July 27, 2008
“You are getting all the overnight handovers”
I peered at the list. There must be about 20 odd patients still lingering in the ED.
“Half of our doctors have taken leave today. We’re really short and you’re taking everything”
Oh wow. This would mean that I’d be the one sorting out all the overnight patients. The docs on duty the night before looked really weary and worn out. It looked like they had a pretty rough night. There were a few patients in the resuscitation cubicles; one was unconscious, one with very bad shortness of breath, and one whom had lost probably a few litres of blood overnight due to an assault.
I consoled myself. At least it’s the registrar who usually takes over the resus patients. The serious stuff.
“Hmm, registrar is busy. Okie Newbie, you take the resus patients”
You must be kidding me.
I mentally pictured my jaw dropping. There I was, in the middle of the morning handover, imagining myself demonstrating all sorts of horrific newbie incompetencies. It’s not easy juggling several patients in an acute setting, let alone now that I’ve suddenly got 20 plus in my hands.
Resus patient #1 – Unconscious patient. His heart arrested and staff were all jumping on him performing CPR. Unfortunately the effort was futile – patient died. According to the paramedics the patient had the arrest in the back of the ambulance and by the time he was brought to the ED it was approximately 20-30 minutes after.
Resus patient #2 – Came in with huge difficulty breathing. Patient was propped up in bed with a huge face mask strapped unto her face. Oxygen was trained via 2 huge lateral blue plastic tubings. She was leaning forward with her arms gripping the bedrails and breathing heavily. For a split second she reminded me of a scuba diver.
Resus patient #3 – Is missing. Or at least I thought he was till I was informed the surgeons have admitted him. This guy appeared in the ED overnight post-assault with a huge knife sticking out of his bum and blood gushing out of his wounds. Previous doctor was exclaiming there was ‘blood everywhere’ and waved animatedly for emphasis during handover. We can only imagine. As inappropriate as it was, the image of a chef sticking a knife into a hot bun came into my mind.
Random patient #1 – Was hard at work coughing till she heard a ‘crack’ followed by a ‘pop’ over her ribs. Chest X-ray didn’t quite show any obvious rib fractures (but then again it’s not easily picked up to begin with) although there was a small area of lung collapse. For further review and could be discharged home if pain is manageable. It’s not uncommon to pop a rib while coughing or sneezing a lil bit too hard. I’ve heard a case where a guy cracked his rib from laughing too hard (and another whom dislocated his jaw). Must be some really funny stuff.
Random patient #2 – Huge tooth abscess. Had a tooth abscess drainage done recently but wasn’t taking the prescribed antibiotics. The infection blown over and the patient ended up with a really swollen jaw (looked as though he hid a ping-pong ball in his cheek). Oral (facio-max) surgeon on-call remained uncontactable for the rest of the day and this guy needed an urgent transfer under another surgeon outside the hospital. The infection trailed up his nasal sinuses and is now discharging from his nostril. Not good.
Random patient #3 – Another jaw abscess except this is on the side opposite of the previous guy. Very huge and angry-looking swelling right under this guy’s jaw. He was in agony whenever he speaks and was obviously frustrated as he had multiple recurrent abcesses before this one. Both of these guys needed IV antibiotics and subsequently tranfers over to another hospital. I have a strong feeling there was a mix-up with the on-call roster of the oral surgeon; he didn’t appear on our on-call list although under the main system he apparently is.
Random patient #4 – I didn’t find him, he found me. I was at the work area writing case notes for another patient when he stood right in front of me.
“You a doctor?”, he said. I nodded. “I need to talk to you”.
He leaned towards me and whispered, “See that nurse over there? The one in pink?”.
I had a look. Yup I could see the part-time nurse donning the pink scrubs.
“Don’t let her anywhere near me. She turned up at my house trying to kill me“.
I took a good look at him. His face was flushed and he looked absolutely determined with his point; speaking with such great conviction. Chances are he’s most likely one of the psychiatric patients who had wandered out from his cubicle and forming delusions throughout his trip. One part of my overactive imagination thought, ah what if it’s real? What if it’s a conspiracy?
My workload smacked me back to reality. I could have given him a mini lecture on the basis of delusions and one’s mental state but was plainly too lazy to even start. Too much to do, too little time.
“Okie, don’t worry. If there’s any concerns you could discuss this with the head nurse”, I mentioned.
The patient was agreeable to this and ventured back to his bed. Seemed pretty satisfied with the reply for someone whom was worried about a perceived murder attempt at him 2 minutes earlier.
