end of the rotation, JW gave me the best assessment of my performance I could possibly think of.

Retrospectively, I thought I could’ve done better with the cannulas. However, I am glad and surprised at myself too, for performing so well in times of stress and uncertainties. Perhaps, I do need a little bit of anxiety for my peak performance. Would ICU be my calling? Who knows?

I have not felt so accomplished for a long time. I’ve aced my Gen Med A rotation here:)

P.S. This story is purely fictional. Please read it with a big bowl of salt. Any reference to any characters in real life, is never intended and coincidental.

Arrivederci.

Broken Heart

It’s easy to forget that I’ve been in this job for more than six months now. Getting pretty well accustomed to the job in GenMed now, which is a good news. Bad news, is I’ll be moving to Surgery in two weeks time.

I always find it very cool and inspiring in medicine when you will learn a trick or two from your seniors on things that you have never seen or done before. I always love it when someone senior tells a story about some of the more dramatic things that ever happened.

This recent story I heard has to take the cake for the blood, gore and probably the highest score in the OMFG! scale.

It was about a gentleman, who recently had a heart transplant, being managed and monitored in ICU after a heart muscle biopsy. Yes, heart muscle biopsy, that oughta give one a picture of what’s to come. Dr. JW was covering the ICU. He was in the corridor when he got a page from the ICU which he replied with a call promptly. Over the phone, the ICU nurse noted that “something was not right” with the said patient, althought the vitals were within normal limit with a BP of 130/70, non-tachycardic. Dr. JW, sensed something was not right too, albeit the rather benign report on the vitals, he quickly dashed down the corridor to the patient’s cubicle.

He made it there in under 30 seconds.

In the same 30 seconds, patient’s blood pressure suddenly dropped to 60/30 in the first 10  seconds and then zero. His ECG flatlined literally in the 11th seconds. JW arrived shortly, assessed the situation in an instant, and then jumped onto the patient and commenced CPR while getting a quick rundown from the nearby nurse.

As his first compression sinked into the patient’s chest, the ICU nurse gave him a brief history which included “…..recent cardiac transplant.” Blood spluttered out of the patient’s sternostomy scar onto Dr. JW’s hands,as if to emphasize the point on the said transplant. The CPR, albeit unable to replace the heart’s full cardiac output, was still able to provide the patient with a systolic BP of 60. The ICU consultant promptly arrived, after a quick assessment, handed JW a scalpel to cut the sutures which held the sternstomy wound together. Dr. JW went to work with the scalpel, after some use of brute force, managed to literally crack the chest open for a cardiac massage.

The ICU consultant was already on the phone with the Cardiothoracic surgeons, repeating the story in a short and crisp manner, a skill honed over years in the field. Dr. JW was still performing cardiac massage when the cavalry of CT surgeons arrived. Calm immediately swept across the cubicles.

“Good job, guys. We will take over from here.”

The patient lived for another day despite having a HOLE in his right ventricle, likely secondary or contributed by the cardiac biopsy.

As boring as the 5-7hourly CABGs surgeries can be, I believed these are the moments that a cardiothoracic surgeon would live for. Perhaps I shall revisit the option of CT surgery in the future.

~.~.~.~.~

“Are you planning to be a physician? If you are, I believe you are very well under way to be one.”

That’s probably the biggest boost to my ego this week.  On the other hand, I find it rather amusing for one of the worst performing students coming out of medical school to get such recognition from a registrar trained in one of Australia’s premier trauma centre. Is she that poor? Or rather am I that good?

Nevertheless, it’s always a good feeling when your hard work is appreciated.

~.~.~.~.~

Application for HMO2 would be closing soon. I am still unsure where to go. Albeit its rather poor reputation, I always think my current hospital is way underrated. Many of the staffs seem to be on a mission to prove something, to make the hospital a better place.

As pointed by one of the consultants I’ve worked with before, “We’ve always try to make this hospital a better place for years, but more often than not, once we trained up the young doctors, they would leave for presumably better hospitals. Hopefully, one of you guys would still be with us in years to come.”

This reminded me of something I’ve asked myself and others before, when speaking on friendship and relationship, but it can be applied for many other things in our life : Would you trade the stability of the current for the uncertainties of the future?

Enough of crap for now. Shall get to the letters and CVs.

Arrivederci.

“A poor historian, is never one who tells a history poorly, but one who writes history poorly, thus such labellings are often self-critical.” -Dr. G. Perry”

Chasing Beds(to the tune of Chasing Cars)

I will do it all
Everything
On my own

I just need
Just one bed
in I.C.U.

If he stays here,
If he just stays here,
He would die on me,
And his family’d ask.

I don’t quite know,
How to say,
Done my best.

Those three words,
Are said too much,
They’re not enough.

If he stays here,
He’d just suffer,
Do you have a bed?
I only need one bed.

Forgot what they’ve been told,
He’s gotten too old,
That’s my patient that,
Try clinging onto life.

Let’s waste time,
Chasing beds,
On the phones.

I need your grace,
And make some calls,
To find a bed,

If he stays here,
He’d just worsen,
Would he die on me,
And just forget the world.

Forgot what they’ve been told,
He’s gotten too old,
That’s my patient that,
Try clinging onto life.

All that I need,
All that I ever need,
Is a bed in ICU,
But there’s none I found.

I don’t know where,
Confused about how as well,
Just know that these things,
Will never change for us at all.

