The Emergency Medicine Posting

Salam.

The Emergency Medicine posting is the last piece to the whole housemanship experience.

HoSHAS Emergency Dept a.k.a the de facto hospital information counter.

During this posting, one will learn, experience and manage the whole spectrum of medical diseases as a preparation for MOship. When I say 'spectrum', I mean all diseases and conditions covered during the five previous major postings, from the mundane outpatient cases to the adrenaline-inducing emergency cases. 

Think oneself as a junior MO instead of a final-posting HO to get the brain firing up in preparation for the wild world of district posting.

So, that's why it's important to familiarize oneself with the common cases, procedures and drugs during each posting. Alas, that epiphany only comes the first time you see a patient in the consultation room and wonder what the heck you should do with such cases. Before you experience that regret, I'm telling you now: jot down important notes in a small notebook during each posting. By the time you come to A&E, you'll avoid significant anguish when you have five notebooks readily available all the time.

I prefer to use the abbreviation A&E which stands for Accidents & Emergencies (it unofficially stands for Anything & Everything as evidenced by the retarded number of unnecessary green zone cases). ED which stands for Emergency Department sounds impotent. 

The A&E is divided into red, yellow and green zones plus an observation ward. Patients who come to A&E are triaged accordingly. Triaging is one of the basic principles of Emergency Medicine. All A&E staff can and will do it anytime/anywhere. Its purpose is to determine who deserves prompt treatment and who doesn't. 

For example, a 40-year old smoker presenting with chest pain:

• If he were breathless and clutched his chest, the triage MA will, without asking a question, automatically think of myocardial infarction, grab a wheelchair and rush him straight to the RED zone. 
• If the same patient comes walking in and complains of chest pain, then he will be sent to the procedure room first for ECG then re-triaged depending on the ECG (or sudden deterioration depending on your luck). If the ECG is mildly abnormal or vital signs are not stable (e.g. very high BP or tachycardia), then he/she will be sent to the YELLOW zone for further workup.
• If the ECG is normal and the vital signs are normal, he/she will be sent back to the GREEN zone for proper consultation.

That means if you come with fever, cough and sneezing, please shut up and wait while we attend to guy with the broken neck or the lady with excessive menstrual blood loss. 

Empathic pain - can you feel it?

There are other red flags signs and symptoms that warrant immediate management e.g. unconsciousness, fitting, or very rapid breathing. Pregnant ladies in late pregnancies involved in non-obstetrics conditions are also sent to the A&E. Referrals from KK and smaller hospitals also get the same triaging; they are usually referred for further workup or further management.

The UK NHS Choose Well campaign aims to reduce unnecessary A&E cases and hence, the posters above. But can such campaigns work in Malaysia? Can people recognize simple URTI, AGE or allergic reactions? Do they know what medications they need and are usually prescribed? The answer is no, yes, yes. People will still flock to the A&E because they want the best treatment for such ailments which is a government MC.

Typical day in the green zone.

As for my 4-month HO experience, I found that each zone has its own learning curve. The red zone is a place for immediate diagnosis and management; the patients have clear-cut symptoms and signs; treatment usually follows guidelines e.g. ACLS for heart cases, EGDT for septicaemic shock and primary/secondary survey for trauma. The yellow zone patients are usually stable and have masked or less dramatic symptoms; it's a place for thorough examination and investigations; if you miss something, it will come back to haunt you. The green zone is where the drama takes place; patients who don't understand triaging and complain about the long waiting time mentally write their complaint letter in the green zone waiting hall.

Once a life-threatening condition has been ruled out or unstable patients have been treated and stabilized, the A&E team will refer the case to a primary team. While most cases are usually accepted and admitted, there are times when cases are rejected or asked to refer to another team first. Sometimes, argument ensues between teams when both teams don't want to accept a case. When that happens, we sit back and enjoy the show.

The end of Emergency Medicine posting signals the separation of friends, the trial of the bonds forged during hardship and stress, the pursuit of further career advancement, the end of the gauntlet of clinical life and the beginning of a life filled with responsibilities.

Last day in HoSHAS. Will be back as paeds trainee lecturer at USIM.

Good bye and good luck, peeps!