Random patient #5 – Young guy whom was stabbed with a pair of scissors overnight. Story was some guy out the blue walked up to him and jabbed his abdo with the scissors. I took a look at the wound; appeared pretty superficial. Patient stated that he didn’t knew he was stabbed until he saw the pair of scissors held by his assailant afterwards. Yikes.
Couldn’t quite decide which one was more astonishing; the thought of scary dudes randomly stabbing people with scissors or my patient whom was still looking all bright and chirpy after being stabbed. Hmm.
Random patient #6 – The cute lady with asthma who just can’t help but to relieve everyone of her life story despite her shortness of breath. Having the hissing nebuliser mask on would usually deter anyone from talking but nah not this one.
She belongs to the category of patients whom would answer your questions with 5-10 minutes of irrelevant details of her day followed by the important bits that you’re looking for. This lady started with “I woke up one morning…” and followed up a re-enactment of the conversation that took place between her and the local bakery shop owner. Still not too sure when the shortness of breath started but I do know that she had french loaf for tea.
Random patient #7 – The patient with a very very demanding mum. All questions are to be directed to the domineering mother whom would be throwing in a demand at the end of almost every sentence. It was an interesting sight; the patient looked distressed, the mum looked pissed, while the granny just looked at the TV screen. The mum was adamant that the patient needs urgent medical attention ASAP by the senior doctor and was starting to get kinda preachy. I think we spent more time pacifying the mum above all else.
The patient is pregnant and was vomiting more frequent than usual. Mum took up the arms and started heckling the staff, ‘commanding’ the attendance of the senior specialist. Honestly, there were many more serious patients to be seen and there came a time where we told the mum straight up that they’d have to wait – they’re not really a priority at the moment. We left the room while the mum scoffed and sulked. Granny’s still watching the TV.
Random patient #8 – Hero. I first saw him with a cervical collar and a heavily bandaged head. News was he scooped up his lil’ son to escape from a wave and ended up running head first into a slab of jagged rocks. He was preoccupied with getting out of the way and didn’t realise he was running towards a huge rocky wall. Ended up lacerating his forehead and getting a concussion.
Thankfully the head and neck scans turned out to be normal overnight and he’s discharged home. I saw his lil’ bub visiting his papa in the morning and they looked really cute together. Awww.
Random patient #9 – This young guy has a cervical collar on as well but his story was nothing similar to the previous patient. After much interrogation and quizzing from the night doctors, he sheepishly revealed the history of his injury:-
1. He was chasing his girlfriend around the room.
2. Girlfriend hopped unto the bed and promptly off to the side.
3. Guy hopped unto the bed after his sweetie but was propelled head-first into the wall.
4. All fun ended there.
I had a look at the notes written by the previous doctor and saw “Head vs. wall“. Nice summary.
Random patient #10 – Now, this isn’t one of my patients BUT I was nearby when his attending doctor was discussing the case with the consultant. My ears picked up the words:-
“…testicles got stomped on by a horse…”
It was incredibly unfortunate to have that certain anatomy at the receiving end of a horse’s hooves, but also immensely lucky that further scans showed the testicles to be intact. Huge PHEW there.
These are the few that I could recall from that particular shift. The rest of the cases are not particularly outstanding (or maybe I’m just bit too lazy to think). I do have a story concerning swollen balls but I’ll save that for another day *grins*.
* * *
July 12, 2008
Random bit #1 : The Greek and the groin
As I was walking past one of the nurses’ workstation, I could see a mini-crowd building up in one of the rooms. I could hear a number of people talking all at once; couldn’t quite make out what they were saying. Curious, I poked my head in.
“What’s going on?”, I asked. There were 2-3 nurses all standing around this middle aged patient. All of them turned to look at the newest entry into their lil’ conversation.
The nurse closest to me threw her arms in the air. “I can’t understand what he wants. He’s been restless for the past hour.” she said, sounding exasperated.
I glanced at the patient. He just shook his head and shrugged.
“Hello mister, is everything okie?”, I started. Within 2 seconds I was greeted with some rapid-fire reply in a language that I couldn’t understand.
“He’s Greek”, said the male nurse. “Can’t quite understand nor speak English”.
The patient reached for his urine catheter. I instinctively grabbed his arm.
“You don’t want your catheter?”, I looked at him. I can understand it’s not a very comfortable thing to have a tube being stuck up your bladder, but if it’s overly painful for him then we’d have to remove it in case of an infection.
The patient just stared blankly at me.
I pointed to his bladder. “Is it painful?”.
He goes spurting his native language in a very purposeful manner. Trouble is, neither of us could understand Greek. The female nurse looked at me and said, “What does it sound like to you?”
