32 posts tagged “hospital”

Boleh masuk lagi

I don't know if it's a coincidence or a result of the recent fuel price hike but ever since the price hike is announced by the government, my ward is packed like sardines. Not in a neat row on the floor, but in whatever position to accomodate as many as possible. And today for the very first time, for a very very long time...we ran out of camp beds! Mattress were literally put on the floor. The last time I remember this scenario was perhaps 7 years ago? It was made worse by the fact the a private medical center was desperately trying to transfer an ill, bed bound patient over to my ward. No prizes in guessing the reason lah. Can't blame them, they are not a charity organization. What to do? Take over lah...

Maybe I should make my own "incident report" and suggest my own  remedial measures which would be umm...3 orang kongsi 2 katil? Hahahaahahahaha

On a more serious side perhaps sending them to district hospitals may sound good, but many refused because there are no specialists there and "tambang pergi balik mahal" - for those who are just waiting for something eg scans, endoscopies etc  hahahaha.....back to fuel price again. They prefer to stay in hospital and wait for 2-3 days. Free food, got missy to call, got company to chit chat, can complain if service not good some more...

Desperately wanted to take a picture of the ward but then to protect the patient's privacy I refrained.

But ONE patient made my day. A really old charming cheerful lady who said "Saya mau balik jaga ayam saya...kalau tidak tiada orang jaga" and laughed. I asked how many chickens she has, she mumbled something and we laughed together. It is always the VERY ELDERLY "uneducated" village folks (ladies usually), many of whom can't even speak proper Bahasa, who have the most sense of humour. I salute them for having such a cheerful outlook and sense of humour even though their days are numbered. Perhaps we can learn something from them.

Chicken

At the end of the day, it was the chickens that made my day.

Minibas

Remember these familiar words? Yeah the famous words of mini buses' conductors in KL perhaps 10 years ago...the pink BMW (Bas Mini Wilayah) ones which will stop anywhere...yeah anywhere you ask even at the roundabout. Aahhh....the memories of my student days in Uni.

Today these magical words brought back those long lost memories. My ward is like those mini buses....boleh masuk...belakang boleh lagi...(Translated: Come in...can come in some more...behind can some more)...hahahaha...despite having camp beds on the floor till the nurses counter. A patient with oxygen was waiting on a stretcher waiting for a bed at the counter. It gets more amusing reading this where our Health Minister said Govt Hospitals were getting ready for increased volume due to the price hike/inflation. Yup we are still in the Bus Mini era. Masuk...masuk...belakang boleh lagi masuk...

Sad to say the measures taken by MOH are NOT WORKING. It's not just because 300 medical officers and 50 specialists resign every year. It is not just about getting enough doctors...To treat patients you need BEDS, you need MEDICATIONS, FUNDS $$$, DISPOSABLES, BLOOD BANK SUPPORT, LABS, DIAGNOSTIC EQUIPMENTS, LAB TECHNICIANS, NURSES, DIETITIANS and the whole lot..etc. Problem is we are still not past the "getting enough doctors" stage yet.

It's really no point getting enough doctors and cut down waiting time to 30 minutes then say no budget for medications, no beds, no scans available etc etc. Unless you want doctors to practise some traditional healing and use "miracle water" to do some chanting....ZAM ZAM ALA KA ZAM! and poof patient gets better! Hey, maybe that's what the MOH wants.

Currently also cannot cope already how to get ready some more ? Duh...

Some sort of healthcare financing scheme gotta be implemented soon.

Ah...the inevitable. The rise in petrol prices.

There will be 40% price increase in petrol (ULG 97) from RM1.92/litre to RM2.70/litre today but there will be a rebate of RM625 per year for each car below 200cc capacity.

Hmm...reminds me of the many "charity work" some of us did many times in the past. Frequently we had to drive about 30km to another hospital to see referrals. Initially we were only allowed to claim mileage, later it was changed to passive on-call claims. I remembered my claims for a couple of months' "expired" because I didn't have the time to drive there during office hours until the end of the "closing account date for that year". That is for Medical Officers.

For specialists though, currently we are doing "charity work" also. On calls for 2 hospitals but claiming only for one. The other hospital which is 30km away, mileage claim could be done if we did go there. But then we need to drive 30km x 2 (to and fro) to see a patient after office hours and then 30km x 2 again during office hours to hand in the mileage claims (a stack of them). Most of the time I just forgo the claims or just don't go. Too much hassle and not worth the effort nor trouble.

