Pengorbanan Kali Ini

Drama queen betul. Heh.

Okay, last night I had to through away my whole work attire (except tudung) to the bin. My top, pants, socks & shoes. They were cheap on clearance ones, but still I threw away my work outfits. All into the bin.

The last case that I saw last night prior going home was an epistaxis (nosebleed), a young professional who has been living with anxiety, which is causing their very high blood pressure & each time this will lead to a nosebleed. X came before my shift started & saw my boss, had their treatment & went home. X came back just before I finished my evening shift with blood pouring out of her nose. 

Normal practice is that I would put on my disposible protective gown & gloves (which are removed once you step out of that particular cubicle) and cover an epistaxis patient with some blue +/- gown, +/- cover the floor with some blue, get the suction ready, etc. It is an arterial bleed, yes, but that extra few seconds of keeping the area safe does make a big difference. So those were what I did anyway with this particular patient.

But of course X didnt bleed when I was attending them. No source of bleeding in either nostrils, other than the obvious 200/120 blood pressure. During the observation, I had to attend to another young hypertensive emergency that already had bleeding & swollen retina in their both eyes that we had to transfer out of the Eye & Ear hospital. And of course, X had to bleed massively while we were doing that. 

On the way to grab a new set of protective attire, X had to cough, cry, stress out. And in turn more blood gushing out of X's nose in response to the climbing blood pressure. And that was when some blood splattered onto my lower half of my front. Sheeeeeessshhhh... So much fun! 
Threw away the attire at home, and yes, I deserve to be a drama queen. 

I dont fully blame patients when this things happens. Orang kata apa guna jadi doctor, hey, kalau takut darah, kencing, tahi & all those disgusting bodily produce. 

Think about you as a patient, mesti u ada sket2 pandang slack kat doctors yg lepas pegang u dia terus basuh tangan, "macam aku ni geli sangat!". Well, think about this again, you as a patient, the doctor dah lepas pegang pesakit lain kat cubicle/ katil sebelah yang u tau ada penyakit u anggap geli or lepas exposed to some darah, phlegm, etc, tanpa basuh tangan terus periksa u. Best tak?

Healthcare is not only about caring & managing health, but also is about prevention. We as healthcare professionals should as much as possible not spread germs, also as much as possible to actually protect ourselves from contracting any diseases. Not worth it at all. In a controlled situation, a little extra of these simple efforts make a very big difference. Of course in real disaster, sometimes you cant avoid it. And nowadays we can actually afford that extra 1-2 minutes to simply grab a pair of gloves/ goggles/ gown. Based on these experiences, I always make an effort to have at least a pair of gloves in my pocket, bags, car, etc coz you will never know.

I dont really have to dwell into it much, just think of the basic. Setiap healthcare professional akan dilatih very basic: DRSABC for any clinical situation. And to me, the first 3 principles can be applied to any situation too.

D= Danger. Avoid, remove any danger.. SAFELY!
R= Response. Check for response.
S= Send for help. 
A= Airways.
B= Breathing. 
C= Circulation.

Yes, and yup, last night memang aku dah jadi a drama queen, tapi at home lah.. Takde kerja la nak meratap bagai kat ED sana nun.. hehehe.
Hopefully doesnt happen that often again. 

Welcome to ED

Taken from webbie Confession of A Junior Doctor:
 http://confessionsofajuniordoctor.tumblr.com/post/102808909879/welcome-to-a-e

Even though I am no longer a junior doctor, more so now a mid-trainee/ early-advanced trainee, this pretty much sums up my life of an ED doctor.

 Confessions of a Junior Doctor

1. Welcome to A&E

   Posted by: tea-and-apathy on 16 November 2014
   I have no idea what it is that I like about Emergency Medicine.
   
   The hours are terrible. The rota is indecipherable. You cannot plan to attend a friend’s birthday or a family gathering. Your social life is non-existent. The patients are largely rude, drunk, smelly and irreverent. There are never enough staff on shift. The urgent care centre referrals are sometimes ludicrous. The GPs send in UTIs as renal colic, PID as appendicitis, persistent patients that they can no longer placate. The specialty doctors think we are either lazy or lobotomised. You spend more time than you should at the centre of “specialty tennis”.
   
   The four hour wait is a travesty. There are never enough observation beds. The pressure is immense. The clock never stops. There is always another patient waiting, another test to order, another result to check. There is always a diagnosis to be made, and treatment to initiate, a conversation to be had. You go from renal colic to brain tumours to heart attacks. You see depressed people, drunk people, old people, children. You see people at their worst. You see time wasters and hypochondriacs and then sepsis and deaths. You don’t have time to process. You don’t have time to think. You see, treat, refer, discharge.
   