I grinned. “Sounds like Greek to me”.
I pointed to his bladder again. “Pain?”.
To my surprise, the male nurse in the room started pointing to his own groin and emulating some pain response. He was clutching his groin and going “OW? OW?” while looking at the patient questioningly.
I knew immediately he was trying to help, but it just looked just downright funny and kinda wrong. He even did the mini squatting motion with every ‘Ow’ he made. The patient looked amused. He shrugged and shook his head.
After shooting some blanks for a while, we decided to call up his son whom would be our translator via the phone. Turns out that the patient was just amazingly persistent in wanting to know what time his family would be visiting him the next day. Ah.
Random bit #2 : My hand is numb, but then again maybe not.
I received a bundle of pages for this same complaint from the same patient. She was admitted for a fractured wrist and was on the waiting list for surgery the following day. First page in the series was from the nurse, raising concerns over the patient’s hand being numb.
Well it’s not a good thing for one’s hand to be numb, especially when you have it encased in a plaster cast. My first thought was the cast was probably put on a lil’ too tightly – impeding the blood circulation to some degree and/or pinching some nerve.
I headed downstairs to see the patient.
Patient : Oh, it was numb. Now it’s not.
Me : Eh, that was quick. Everything okie now?
Patient : Ya.
Me : Alrighty then. Just let one of us know if your hand’s feeling funny again okie?
Patient : Okie.
Seeing that everything appears to have settled, I headed back upstairs to another ward. Within 10 minutes, my pager beeped. Ah, the hand’s numb again.
Me : Hello. How’s the hand? Numb?
Patient : Ya. Um, just a little bit numb. But if I massage it, it goes away.
Me : Hmm…well it’s looking a lil’ bit swollen than previously. I have a feeling the cast is on a bit too tight.
Patient : Um, are you gonna saw it open? *looks anxious*
Me : There’s a good chance we’re gonna have to do it. The cast is keeping your fracture immobilised but if it’s gonna cut off your blood circulation then there’s more benefit of having it off than on. That could be the reason why you’re feeling a bit numb now.
Patient : Well…yes.
Me : Okie, I’ll discuss this with your treating team just to inform the senior doctor and getting approval to split the cast. If he gives the green light then we’ll do it.
Patient : …okie.
I made a quick phone call to the senior orthopaedic doctor explaining the situation. He told me to proceed so we gathered the equipments necessary for the procedure. This includes a few ‘scary’-looking instruments like the plaster saw and the retractors.
Patient : While you were talking to the doctor, the numbness went away.
Me : Hmm.
I had a strong feeling that IF the cast is to remain on her, I’m gonna be getting a lot of subsequent pages overnight about her intermittent numbness. The cast looked tight to begin with, and the increasingly swollen hand is a big NO-NO. And besides, I can’t possibly keep running up and down the place playing hide and seek with the numbness.
Me : Ma’am, your hand appears to be more swollen now. The numbness appears to be coming on and off but I’m quite concerned still as swelling is another indication that your cast is on too tightly. The cuff is trapping your circulation and it needs to come off.
The patient hesitantly agreed. She was more worried about the sawing part which I could understand. The saw has a circular blade which actually works via vibration instead of an actual rotating motion as per the usual hardware saws. The blade is actually dull; covered in blunted serrations. But then again, a saw is still a saw through the eyes of the patient. The deafening noise that it makes while turned on didn’t help to alleviate her anxiety either.
After much grunting (from us) and much yelping (from the patient), the cast came loose sometime later. Swelling’s going down, and no recurrence of any numbness. Yippee.
I went to work in a dark-coloured shirt with dark blue pants. Left work looking many shades lighter with plaster cast powder all over me, accompanied with several white handprints on my bum (absent-mindedly dusted my hands on my pants). Looks funky though.
Random bit #3 : “Let’s go raid some towns!!”
Naw, it’s not a mad patient. It’s just one of the my fellow colleagues. I was in the ED and I caught sight of this tall lanky guy waving at me from across the room. I haven’t seen this fella for ages. He looked like he was about to burst with some fantastic news; hopping over with a huge grin on his face. The conversation went somewhat like this :-
Me : Hello! Whatcha doing here? *He’s normally in the ward*
Him : Oh no just accompanying the resident to see this patient. GUESS WHAT?
Me : Ah?
Him : I got my priest to level 65++!!! *enormous smirk*
Me : OH WOW! Which server are you playing at?
Him : Frostmourne. You should come and join too!