The amount that you can claim for a trip  = 60km x 50 cents (say 50 cents/km, check out here) = RM30. But you actually travel 120km (additional 60km to hand in the claims during office hours!). With the petrol price of RM1.92/litre with a consumption of say 10km/litre ( your car damn efficient lah, and no jam) , you'll be spending RM1.92 x 12 litres = RM23. The RM30 ringgit mileage claim seems appropriate.

But with the petrol price increased to RM2.70/litre, you'll be spending RM2.70 x 12 litres = RM32.40. So essentially if the  mileage claim remains unchanged, you'll be paying RM2.40 to go and see a patient. I repeat, you'll be paying to see the patient even if you claim mileage !!!

Don't know whether my calculations are correct or not.

Anyway it doesn't sound like a good deal to me and to quote someone, "What about the wear and tear to your car?"

Can someone tell me whats the b****y obsession, really obsession, of the patients especially Chinese patients with cholesterol and uric acid? The b****y "tang kou soon" and "ngiau suan"?

If I hear another query about "tang kou soon" and "ngiau suan" I'm gonna scream. Every ailment is attributed to this "tang kou soon" and every bodily pain is attributed to this "ngiau suan". A raised cholesterol of 0.01mmol/L above the upper limit of "normal" will cause panic despite the patient having more pressing problems like err....cancer for instance. It's irritating man...Whatever joint pain humanly known will be attributed to the mildly raised uric acid.

Anyway on a different note, got the most irritating patient today. An elderly patient who came with the spouse. Came with a stack of "health screening" investigation. A referral letter from her previous doctor from a private medical centre mentioned that she has been taking a lot of Chinese medications, herbs, "food supplements" and what not, suspecting those could be the cause of most of her problems.

"Aaa...why there is a line under the RBC value? Why is it a bit low despite normal Hb? How to make it normal?"
"Why my sodium is low? How to make it normal?" For crying out loud, the patient's sodium is 134 mmol/L whereas the normal limit is 135-150mmol/L
"Why my gamma GT is high? It has been high since last year. Got medication to bring down the gamma GT ah?"
"What is triglyceride? How come mine is high a bit? Got medication to bring it down ah?"
"I think I feel tired because of the raised gamma GT lah"
"How come I sometimes feel a bit giddy?" Pissed off, I answered I don't know.
"Is my blood sugar normal ah?" I answered 5.1 mmol/L is perfectly normal. The patient said "Yes ah? Really meh?" And proceeded to scrutinize the normal values printed beside the result.
And so it goes...bla....bla...bla...

And lastly the final one, a real good one : "Why you never see all my results properly? I paid a lot to get this done in private you know?"

Despite my best explanation to the patient which was obviously received with one ear in and one ear out, and explained perhaps an ultrasonography of the liver is necessary to exclude fatty liver disease, the patient finally said ah yes yes yes...ah scan of the liver. I thought I saw a glimmer of hope of ending this never-ending consultation. I wrote the request for the ultrasound and asked the patient to take a seat outside. The patient said "Er doctor, can the ultrasound be done today ah?" I explained this is not an urgent case and an appointment of 2-3 months is the norm. To say the patient was shocked was an understatement.

10 minutes later, my nurse informed me the patient is very angry, doesn't want the ultrasound but want the scan (presumably CT scan). Said this ultrasound is no good, I want THE scan. The patient came in again. I said " Do you want to be exposed to a lot of radiation just to see some fat in your liver?" I explained something called risk vs benefit. The patient snickered and walked out.

I doubt this patient will return. I hope the patient doesn't return.

This patient has got this disorder called "Disease of Lab Results"

Was on-call with a Medical Officer recently and she updated her facebook with this ;

" will throw her phone if it rings again about some bloody bastard who wants to leave the hospital to sign some stupid document with his *ucking lawyer "

Here's her blog. For those readers with a low tolerance with word that rhymes with LUCK, a word of advice - brace yourselves hahahahaha.

Which brings to mind a rather outdated procedure in the hospital. Any patient who abscond from hospital will be reported to the police (Yeah, and what will the police do about it?). Any patient who wants to leave or be discharged from the hospital will need to sign the "Against Medical Advice" or "At Own Risk" form and countersigned by a doctor of the ward. Perhaps reporting the absconding patient with public health interest (infectious disease, psychiatric patients, medico-legal cases etc) to the police is understandable but for other reasons it's rather pointless. For example those patients with heart failure or poorly controlled diabetes who abscond because they feel they are fine.

