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Tuesday, January 10, 2012

Perihal Handovers

About an hour ago aku bangun dari tido. Seb baik sempat solat Zohor (Asar masuk 531pm nowadays). Working nights this week, frm last night 'til Thursday night. Aku kuar frm hospital around 9++am pagi tadi. Cam biasa junior reg looks after short stay uni (benci!!) & therefore the longest to stay coz of long handover for short stay, while still ada lagi patient on the floor to handover to the a.m. floor doctors.

Aku nak citer pasal how I made a HMO cry during a handover on Friday afternoon last week. Si HMO ni kita namakan dia "Dr. M". Dr. M handed over to me a syncope of unknown cause but stable, still in the mid of investigations prior to the patient being sent to short stay unit. I checked the medical notes written by this HMO, & when I noticed ada byk glitches, aku tegur la. Syncope = unconscious event, as an ED doc kita kena cover all basis. Meaning kena look at all possible causes: neurological, cardiovascular, metabolic. Then aku list down all the things yg dia kena buat before handing over to me: complete the history taking, tulis the drug chart coz patient tu punye regular meds dah overdue, fluid chart, anticipated short stay plan including disposition plan, etc. Haaa.. tengok tu, punya la banyak kekurangan. Mana boleh aku je nak buat semua kerja dia yg tak siap nih. Aku cam garang la jugak, kalau tak complete menda yg dia should have done earlier tu aku tak nak amik the handover.
Lepas dia buat menda tu dia got back to the doctors' room & nangis depan semua org including consultant aku & balik rumah.. Aku cam.. errkk.. takkan la cam tu pon nak nangis, bukan kasi patient mati pun.
Sebelum dia dok handed over to me that patient that day, dia ada handed over 2 terribly incomplete patients with bad consequences to me on Tuesday sebelum tu. Sure la aku hot sangat-sangat. Kisahnye: 1st surgical patient, dah accepted by surgical registrar over the phone & was going to theatre that very evening & plan was surgical registrar would see the patient before operation. In the meantime the patient should be fasting & having IV fluids, IV antibiotics, blood tests, pain killers. The handover was just babysit the patient coz kononnye semua dah settle. A few hours after the handover, nurses datang kat aku kata patient tu takde IV canulla hence tak dapat semua menda lagi, and he was getting more dehydrated. Apa lagi, panas aaaa kejap hati aku ni. Dah la when someone is sick, to get an IV access memang susah. Dgn si patient ni mmg susah gila sampai one of my bosses helped me using the ultrasound machine pon cam susah gila. Dah delayed dia punya treatment that could have helped in his recovery post-operation & reduced length of hospital stay. Seb baik kami berjaya buat semua tu before this bitchy surgical registrar jumpa the patient that evening, kalau tak sure ngamok abis dia. Geraaammm!!!
2nd patient ialah this poor 90yr-old lady functioning well lives alone kat retirement village unit, as per handover dia ni unconscious due to severe hypoglycaemia BSL was 1.3. Dia ni kononnye 'slightly' dehydrated due to gastroenteritis (surprise, surprise not properly enquired by this HMO). Dah resusitated by ambulance & now receiving treatment kat ED for hydration & for sugar replacement, before transfering to private hospital. Aku tengok notes.. hmm.. cam something missing je, most of blood tests cam tak complete & the initial resus management kat ED cam something wrong. Masa tu cam busy nak mati so on my side I missed looking into those during handover (silap aku). Then masa kat short stay tu patient tu deteriorated, lepas aku dah start my part of treatment aku gi balik ke dia punya notes. Memang banyak missing!! Aku yg memang ada anger issue ni lagi la panas je, tambah lagi baru je struggling dengan surgical patient tadi tu. Aku terpaksa order banyak lagi blood tests, rehydrate this patient, etc. In short she was actually in multi-organ failure way back in resus cubicle way before aku took this crap handover. Cam mana aku tau, aku tak order new blood tests, aku order retrospective blood tests. Meaning aku tak amik new blood frm the patient tapi order tests on the blood yg pathology lab dah ada 5,6 jam dulu tu masa dia mula-mula sampai ED. Seb baik ada sorang senior ED registrar ni baik hati nak tolong aku manage this patient. Aku risau la jugak bila balik rumah tu walaupon dah handover kat the night registrar. A few days afterwards, I heard from one of the bosses regarding this poor old lady. She deteriorated overnight, multi-organ failure, tak jadi nak hantar kat private hospital but terpaksa admitted at my hospital & very sick.
Grrr.. sure la aku geram gila. That patient could have died that night. Yeah, sure, she's 90. But she's a functional 90yr old & she absolutely didnt need to die due to medical mismanagement. She could have gone to the private hospital where she really wanted to go & discharged the next 2,3 days. Tapi dia admitted to hospital for 9 days. If she was my family member, I would want her to have a chance to be back to her previous function, given that she was functionally well prior to this episode. And I am a doctor & I am fully aware of the old lady clinical situation (which was initially simple to manage if the initial treating doc was aware as well).

In short, before I took the Friday handover frm this particular HMO, I talked to her about the 2 patients that she handed over to me on Tuesday & what she should have done right & what she could do better in the future. Dia cam tak berminat nak dengar semua tu.. just jawab.. "yeah yeah..". Aku sabar je lagi masa tu. Bila tengok another crap job of hers with that one, aku terus tegur dia lebih garang lagi. Good thing is aku tak yell at her, just slow monotonous firm voice & straight to the point. After all, dia dah HMO bukan intern lagi.

Memang all the juniors (HMO & interns) wajib discuss patients with the consultant in charge on the floor. So that takde missed care & this will be a learning opportunities for these juniors. Thats why its also important that these in charge consultant kena gi check all points of care with the junior doctors. Kalau the juniors malas/ miss stuff/ rasa cam dia pandai gila with their limited experiences, & unfortunately the consultant plak either malas/ super busy, memang akan jadi kes berantai la of missing stuff.
In that crap handover case, unfortunately the department was on bypass & superbusy so byk la swisscheese holes. And to me, whatever it is, the first clinician kena buat their job properly & clinically thorough (yg relevant je la). And after all, these clinicians are doctors not medical students. So sila treat patients like you are a doctor.

Kalau nak handover kat aku, aku kena tau semua since aku yg akan jaga these patients for the whole of my shift before handing over to the next person kalau diorang masih ada di ED. Aku tak nak inherit pts yg I have to go thru every single thing again myself & kena buat most of the investigations.. kalau cam gitu, patient's care is delayed & mungkin makin teruk. Its like cleaning other people's mess. Kalau diorang sakit aku yg bertanggungjawab nanti.. and kalau diorang sakit sebab unfortunate events/ natural course of the disease takpe, tapi kalau diorang sakit sebab the previous doc has missed lots in the patient's care.. memang aku marah sangat. Plus my time would be better spent to see the other patients waiting to see a doctor, than me wasting my time cleaning other people's mess.

Sabar je la...

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