Note : The conversation was peppered with Warcraft-speak. I used to have a few characters on the World of Warcraft; once upon a time I was fairly active on my server. I froze my game account 1-2 years ago as I was having my exams and didn’t really pick it up again since.
Me : Hmm but I’m working funny hours, and I’m always catching up on sleep. Not too sure if..
Him : AW COME ON! My group is a good one and we’re doing a lot of dungeons. I mean, we have a good healer *pauses to acknowledge his priest*, we have a tank etc.
Me : Are you Horde?
Him : Alliance.
Me : MAN, I would wanna go Blood Elf!
He gave me a mock frown. If I’m taking up a Blood Elf it would mean I’d be playing against him instead as we’re from opposing factions. I told him I’d consider joining if I have enough time on my hands. Sleep has become increasingly scarce as I’m working, and I think a few more hours of sleep would edge over a few hours of Warcraft anytime (although I must admit, Warcraft won this face-off many times when I was still in med school).
We bid farewell and he left. My consultant came up to me, looking alarmed.
“WAS THAT YOUR PATIENT WHO JUST WALKED OUT??”
“Oh no no..that was a nurse.” I explained. He wasn’t wearing his uniform and he kinda looks the part of a patient about to pull a runner. “He carries an ID tag, just that..um, he turned up in full winter gear today. I know him, he’s the staff”.
The consultant looked somewhat amused. “Well, can’t tell the difference”.
Random bit #4 : What the…?!?
I was driving home one day from work. It was just after I’ve pulled a late shift and the roads were quiet. The car which was in front of my on the highway changed lanes and started slowing down considerably. He has deccelerated so much so that I’d be passing him very quickly. I stole a glance over as I overtook him.
Ah the bastard. He was making a really vulgar gesture at me. He had intentionally slowed down his car to perform his lil show. I saw him gesticulating once, and that was it.
I drove my normal speed; leaving him behind. I thought that was the end of it but I was wrong. The bored fella actually sped up right till he was parallel to me, and repeated the same idiot act again hoping I’d look over and be offended.
I continued my journey home, feigning being oblivious to him. It started to get really irritating as he got into this repetetive act of keeping up with me till we’re parallel – just to take his hands off the steering to rudely gesture across. This kept going for the next 10km approx. Geez.
In the back of my mind, I did think about what a horrendous shocker it’s gonna be for him if I’d suddenly pull out a gun and aimed it at him. It’d be almost like a scene from some movie where the street punk gets his reckoning. Oh well.
In reality, the most that I could do was to applaud his performance with the one finger salute. There were a few moments when I’d ALMOST flash the finger – except that the last thing I needed at that time of the night was to get into more trouble. So regretably, no.
Random bit #5 : Kindly ignore the runaway patient, thanks.
I was in the ED explaining to a patient’s family regarding his prognosis. Both wife and daughter were listening intently when all of the sudden there was a scream followed by a flash of white.
To my amusement, a female patient had just hopped out of her bed and begun chasing her nurse. The flash of white that I glimpsed was her half-undone hospital gown flailing after her. I shall refrain from commenting on the colour of her undies here.
I laughed sheepishly (the “ehehehe” kind). The daughter quickly resumed the discussion after a quick shrug whereas her mum spent the next few seconds looking over the yonder with that distinctive W.T.F. look on her face.
Random bit #6 : YOUR PENIS, I SAY!
An elderly gentleman came in to the ED with a really tender lower abdomen. He hasn’t really passed much urine over the past few days and we’re guessing he’s in urinary retention. I could feel his bladder was as huge and as solid as a rockmelon; he needed a bladder catheter in real quick.
Me : Okie you’re gonna need a catheter in your bladder. We need to drain the urine.
Patient looks at me wide-eyed.
Me : Oh, it’s a draining tube we’re going to insert up to your bladder. The pain’s from the retention.
Patient shook his head slightly and his voice boomed, “I CAN’T HEAR YOU I AM DEAF”.
The nurse poked her head between the curtains and gave me a sympathetic smile. “You’ll have to shout”.
Oh. I raised my voice a few times, getting louder with each subsequent attempt. He’s still shaking his head.
Patient : YOU WILL HAVE TO SPEAK UP DOC.
Me : I..uh…okie. YOU NEED A CATHETER. CAN HEAR ME?
He nodded. Good.
Me : WE NEED TO DRAIN THE URINE. TUBE UP YOUR BLADDER.
Me : I’LL GO GET THE EQUIPMENTS. BE RIGHT BACK.