If he stays here,
If he does die here,
Who would stand by me,
And answer to the world?

Hehehe…..Inspired by working in the Emergency Dept where all the ED doctors were busy chasing beds to place patients.

Alright, too sleepy to edit. Might make some changes later.

Arrivederci.

Of Cold and Flu

Doing some readings in my past time. Thought might as well jot it down here for future references.

In the last decade, there have been a few respiratory viruses making their rounds throughout the world: The SARS virus, H5N1 and now H1N1.

SARS virus – the famous Severe Acute Respiratory Syndrome virus, which I can vividly recall the TV broadcasting the situation in China where the healthcare workers were quarantined BY the Chinese government that reportedly tried to downplay its severity until it was too late. SARS virus is a Coronavirus (SARS CoV), a positive sensed, stranded, enveloped RNA virus. Its 2003 outbreak affected 8000+ cases with 900+ death, giving us a mortality rate of roughly 11 percent. 6 years since its global introduction, there is NO human vaccine that’s been successfully produced to date.

H5N1 – “The Avian Influenza”, “The Bird Flu” is a an Influenza Type A virus, a negative sensed, single stranded, segmented orthomyxoviridae RNA virus. It’s considered an unstable virus with high rate of mutation since its introduction. As of May 2009, it has 373 cases with 233 deaths, giving a mortality of roughly 62%. It has however limited human-to-human transmission potiential with cases thus far have a trend of being reported in cluster. Its high mutation rate allows it higher probability of reassorting with other strains and co-infecting a host organism such as pig. Human vaccines exist but its efficacy has yet been tested in a pandemic scale.

The 2009 H1n1 virus – the current trend, the “Swine Flu” is an Influenza Type A virus, similiar to the H5N1, a negative sensed, single stranded, segmented orthomyxoviridae RNA virus. Not much I can read about it. Said to be a highly unstable virus as well. It has affected 21000+ cases thus far, with 100+ deaths giving it a mortality rate of roughly 0.5%. Work on vaccine is under way.

So there conclude the 3 viruses I’ve read about a little bit today. So what’s the deal with the H1N1 virus, its mortality pales in comparison with its more famous brethens. I thought about it for a while. For that, perhaps, we need to go back to the basics of epidemiology of disease. It’s a world of fair trade. A disease that’s highly virulent and pathogenic would “have burned itself out”, due to its high mortality and morbidity rate resulting in lower incidence and prevalence as time passes. There is less case present to cause more cases, in short.

The H1N1, on the other hand, belongs to the high prevalence, low virulence group. As it has a lower mortality and morbidity rate, it would have a very high incidence and prevalence. As mentioned before, these 2 viruses have very high mutation rate and share a common host organism in pig. If you cross the 2 viruses…… you get the idea.

I quote one of the consultants, we woulda shit our pants when “pigs really fly.”

God bless me as I am now on the frontline (the Emergency Dept, the cheapest ones the hospital can employ at that)

Then again, I am not an infectious disease specialist. Fair to say, I am not an expert in this subject. All right, time to go back to the more interesting topics in my study – Acute management of chest pain in ED……

Arrivederci.

A Week to Forget

After all the happenings of the past week, I just had to graze my the bumper of my new car against an electricity pole. On the last workday of the week. Ouch. Dang. 4 horizontal deep laceration to the level of surface of the the body kit at the R) anterolateral aspect of the car bumper. Whatever the Titanum coated paint also gone. Damn damn.

~.~.~.~.~

Albeit all the happenings over the week, I did achieve something the previous weekend while on duty at the department. I managed accomplish one of the more advanced suturing techniques. Had a 4 y/o kid who presented with a laceration on the thigh with skin loss. Given him some intranasal midazolam to calm him down a little bit. Didn’t know I can give midaz intranasally until told by one of the senior HMO. Neat stuff to know for the future. Paeds dosing, if I recall correctly now, it was 0.2-0.4mg/kg. However, he only really got calmed down once we got the Etonox going.

I had some doubts regarding the laceration thus I asked one of the senior HMO for some inputs. He advised me to “go under” so I could pull the skin together and then suture it. Suddenly, something clicked within my head then and I immediately understood what he meant and went to work. I did as he told. I used one suture to hold the midpoint of the laceration together first without knotting it, then proceeded to suture next to it with another suture line. After an hour of work, I managed to close the skin together. Much later, I was told, the technique I used was similiar to a simple flap usually done in plastics!

All in all, I was pretty happy with my work:)

~.~.~.~.~

I am starting to enjoy my work again. I was getting a little bit tired of it initially after spending such a long time in the same department. Probably since the weather got a bit cooler, the traffic in the Emergency Dept had become more manageable, rather than stressing about ways to the patients out of the department. Of course, that would be the ultimate aim for any patients:)

Doing rotations in the ED, I think I’ve learned quite a bit. Probably a lot more than I had initially expected. The procedural skills I’ve learned and the confidence in doing it would definitely come in handy if I am to pursue a training in the surgery. I’d think I am more physician-inclined than surgery. In a few months time, I gotta make a decision on where and what sorta residency to pursue next year. Medical? Surgical? General? Back to my “home hospital” in Heidelberg? Clayton? Or staying put where I am right now?

Time really flies.

~.~.~.~.~

I am currently organising and salvaging my photos and musics from my old hard disk. Gotta take a while.

Till next time.

Arrivederci.