Reminds me of ONE tuberculosis patient in the US not too long ago who absconded across the Atlantic and was pursued relentlessly by the police till he was caught. We have a Multi Drug Resistant tuberculosis patient (as far as I personally know) running around the state without any problems, not to mention the NUMEROUS active tuberculosis patients who are assimilated with the public without problems too.

Back to the topic, I truly believe patients are responsible for their own health. Many times, relatives force the patient to be admitted against his will and then not surprisingly the patient will ask for a AOR discharge ASAP which irritates everyone to their limit. I mean if you don't want to be admitted just say so!!! Don't get yourself admitted to avoid argument but the moment your "relatives" leave, you ask for a discharge. Does anybody realize the amount of work that is involved (plus paperwork) if you are admitted and then discharged after an hour ? Not to mention wasting bed space (and preventing other people from being admitted), wasting tons of papers, wasting water and detergents to wash your bedsheet (which was used for an hour) plus lots of other nursing work? This is blatant abuse of a public facility and people like that should be penalized severely.

Another version of the same thing is patients who want to leave the hospital to settle some personal stuffs - seeing his lawyer, going to the bank, visit their "relatives", sign some documents, even to do BUSINESS!!! - some mega businessman he is ! These patients like to walk in and out of the hospital at their whim and fancy.

I say whoever walks out of the hospital consider it an AOR discharge immediately without hesitation. No need signatures or anything. And patients who walk out cannot be readmitted again to the same hospital for say 72 hours. Since they are well enough to walk out they must be fine. Don't bloody waste our time which can be used more productively with patients who actually wants treatment. And whoever who wants to leave, just open the doors to them on the condition they cannot be readmitted to the same hospital again for 72 hours.

Problem solved.

Recently was on call, saw the numerous patients who are/were being artificially ventilated for various reasons. Among the reasons were inoperable metastatic lung cancer, liver failure with cirrhosis, progressive/untreatable lung disease and hypoxic brain damage.Their prognosis is worst than dismal at best. I really don't know if the patients really want to go like this. Is this really how they want to be "treated" or to leave this world? In any case they have no choice - not over here. Are we "treating" their family members rather than the patients? The world is a stage...

What would the patients say if they can or are allowed to make their own decisions? In any case, it would be over-ruled by the family members on the premise that the patient is not mentally alert or in right frame of mind to make that decision. Who wants to have a heated argument with the family members of a DYING patient? And with the sequelae that follows...

The best way is to have a living will - a legally binding document which cannot be over-ruled by the family members. To state how they want to be treated if they have a terminal/life threatening condition. Alas this is a very alien concept here. In any case, any living will has to be voluntarily produced by the family member or a legal officer - which may be with-held or destroyed too.

It is very disconcerting to see terminal dying patients having tubes shoved into their lungs, their stomach and urinary tract. And members of the public/relatives ( who can tell who is who? ) going in and out of the ward, peaking here and there - like watching a bloody blockbuster movie. And they love seeing CPR being done - like it's an entertainment show. The healthcare personnel will appear "uncompassionate" if they ask the "relatives/visitors" to leave to attend to/ resuscitate the patient. Some of the healthcare personnel are harassed and scolded by these relatives too. And like Murphy's law, these patients WILL deteriorate during visiting hours when the ward is like a fish market. Some visitors will just REFUSE to leave because they say IT'S THEIR RIGHT TO BE THERE DURING VISITING HOURS. And they will just stand around looking at the "drama" involving other patients. Bloody B***tards !!

So are you going to stand there arguing with the visitors or resuscitate the patient? Your choice.

Ventilated patients gasping for their breath, sedated or even already unconscious are being poked daily for bloods, their every bodily functions being "taken care of" artificially. Swollen limbs, bed sores, bruises, haematomas everywhere. Faecal smell permeates the whole ward every time a pampers is changed. Until the patient's heart finally stop, inevitably.

Is this how you want to die?

If I have no realistic chance of a meaningful life,
Please spare me the indignity of a prolonged painful death,
Kindly do not shove tubes down my every orifice,
Please do not inflict more pain by poking me daily for bloods,
And above all, do not hook me up to a machine while I die.

After their goldfish died time and again in the puny round fish bowl without aeration, my nurses asked me to get some fishes for the ward. So one fine day I went to the day market and bought some fishes for the ward.

