Received this referral letter some time ago. >_<
Not too long ago, some one decided to adopt a rather ridiculous, in my opinion, infection control measure in the ward. Whenever a patient is detected to harbour a multidrug resistant (MDR) micro-organism, a thin red line will appear on the floor around the patient’s bed!
No doubt the intention is noble – it is to warn others, especially health care workers that there exist, in the ward, a patient with MDR bugs and (hopefully) take precautions when handling a person.
But no one really bothers. Hardly anyone notice the existence of the red line. Certainly the red line does nothing in infection control. The MDR bugs are color-blind and are certainly not threatened by the ominous red line.
This is what happens in an institute with little enforcement of infection control practices, where the isolation rooms are severely limited and always occupied, and where even alcohol-based hand wash is not freely available.
The thin red line makes a mockery of the whole idea of infection control.
I became very ill last Thursday night. I had been unwell a few days prior to that – the usual under-the-weather-feeling coupled with intermittent diarrhoea. In fact, on Wednesday evening, I had a bout of chills and fever which subsided on its own. My worried spouse asked me to be admitted, which I stubbornly refused (all doctors are stubborn people).
Thursday morning, I was fine and was even able to perform the ward rounds after I had my blood sampled and sent for various tests including culture and sensitivity.
I suddenly turned bad on Thursday evening after dinner. My daughter was fast asleep as I had asked her to go and sleep and that I would wake her at 8 pm to take her for her tuition class. The wife and son had gone visiting the in-laws. At 7 pm, I felt especially unwell, the chills and rigors came in waves and I vomited out everything that I had eaten in the last decade. To add to the drama, my wife came back horrified to find me on the toilet floor, being too weak to get up.
She bundled me up, packed a few necessities and drove me to the nearest private hospital (the government hospital was too far away and I was in a bad state). En route, I managed to call my colleague at the hospital where I worked to determine from my blood tests sent in the morning if they found evidence of malaria (I had recently travelled to Bangkok but stayed in the city throughout the trip – but who knows…).
It was negative.
I won’t go into the details of my hospitalization although I would mention the one thing which struck me as being ludicrous, almost to the point of being darkly comedic was when the attending physician of the private hospital approached me a while after my blood was drawn for various tests and promptly announced: “The good news is, your cholesterol levels are normal!”.
Imagine the scenario – there I was lying on the uncomfortable hospital bed in the ED, breathing laboriously (my oxygen sat was 93%), tachycardic (rate 130/min), highly febrile (39 degrees Celcius), hypotensive (blood pressure was 80/50 mmHg), feeling weak (the potassium level was 3.0 mmol/L) and terribly unwell and then BAM! I’m hit with the ‘good news’ that my cholesterol levels were normal!
I wasn’t elated, not in the least.
Anyway, it’s still a mystery as to what actually caused me to be hospitalized for 4 days (3 nights) and I’m still on the road to full recovery, more than a week after being discharged from the hospital (my darn appetite has altogether disappeared!), so if you meet me in the corridors, don’t ask.
What I CAN tell you is what the illness was NOT caused by:
1. It wasn’t caused by high cholesterol levels. (the good news, remember?)
2. It wasn’t caused by dengue (I had dengue serology done 3 times in 2 days although the blood works did not suggest it)
3. It wasn’t caused by syphilis (I don’t know why VDRL had to be done!)
4. it wasn’t Mycoplasma (the titre was normal)
5. It wasn’t a urinary tract infection.
6. It wasn’t any bug in the blood (cultures eventually came back negative)
7. It wasn’t malaria (the smear was done twice)
8. It probably wasn’t typhoid or typhus (so the street food I ate in Bangkok wasn’t to be blamed).
I honestly don’t know what it was.
It cost a whopping RM 3800 for 3 nights of hospitalization.
I have a feeling I’d been milked nice and proper.
It’s personal policy that I do not let know that I am a doctor whenever I deal with anyone in the hospital. So, I take my number just like the bloke next to me, I wait my turn, I listen to the instructions given, I fret and get annoyed, just like the next twenty or fifty people waiting to be seen by the doctor. Call it a kind of social experiment.
I simply wanted to see how people are being treated. I didn’t want to be accorded artificial special treatment because of my ‘status’.