He smiled and settled back in bed. When I got back, he’s still dressed in the sweater and jeans that he came in with. It’s be easier if we get him in a hospital gown (easy access, ahem!).
Me : YOU’LL NEED TO CHANGE INTO A GOWN.
Patient understood and removed his sweater. Next thing I know, he had the gown on with his jeans still underneath.
*The following conversation took place behind closed curtains but within a public observation ward. I’m pretty sure everyone within 10 feet could hear us as we were both shouting above the usual background chaos of the ED.*
Me : YOU NEED TO TAKE YOUR PANTS OFF.
Patient : YOU WANT ME TO TAKE MY PANTS OFF?
Me : YA THE CATHETER NEEDS TO BE TRAINED THROUGH YOUR…*points to his groin*
Patient : TUBE NEEDS TO GO UP WHERE?
Me : THROUGH YOUR PENIS, AND INTO THE BLADDER.
Patient : PEE-WHAT?
Me : …THE PENIS. URINARY TRACT.
Patient : OH I GET YOU. SO I TAKE MY PANTS OFF?
Me : YES PLEASE.
I was trying horrendously hard not to laugh. I could hear the few patients next door giggling, and a senior colleague of mine going E-HEE-HEE-HEE around the corner.
Random bit #6.5 : YOUR PENIS, I SAY (II)
I begun the procedure by prepping the the gentleman’s groin area with some antiseptic. Once done, I had to carefully retract the foreskin to visualise the uerthra.
Honestly, it’s not easy to retract the foreskin once it has been swabbed with some alcohol solution. Pardon me, but it keeps ‘wiggling’ (for lack of a better word) back up and obscuring the urethral opening. In practice, we can only use one hand to manipulate the foreskin as the other hand is ‘sterile’ and all contact is restricted to catheter handling.
I had a few slippery attempts; the scene equally as awkward as it was amusing. Out of goodwill, the patient grabbed his previously-cleaned penis and retracted the foreskin.
*All verbal exchanges were done at a VERY HIGH volume as the patient is, well, deaf*
Patient : HERE LET ME HELP YOU.
The nurse groaned. I groaned. The patient had just contaminated the procedural area and we’d have to swab him again.
Me : OH NO LET GO. YOU CAN’T TOUCH IT.
Patient : HUH?
Me : LET GO OF YOUR PENIS SIR.
Patient : I LET GO? BUT THIS IS EASIER!
Nurse : NO NO WE HAVE TO CLEAN IT AGAIN.
Me : YOU JUST CONTAMINATED IT.
Patient : OH SORRY. I WANTED TO HELP.
Me : IT’S OKIE, JUST UM, SIT BACK.
I just had to laugh after that. It must have looked really peculiar and hilarious; to have the few of us shielded behind the curtains for the patient’s modesty/privacy but yet resorted to yelling out every single explicit detail. The irony.
Random bit #7 : To war with the finger
Yes, it’s the rectal exam. I happened to be performing one in every 2-3 patients lately. There was a shift where I believed to have probed the behind of every single patient I’ve seen – mainly elderly patients with bleeding from their behinds.
It isn’t a very tedious nor a difficult task to do, except that you’ve gotta be careful for yourself. You wouldn’t want to finish off a rectal exam getting excrement streaked on your sleeves. Given that rectal exams are unpleasant, patients tend to be anxious and they may tense up their abdo without realising it. When this happens, half the time this would induce a ‘mini propulsion of bowel gas’ (yup, the fart) causing any semi-liquid stools to be forced through between the anal spinchter and your finger.
What’s on the other end of your finger? You.
I have seen a senior doctor getting sprayed over his shirt and tie by the glorious brown stuff. It’s funny when you’re not on the receiving end, I must say.
What I’d usually do nowadays is to get a thick waterproof napkin; partly to shield the bed as well as to shield myself. I’d toss all the paraphernalia that’s hanging around my neck (ID tags, steth, pen, etc) and roll my sleeves way above the elbows. Double gloving is the order of the day when it comes to the hand that would be doing the honours. I’d often take a step back to estimate the ‘predicted faecal projection distance’ so I’d know how much I’d have to lean away.
One thing I didn’t mention, is that every rectal examination begins with the inspection of the anus.
Given that it’s usually not a very visible area (hence the term ‘stick it where the shine don’t shine’), we’d have to peek at it really closely. It is during this time that I would be mentally chanting “Please don’t fart, please don’t fart, please don’t fart…” over and over again.
It may come across as funny here but I’m pretty sure anyone would’ve wished for the same thing if they’re in my shoes. The only thing worse than getting your shirt sprayed with stools… is to catch it with your face.