From my childhood experience of rearing numerous fishes, from the "longkang" fish to the fighting fish (bettas) to the  discus, by trial and error I discovered that some fishes are just too delicate. The usual goldfishes are particularly quite fussy (not the black variety though). They need the right temperature, the right pH etc and particularly aeration from the bubbles.

So I thought - forget it. Goldfishes won't survive the ward. I thought hard....and finally got a pair of "ikan sepat" (snakeskin gourami, Trichogaster  pectoralis - I googled it, not  from memory hehe) and a pair of "ikan haruan" (snakehead fish, channa striata ) - I think it's haruan. Hah ! These fishes are hardy and won't die. They have special organs to breathe oxygen from atmospheric air and therefore do not require aeration. As long as the tank has water, they will survive hehe. So far they have settled in their bigger plastic tank which I bought too.

Here's the new addition to the ward. Let's see how long they will survive hahaha.

New patients

In my practising experience, this term is a rather foreign term here.

Example 1:

An extremely ill elderly lady has end-stage kidney disease. She will succumb in days, weeks or maybe months if renal replacement treatment is not instituted. She is old and frail. Dialysis carries a significant mortality risk for her. She declined any dialysis despite proper explanation ( to reasons only known to her ). She was ready to leave this world. BUT...her relatives (including children) somehow insisted she must get dialysis and managed to "persuade" her to have the dialysis against her wishes. So she underwent a risky procedure and was dialysed. She developed multiple complications and was artificially ventilated. She is now on tracheostomy (a tube into the windpipe) for breathing. She developed severe pneumonia and will probably succumb to it soon. Now she is just lying there, apathetic to her surroundings and would allow anybody to poke her, prick her, dialyse her, feed her etc. She just lies there gasping...doesn't speak nor move, staring at the ceiling, oblivious to her surrondings. Only god knows what is running through her mind.

But probably her relatives will be satisfied with the "heroic effort". After all we've done "everything possible" to "save" her. Patient's rights? What's that? After all, as I've said before a dead patient cannot speak for you but a living relative can certainly create hell for you.

Questions like "Why the doctors didn't do anything to "save" her?" or "I will lodge a complain/sue you if you don't dialyse her and she dies" can be expected from relatives.

Example 2 :

Again an elderly bed bound frail lady with multiple co-morbidities including previous stroke has chronic lung disease with failing lungs due to disease progression which is basically untreatable. She is unable to breathe properly to keep herself well oxygenated. She was previously artificially ventilated before and was not fully conscious any longer. Her VIP politician son THROUGH THE PHONE insisted everything must be done to "prolong her life" despite explanation of her condition. Politics came into the picture also. Veiled threats were made. So finally she was put on an artificial ventilator again. She developed cardiac arrest, was resuscitated and is still unconscious. (probably due to stroke/brain damage). So there she is, lying unconscious, the ventilator breathing for her while she is waiting to die from an inevitable hospital acquired infection/cardiac arrest again. BUT son is probably satisfied. "Everything" has been done to "prolong her life" - more like prolonging her death. And the hospital is probably saved from a potential lawsuit or a complicated sequelae with politics in tow.

WHAT ABOUT A PATIENT'S RIGHT TO DIE IN A DIGNIFIED MANNER?

I pity the many junior doctors who are bullied by the relatives in this manner. Even myself have succumbed to these pressures at times. After all you have 30 other ill patients to take care of with 40 others waiting in the clinic downstairs. You can fight, you can try to protect the patients' rights. But when relatives keep barging in your clinic every 5 minutes "to discuss with you" and takes your precious time away from other ill patients, you ask yourself "Is this a battle worth fighting at the expense of other patients?" Are you prepared to get physical (trust me, this is a real possibility) if necessary? Are you prepared to go to court? Are you prepared to go through months of attending a complaints committee meeting? Are you prepared to write tons of rubbish reports? After all with or without intervention the patient WILL eventually die. After all who cares about the lack of beds for other more deserving patients?- not my problem. Who cares about wasting resources in a public hospital? - not my money. Just do whatever the relatives want and save yourself from A LOT of problems. Trust me, these thoughts run through EVERY DOCTOR in public service. The poor junior doctors most often are the ones getting bullied - they have their career to think of too. Sad scenario.

WHAT ABOUT PATIENT'S RIGHTS, I ASK?

Welcome to the real world!

To go in peace