Several weeks ago, my wife took my 10-year-old son to the hospital for his ENT appointment. Atopy runs deep in my children’s genes (inherited from the maternal side – I’m allergic to nothing except extreme stupidity) and so Ryan was afflicted with allergic rhinitis, albeit mild. Although they were there early enough, it was past noon before Ryan was eventually seen by the doctor. By then, my wife was anxious to go to work and asked me to take over. Thankfully by then, my routine of morning rounds, seeing referrals and taking medical students for bedside teaching was done and so I quickly made my way to the clinic.
“The doctor said he needs to take his puff twice a day now. Just wait near this door for the prescription. His next appointment is in 4 months. I’m off to work now. Bye!”, my wife said hurriedly as she left Ryan in my care while we waited patiently in the clinic packed with more than a 100 people.
It took another 45 minutes for the nurse, an elderly woman, to appear at the door and shouted Ryan’s name. I quickly informed her that I was Ryan’s dad and may I have the prescription.
“Oh, you must be Dxxxxx”, said the nurse, addressing me with my wife’s name, after peering at me over the rim of her golden-frame glasses, and handed me the slip of paper.
I didn’t bother to correct her. Instead I took the slip of paper and exited the clinic with my son. On the way, I happened to look at what was written on the paper. I was surprised to find that his appointment was scheduled for 6 months later while the prescription for the nasal puff was amended to be administered once a day instead of twice and the supply was written for only 4 months.
I stopped my son, who by now was hungry and told him we needed to go back to the clinic to sort out the discrepancy. We went back to the clinic and I knocked at the door of the room where the nurse appeared from before. After a while, she opened the door and peered out and asked me what was the problem.
I explained to her that my son was advised to take his puff twice a day instead of once because his symptoms were not controlled and that his next appointment was supposed to be in 4 months.
“There are too many people in this clinic, so we had to extend the appointment to 6 months”, she explained, with a little annoyance.
“Ok, fine”, I said, “but the prescription is only for once a day and for 4 months only”, I pressed my point.
“Well, the consultant do not think he needs it twice a day”, she barked at me, raising her voice a notch.
“But the doctor who saw him said he needs it twice a day”, I persisted. “And 4 months is not enough, what happens for the two remaining months after the medication has run out?, I asked.
“That, you will just have to take care of yourself”, she said dismissively. I took it to mean I would have to source the medication from elsewhere until my son’s next appointment.
By now I got a little miffed. “You can’t do that! I would never do this to my patients”, I said determinedly.
By then, something must have flickered in her mind and she asked, “Are you a doctor? What doctor are you?” although she was quite oblivious to the the name tag I was wearing which suggested that I am a doctor.
“I’m a doctor at the MOPD (Medical Outpatient Department) and I always make sure my patients have enough medications”, I explained.
“Well, MOPD patients are different from ENT patients. MOPD patients have to take their medications. ENT patients don’t need to. They can skip medications!”, she retorted, looking smugly triumphant.
By then the medical officer who saw my son earlier had appeared having heard the commotion we were creating, and asked the nurse what’s wrong.
“This doctor here wanted bd dose of the puff but the consultant struck it off and only signed for daily dose”, she informed the medical officer.
“No, he needs it twice a day, and it is for 6 months, please make the changes in the prescription”, he ordered the nurse.
“Dr XXX (the consultant) is not going to be happy about this”, the nurse murmured spitefully while making the changes to the prescription.
I thanked the medical officer profusely and left the clinic with the re-amended prescription.
The whole incident left me with a sour taste. The nurse displayed a woefully uncaring attitude and in my opinion has no place working in a healthcare setting. The consultant was careless and flippant in simply striking off the prescription written by his/her medical officer without discussing it with the MO to find out the justification behind the double dosing needed and he/she did not bother to inform the patient (or in this case, me, as the carer of my son) regarding the dosage change. It was also highly irresponsible of them to short change patients with regards to their supply of medicine.
Things could be better. A whole lot better.
Strawberries are nice. They smell nice, they taste nice, and they are pleasant to look at. But strawberries are also fragile. Keep them out in the heat for too long and they physically deflate, they change color, they turn bad. They don’t stay fresh forever. They don’t last very long and wilt at the slightest adversity.