   People complain about the waiting time, disagree with your assessment, believe google before they believe you. You go home at night paranoid about the patient you sent home; constantly questioning your decisions, your abilities and your sanity. You see multiple patients simultaneously, you are a porter, a nurse, a cleaner, a friend, a confidant. You tell people good news, bad news, sad news.
   
   You are charged with the unhappy job of treating people’s liver disease from excessive alcohol, lung disease from smoking, diabetes from overindulgence. People expect you to take responsibility for their lifestyle choices. You endure the abusive drunkards, the psychotic schizophrenics, the deranged elderly. You put up with the people who have neither an accident nor an emergency.
   
   You exhaust yourself looking after these people, so much so that you go without food, without bathroom breaks, without the most basic of human needs. You are vilified by the media, who feel you are paid too much for what you do. You are misunderstood by friends and family who watch too much ER and Casualty. You become unacceptably irked by poor resuscitation techniques on TV shows. You complain about unnecessary attendances and then carry out wholly unwarranted tests because you are scared of being sued. You will inevitably have complaints filed against you for merely doing your job. You will make poor management decisions and people will die. You will make excellent management decisions and people will still die. You will defy the odds: CPR will work; the patient will recover from sepsis; be discharged from hospital, and then die at home a week later.
   
   You will miss things. You will be wrong on a daily basis. Everyone thinks they know more than you. You finish a shift and barely have the energy to walk to the car; let alone drive home. You spend at least half of your days off comatose in bed. You don’t see your housemates for weeks due to opposing shift patterns. You do locum shifts during your time off because there are never enough doctors and you know how awful it is to work when they’re short staffed. The barista at Costa knows what sort of day you’re having based on whether you order a medio cappuccino or a double espresso. The packed lunch you brought 3 days ago is still sat in the refrigerator. Once you leave work you are unable to make the smallest of decisions because you have used up all of your brain cells.
   
   You are stressed out, overworked and rarely thanked. And I can’t think of any specialty that I would enjoy more.
   

Harap-harap Bukan Gastroenteritis...

Perut aku & hubby dah mcm mual-mual & meragam sejak a few hours ago. We had some oily kebab from Dandenong market for lunch after beli groceries tadi. In the past 2,3 weeks ni there's a lot of gastro running around. Likely related to the fluctuating heatwave here in Melbourne. Aku ni jarang la kena gastroenteritis (cirit-birit) ni despite my repulsive eating habit, Alhamdulillah. 
Kat spital pon ramai yg bergastro bagai. Ada yg biasa-biasa je sehari of fluid therapy dah boleh balik. Ada yg critically ill sampai multi-organ impairment. Dasyat betul penangan gastroenteritis ni. 

Aku harap-harap la tak berpanjangan and hope this is just the reaction to eating filthy oily food. Kadang-kadang bila aku makan oily food from outside perut rasa tak sedap, epigastric pain, nauseated & altered bowel habit. Gastritis or gastroenteritis? Kalau this is a true gastro memang naya la coz this coming monday aku will be working night shifts again, but in ED. More over esok nak gi breakie feast at Dr. AI's place and then housewarming Dr. NA in the evening. Dah siap-siap beli fruits for the breakie & sayurs for the evening housewarming. 

Esok ni angan-angan nak buat kerabu mangga + pegaga, sayur bendi + snow peas + kacang panjang + kobis & peria goreng. Cita-cita besar la tu. Hehehe.

New Contract Year Feb 2014

All doctors in Victoria started their new contract year on the 3rd Feb 2014. I am one of those that are continuing from last year to this year. 
Agak rollercoaster jugak last week with the new doctors starting, ramai yg from other hospital network, ramai jugak yg first time residents/ registrars. Interns dah start 2 weeks prior so the first slow-wave dah lepas, now the next slow-wave pulak with the new doctors. 

I started the working year with being on the senior registrar job. This includes being in charge of the yellow stream & being the rapid assessment in-charge. Sangat-sangat stressful.
Nanti-nanti aku citer. 

This week I'm coverning someone on leave in ICU. Starting today with night shift sampai rabu malam. Then on-call for ICU over the weekends. Such long 3-14hour shifts; kami start at 8pm then rostered to 9am the next day, tapi tak semestinya abis on time coz ramai org byk ckp during handover. Minggu depan aku go back to ED.

I just got back from seeing my colleague for a breakfast at Axil Coffee in Hawthorn. Lama gila tak jumpa dia. Now dah nak ready untuk tido. Hopefully I get a good rest so that segar masa kerja nanti.

And aku doakan satu rakyat Victoria ni sihat sejahtera this week, so that takde yg berpusu-pusu masuk ED, and those on the wards semua stable takde metcalls/ code blue, and those in ICU are not extremely complex. Hopefully this week will be cruizy for everyone. Amiin, Ya Allah. 