The Fasting Month

Salam.

I suppose it's not too late to wish everyone a blessed Ramadhan.

IFTAR AT WORK

For me, it's my third time as a HO. The first time was during tagging in medical posting. I had to break fast with dates that I snuck in my white coat while clerking new cases during Iftar. Now in the emergency posting, I sneak out to a wholesome meal while clerking new cases during Iftar.

It's all about prioritizing and time management ;-)

IFTAR AT HOME

Whenever I get the time (after NO and working PM or ON the next day), I'll go back to Bangi to break fast. I've been coming back home a lot these days. Usually by express bus followed by the LRT.

Aim: to meet my daughter but more importantly, she gets to meet me.

Plus, with the missus occupied with her finals these few weeks, she could use the rejuvenative sleep that's usually denied by the nocturnally active baby. So that's where I come in - I play with my daughter in the middle of the night.

After all, who could resist this cute face nudging you to entertain her in those ungodly hours?

The Real-life Medical Syllabus

Salam.

Today is my 57th day at work.

The wall art reads, "Dr Yusoff was here." 

I realized that I haven't been writing about the medical posting itself.

Internal Medicine in the real world is all about medical emergencies. And when we say medical emergencies, there's only two words associated with them - Sarawak handbook.

It's the ultimate guide to medical life, used by MO's and HO's everywhere.

What you find in there is what you'll find out there. From the very dramatic status epilepticus to the very silent hypertensive emergency, every topic is covered and presented well. Plus, the mid-posting and end-posting assessments will cover medical emergencies usually.

Another awesome mini textbook is the Oxford handbook - complete, concise, can fit in the white coat pocket.

If you're tech-savvy, then your smartphone should already have Medscape.

SYLLABUS

ACS (UA, NSTEMI, STEMI), CCF, APO, CVA (ACA, MCA, PCA; SAH, SDH, EDH), AEBA, AECOAD, URTI, CAP, HAP, HCAP, PTB, DM, DKA, HPT, DF, ARF, CKD, CLD, AGE, UTI, RVD - to put it simply, those with abbreviations are encountererd on a daily basis*.

My post-shift jajan binge collection - also encountered on a daily basis.

The main diseases need to be understood thoroughly - from the various presentations to the investigations to the management and progress.

Honestly, it's hard to focus on the subjects of the posting if you're a first poster since you'll be more focused on adjusting to the system and the associated life (or lack thereof).

To overload or not to overload? - that is the question. 

The management part is a bit tricky in the beginning, but after a few encounters with the same disease in a variety of presentations, it'll become second nature. Understanding the disease process and pharmacodynamics of the medications will help tremendously, rather than blind memorization of the treatment.

So kids, learn your stuff well while you still have the free time.  

 Free time well-spent.

It took me around one month to get settled in - even then, I still get scolded at times for reasons associated with lack of comprehension of (and adaptation to) the system.

Holding on to important things in the crucial moments. 

As for the compulsory procedures, my logbook is still free of signatures (and my midposting assessment is next Monday, haha). So far, I've done one chest tube insertion and one peritoneal tapping. And oh, countless CPRs (personally managed two resuscitations by myself while the MO is busy somewhere else).

Learning the system, one leaf at a time.

There's a lot to cover in medical posting - and honestly, I don't mind a one-month extension as I can get more medical exposure and training.

*This list is not exhaustive - I can't find an abbreviation for epilepsy, leptospirosis, melioidosis, deliberate self-harm (paraquat, organophosphate, corrosive agent ingestion), alleged snake bite, dehydration, non-compliance. And let's not forget the medical emergencies.

The First Eid As A House Officer

Salam.

I hope it's not too late to say Eid Mubarak, everyone!

Today, I'm on my ON shift; it starts at 10pm until 10am tomorrow.

So I usually use the free time I have during the day to 'live' a little - I wash my clothes; I buy grocery supplies; I edit the pictures I've snapped and share them with you people; I write this blog; I take a joyride on the scooter, letting the road take me on an uncharted adventure through Kampung Paya Luas behind the hospital; and many other stuff unrelated to Medicine.

RAYA

Initially I didn't plan on getting any Raya leave as I've been taught that sacrifice in the early years of medical profession is a given.