The Strawberry Generation is what some of us call the new generation of mass-produced doctors in this country and its not without justification, despite what others who think otherwise. The complaint pages of major newspapers are often filled with letters of frustrations and disgruntlement written by young doctors who could not bear the rigor of working under intense stress and difficulties – young doctors who whine about bad working conditions, lack of rest, unsympathetic superiors, etc.
We have too many strawberries around.
The other day, I did what I have never done before in more than a decade of teaching undergraduate medicine – I walked of my class. I did that after discovering that none of the 10 or more students gathered around me that morning for bedside teaching had done their part of the work – they were supposed to have clerked and examined a patient each prior to the class. Without a good case presentation, there was no point in carrying on with the class.
I expressed my disappointment, mumbled that I had something else to do (I had an entire eard rounds to do and several referrals to see) and not wishing to waste anymore of theirs or my time, I walked through the circle, hearing a few whispered ‘I’m sorry Sir’ and walked away.
I wasn’t happy with what I did and I wasn’t angry, not in the least bit. I am hoping that what I did would push the message home to these young students – that medicine is tough, it’s a life long commitment and it requires a lot of hard work.
I want my students to be made of better stuff and avoid being labelled strawberries when they graduate and start work.
Voluptas ex malo (Latin): deriving pleasure from evil/bad.
A man with newly diagnosed HIV infection was seen at the ED for minor complications from his medications. He was received by a nurse at the ED who attended to his complaints and he was subsequently seen by a doctor who decided to admit him for observation. After a few days he was discharged well. After a week or two, he noticed his office mates behaving strangely towards him. A close colleague who often makes him a drink in the morning has ceased to do so. Others made excuses when invited out for a meal.
Before long, he heard whispers circulating in the office – that he has been afflicted with the dreaded disease and that it is highly contagious. Even eating and drinking together might spread the disease! His work life became a living hell. He lost concentration and found it hard to work. He didn’t know who he could complain to and so he returned to his treating doctor and complained to him.
The source of the trumour (a true rumour), which the distressed man strongly believed, was the ED nurse who first attended to him. It turned out that she is the wife of one his office mates!
Perhaps it was from an innocent bedtime story shared between spouses or perhaps it was shared out of malice or simply because it was such a ‘juicy piece of gossip’, but whatever it was, a man’s career is in jeopardy because a healthcare professional has breached an expected code of conduct.
The story isn’t an isolated case of course, there’s the blabbermouth at the mortuary who let slip the diagnosis of a deceased man from HIV to the entire kampong resulting in the entire family of the deceased to be ostracised. There’s the hush-hush juicy round going from one professional to another that so-and-so has HIV or so-and-so is gay. There’s the case of specialist-in-training who shouted loudly at a patient in the ward these words: “You have HIV and you deserve to die!” (We didn’t gazette him). There’s the case of an entire family moving interstate to escape the harsh backlash from people whom they used to be on friendly terms with because a member of the family has HIV and they some how knew…because some one blab!
The stories could fill a book or two.
We can do our part – ask before you speak: is what I am about to say, even if it’s true, going to cause hardship to another fellow human being? If the answer is yes, then zip the mouth.
I was horrified to discover during the ward rounds today that a patient’s life was placed in mortal danger by an evidently incompetent house officer. The patient presented with a mild stroke and has a history of diabetes mellitus and chronic kidney disease.
Apparently, the nurse alerted the ‘reaper in a white coat’ yesterday regarding the high bedside blood sugar level of the patient. What the fellow did was he ordered an intravenous infusion of insulin for the patient without doing the following first:
1. Determine if the patient’s high blood sugar level needs rapid controlling (there was no indication actually)
2. Determine if the patient has chronic kidney disease because a patient with chronic kidney disease is very prone to hypoglycemia (a potentially life threatening condition).
3. Consult a senior colleague first before giving the order.
As a result, the patient’ sugar level plunged to dangerously low levels within 4 hours. The house officer also neglected to order for the patient’s blood sugar to be monitored frequently (at least hourly) but thankfully an alert senior colleague discovered the situation in time and promptly instituted remedial measures!
In short, the patient could have died.
The same senior colleague told me that the in-vogue practice amongst many house officers now is to order intravenous insulin whenever they are bugged by nurses alerting them to patients with high blood glucose levels, regardless whether they actually need it or not!