Dah Bosan Dengan Situasi Kini? Begitulah

http://zouldahanblog.blogspot.com.au/2014/01/aku-dah-bosan-menjadi-doktor-bertauliah.html?showComment=1391331877119

Good reading, good summary of our frustrations re: today's public health. I can say that here in Australia, we are going through the same frustrations as well.. 
Sigh... apa nak jadi dgn public..

Alhamdulillah.

Alhamdulillah,
I passed my MCQs for Anatomy & Pathology ED Primary Exams.
The VIVAs will be next few weeks in September.
Wish me all the very best all. InsyaAllah.

And, Selamat Hari Raya Aidilfitri 1433H. Maaf zahir & batin. Take care everyone.

Ambo ride

Semalam punye la busy kat ED. Initially tak le busy mana, and I had to see one of the DEMTs (Director of Emergency Medicine Training) about my coming exam. That already took almost an hour, which was fine coz it means less time on the floor. Hahahaha.. bunyi agak pemalas kan? Memang sangat-sangat demoralized lately (... erk.. slalu pon gini).

First patient I took was a stroke patient. Symptoms was dysphasia. Mid-age lady in her 60s. Admitted under neurology.
2nd one was another stroke. Wah, back to back stroke cases aku dapat.
Youngish man 50yrs old, came in with total right hemiparesis, aphasic, poor comprehension, projectile vomiting. Hantar straight to CT scan of the brain + perfusion scan (circle of Willis), but he only got the plain CT brain. Kureng betul radiographer tak buat perfusion scan. Turned out to be dia ada haemorrhagic stroke: large left subcortical bleed injecting into the ventricle.. in another word, bad bleed that causes irreversible damage.. needs to be evacuated.

The wife was present, kesian, diorang takde sapa kat bumi Aussie ni coz both r frm the UK.
Anyway, he was stable all through out ED stay. We had to transfer him to St. Vincent's hospital coz kat spital aku takde neurosurgery specialty. First time aku ikut as an escort in a patient transfer. Dok dalam ambulance.

Seriously kagum & excited, even though seram jugak coz takut patient to crash on me while on the way. I guess the only things yg aku mampu buat as a junior doc at that point ialah airway management & aku boleh intubate (Alhamdulillah). Sebelum bertolak tu aku dah sediakan all the resuscitation drugs in my hand + the resus bag (yg berat nak mampos) dah sedia ada to come with me for the journey. The bosses kasi aku taklimat & nasihat sebelum pergi coz aku tak pernah pegi ikut inter-hospital transfer ni. The deputy of ED puan prof cam ragu2 nak kasi aku pegi coz aku sangat junior in my training. Tapi the bosses yg suruh aku pegi tu relax je ckp this is a perfect opportunity for me to learn. Thanks bosses for believing in me (at the time when I really needed the support).
Sepanjang perjalanan gi St. Vincent's aku sentiasa check his blood pressure. Despite him doesnt have blood pressure issues, he was hypertensive on presentation up to 220/115, which is quite a common complication of a haemorrhagic stroke. We gave him hydralazine, GTN patch, those brought down the BP to a stable 170/100, even though we alwiz like the BP to be below 160 systolic & 90 diastolic. Tapi at the same time tak nak drop the BP too quickly too much coz tak nak other unwanted complications to the already injured brain.
Oh ye, one nurse yg looked afta the patient kat ED kata I deserve a pat on the shoulder coz berjaya masukkan a large bore cannula 16G kat patient tu masa sumer org failed to get another access. Bangga la jugak :P Selalunye case yg critical like this we like to have 2 secure IV access, 1 has to be a large one of minimum size 18G.

St. Vincent's hospital is in the city, sampai-sampai je aku sangat kagum dgn hospital besar banyak tingkat tu. The neurosurgery registrar sambut kami dgn baiknye, he was nice on the phone. Naik terus ke tingkat 10. Cantiknyeeeee ward kat spital ni. Nice view of Melbourne city. Rasa cam nak tukar specialty training supaya dapat dok kat tingkat atas2 of the hospital to have this kind of beautiful view. Terlupa kejap pasal patient haemorrhagic stroke aku ni. Hehehe.

Anyway, it was a short trip from Box Hill Hospital ED to St. Vincent's Hospital. ~15-20minutes je, despite the ambo was running at the speed limit coz hujan lebat. And my hospital kasi aku taxi voucher to come back to ED, and my au$40 worth of trip back was free. =) Seram gak tunggu sorang-sorang kat luar ED St. Vincent's tu for the cab. St. Vincent's terkenal sebagai catchment hospital for psych + substance abuse people. Habis baju aku bau asap rokok coz masa tunggu kat luar tu ramai sungguh org kuar masuk hisap rokok kat pintu luar despite kat situ besar gila sign takleh merokok.
The whole trip pegi-transfer-balik took only ~1 hour. Boleh dikatakan my only exciting case on yesterday shift. Sampai ED Box Hill dlm kol 11pm. 1 jam je lagi until my shift nak abis.