This is a very dangerous practice.
I lodged a formal complaint today, something I hardly ever do but I draw the line when patients’ lives are placed in jeopardy because of a doctor’s incompetency.
Grim reapers-in-white-coats should either be retrained or not be allowed to practice.
The other day, at the end of a short class, I noticed a student scribbling furiously into his log book. I went near him and asked him what was he frantically writing into the log book.
Student: Oh, I’m trying to recall all the clinical cases I have clerked in the ward. (he answered sheepishly, much like how a boy caught with his hand in the cookie jar would answer)
Me: Oh….(and deciding to be mildly sarcastic)…how about you trying to remember all the hospital registration numbers of these patients as well?!
By now, a small group of students had gathered around us. Some one in the group said: “Ah, Sir, surely you will understand, you were once a medical student too!”.
Me: Yes, I was once a medical student, but I did not do what this fella is doing when I was in medical school. I made sure that I got the details of every single patient that I saw or clerked and promptly got the entry signed by the lecturer that day.
Everyone laughed guiltily before dispersing.
I love teaching statistics. I love to tell my students that in a typical population, the distribution of the people within the population would be following what is known as a Bell Curve or a Gaussian curve. Roughly 95% of the population will be concentrated in the centre of the curve while about 2.5% of population will be found at both extreme ends of the curve.
I like to point out to medical students that most medical students are average Joes (or Janes). There are a few that fall in the extreme left of the curve – these are probably those who do not want to be doctors in the first place. At the other extremes are the bright sparks – the small group of students who possess within something extra within themselves that would clearly distinguish themselves from the average Joes or Janes.
Nobody remembers a mediocre person.
But everyone remembers an exceptional person.
And in Malaysia where we churn out between 4,000 – 7,000 new medical graduates a year, you better darn well be exceptional!
After being doctor for 16 years now, I thought nothing would disgust me in the wards. I have blissfully survived many unpleasant things such as unruly and even violent relatives of patients or even the patients themselves; psychotic patients; amorous patients; amorous patients doing it on the bed in the middle of the night; amorous male attendant who tried to hook me in the night; urine, snort, blood, feces and other organic waste products on the bed, floor, window, curtains, and walls; stinking pressure sores the size of Antarctica and deeper than the Mariana Trench; patient’s who smoke in the bathroom right next to where the oxygen tanks are kept; patients who conveniently use their intravenous cannulae for a drug trip in the toilet; suicidal and homicidal patients; rude bosses and colleagues…and the list goes on and on and on.
I thought was immune to any insult to any of my 5 senses.
I couldn’t be more mistaken. Several weeks ago, I was conducting the morning ward rounds and generally it was a rather smooth rounds – the house officer, miraculously actually knew the cases and the medical officer was a competent fellow. There were only 4 more patients to go and as I approached one particular patient, the fellow was sitting upright in bed and coughing rather violently. He has pulmonary tuberculosis!
He took a look at me and before I could utter “Good morning”, he coughed out a huge blob of greenish-yellow phlegm and spat the disgusting goo onto the floor, right by my feet!! He then looked at me with the look that says, “So? Sue me, I don’t care!“.
His disgusting action completely caught me by surprised. I was mortified for an instance. Every infectious diseases trained fibres in my body was in revulsion. I wanted to hit the dirty fellow!
“Why did you do that for?“, I asked as soon as I had recovered my composure.
“I don’t have a receptacle to spit into“, was his casual reply.
“There’s the dustbin just under your bed“, I pointed to him.
“It’s too far for me to spit“, he replied, unperturbed.
I wanted to hit him again.
Instead I berated him (yes, I did and seriously, I hardly berate anyone at work, so yeah, I was pretty worked up then). I told him off for his filthy habit. I told him off for endangering the health of other patients and relatives (and health care workers) around him because his blardy phelgm is highly infective.
He kept quiet.
I didn’t see him that day. He wasn’t in any mortal danger. The medical officer attended to him. I went on to the next patient and finished the rounds soon after and left. But the foul image of a grown man with such filthy habits burned into my memory. I cannot believe that in this day and age, we still see such uncivilized behaviour in our fellow human beings.
Writing this makes me shudder. It will be a long time before I get over this.