The whole case is kinda a sad one, but very satisfying personally & professionally, and aku bersyukur aku involved in this. I cannot imagine if that happens to my family, let alone my partner. Na'udzubillah. Sedih jugak aku memikirkan how that wife nak look afta her husband yg dah non-verbal & sebelah badan lumpuh, with no family support around. Kalau orang tanya aku sekarang sanggup tak aku jaga a family member kalau jadi cam ni, of course, aku sanggup. It will be difficult, no doubt. But for love, I'll do it, and semoga Allah swt bagi aku & my family kekuatan if this ever happend.

Aku doakan semoga all of us diberi kesihatan yg baik, keimanan yg kuat supaya kami tak lupa kepadaNya, and diberi kesedaran jaga diri baik2 for now. Amin.

Now kena get ready to work.

Nice & warm

Came home late pagi tadi. Biasa la kerja aku ni, the last few hours sure ada menda jadi punye.

2jam sblom abis shift, datang this man with massive anterolateral STEMI developing in ED. Signs of it datang kat rumah, so ambos called us prior arriving & faxed the ECG with the early changes to us. Dia ni 2 days post stent insertion to LAD coronary artery kat private spital. Kitorang punye la call the cardio registrar suruh datang like NOW NOW NOW coz this patient's ECG masa arrival was minimally bad, then quickly got worse setiap 10minet. Isu nye ialah, cardio registrar cam pelik apsal dia datang spital aku which is a public hospital sedangkan dia ada private insurance & dia buat stent dia kat private spital yg dlm 10mins away frm our spital. Dipendekkan cerita, the patient pegi jugak ke cath lab afta dia berada kat ED slama 1 jam setengah. Then before aku balik tadi tetiba terdengar panggilan Code Blue from cath lab.. hmmm.. dalam hati aku sure tu patient aku tadi tuh.
Dipendekkan bebelan lagi, kalau dia cuma tunggu setengah jam di ED before going to cath lab for re-angio, tak perlu lah dia ke ICU intubated bagai. Yet, slalunye org tua-tua gini kalau dah nak kena heart attack yg massive cam gini, 1/2 jam ke 1 1/2 jam ke, still poor outcome jugak. I hope dia selamat in ICU.

Normal ECG dari mana-mana buku medic

ECG patient aku selepas 1/2jam dia kat resus tu.
Okay, adik-adik, sila describe this ECG to me =)

Moral of the story: jangan merokok, makan makanan sihat & seimbang, senaman selalu, jaga berat badan, tido yg cukup, pakai sunblock slalu, kurangkan stress, jauhi dari aktiviti2 yg berisiko tinggi & tidak berfaedah, jaga diri baik-baik & last but not least doakan lah kesihatan & keselamatan diri sendiri. Kalau dah sakit tu susaaahh nak reverse balik...

Earlier last night aku dah miss satu peluang to intubate a young overdosed patient. Pasal dia tetiba bangun plak from pengsan dia. Boss aku dah panggil aku suruh buat sebab patient ni muda & kira senang la kan. And aku plak dah terlompat-lompat gumbira coz ada chance utk praktis intubation. Aish rugi! Hahaha. Tapi bagus la takde la rugi satu ICU bed kat spital tu semata-mata nak fit satu manusia yg nak tarik perhatian ramai dgn cara overdosing on drugs or memang nak bunuh diri tapi kurang bijak lagi utk bunuh diri cara yg betul. Buang duit!! Hehehehe.

Semalam petang satu lagi buku yg aku order sampai. Ni salah satu buku yg aku dok asik pinjam kat library rebut-rebut dgn medical students. Dah la kat library tu takleh renew buku. Beli je la senang. Best buku ni. Good & easy to read utk org yg terlajak cam aku ni.
Hari ni cuaca sangat best. Terang & warm, rasa cam kat rumah aku kat KL. Temperature 29°c- 31°c. Semalam dlm 25°c-28°c gitu =). Rugi betul aku kena tido siang coz of the night shifts. Ni jap lagi & esok start kol 10pm, abis pagi Isnin. =(
And aku sangat sedih coz this weekends ialah long weekend coz Monday cuti hari buruh. And weekend ni ialah Moomba festival yg setiap tahun aku tak pernah miss fireworks dia. And aku sedih coz aku kerja night shifts plak la hujung minggu ni + ada presentations kena buat on this coming Tuesday & Wednesday. :'( Kalau kerja siang at least bleh pegi tengok fireworks malam-malam. Sedih jugak hujung minggu yg panjang ni slalu orang pegi jalan-jalan, aku plak dok ngadap muka patients2 yg separuhnye ntah apa-apa. Geram!!!