But then, during the departmental Raya meeting, my off day was coincidentally on Raya day 1. So I thought, I might as well get leave on Raya day 2, so I can spend my last Raya as a single person with my family.

Iftar as a single person.

For my department, getting an off day meant working the ON shift the night before. In other words, I was to work on Raya night amidst the happy Takbir and cheerful firework sounds in the night air. Oh, how it'll hurt.

So I informed my parents of my two-day leave and Dad planned to come and fetch me after Raya prayers. I planned to finish my work earlier and leave for prayers earlier (at 9am). I was expecting little work on that night.

Usually as Raya day approaches, the admissions would drop, chronic patients would request for AOR (at-own-risk) discharges, and cases at A&E would request to not be admitted.

But not this year.

Iftar at departmental level.

When I reported for duty, there were more than 10 new admissions that night. What the..!

That's the number of admissions on a normal day until midnight. As it turned out weirdly this year, patients requested to be admitted, not many patients requested for AOR discharge, no deaths and no terminally ill patients. So the ward was choke-full of patients on Raya night.

It's not a problem to clerk new cases, manage them, take blood and present the cases to the MO. Plus, the specialist on-call planned to come the next morning. So, no pressure there too.

The problem was taking the routine morning blood for tests.

BLOOD-TAKING

That early morning, after finishing rounds with the MO (total new cases: 17), I only started to collect blood at 6am. Blood collection by a junior HO in the medical department usually takes 5 hours if done alone.

I take my jajan breaks and pray Subuh when I got bored or pissed off at veins of an IVDU patient.

I favoured the blue needle since it was small and less traumatic to patients, but I found that it was slowing me down if I didn't get the vein on the initial prick. Fatefully, the supply of blue needles on the blood-taking trolley ran out. So, I decided to use the green needle (a slightly bigger caliber needle).

Surprisingly, my work became a lot faster! It was easier to find runaway veins, hit arteries, draw blood, less sample lysis, and since they're rarely used, there's tons of them on the trolley.

But that deciding factor came too late. I finished at..

11am!

So, I missed my Raya prayers.

Dad, who came to fetch me as early as 8am, was forced to wait for me after Raya prayers for 2 hours. I felt horrible for making him wait, but he said that he made use of the spare time learning Arabic via audio CD, so I was a bit relieved.

I slept on the journey back home to Bangi.

My family spent one night and one day in Gopeng, Dad's hometown, visiting relatives, paying respect to those who've passed on and ate a lot of kuih Raya.

I'm sure my younger brothers missed the joyful mood of Raya this year but for me, I enjoyed this little time even more. Somehow, after talking to dozens of strangers, feigning interest in their lives, my communication skills with my relatives have improved.

That, or either I've matured (I don't think it's the latter).

p/s My first pay was spent on duit raya for my brothers and some smaller cousins :) 

p/p/s Me - taken yesterday. No weight loss or gain. Macho as ever.

The Ramadhan I'll Miss

Salam.

It has been a very unnoticeable Ramadhan this year.

Iftar and Tarawih prayers at the hospital lobby last week.

Rushing to review patients, adapting to the system, the core subjects to learn in each discipline - they make you lose track of the progress of this holy month.

Ordered some tarts from the nurses for my post-shift junk food binge.

I miss the gathering of friends for iftar, the spiritual nights of Tarawih and Qiamullail, the peaceful atmosphere. Heck, I miss a lot of things.

I miss my kittehs :(

But that's part of moving on.

One day, you're a medical student being looked up by society; the next, you're a junior doctor, 

a low-life, ignorant and inept.

See you guys in late September!

Things get better in the long run. Once you know your way around the system, you'll find your niche.

A mix of paper and paperless work is as confusing as a man with vertigo navigating through KL city blindfolded.

FREE TIME

The shift system allows for more personal time. Some spend it sleeping it off, others spend it with their loved ones. 

Me? I like to keep busy with my hobbies. It's one of the things that keep me looking forward to tomorrow.

When I first came to Temerloh, all my favourite activities came to an abrupt stop. It was a stressful and alien time. But after a month learning and adapting to this new phase of life, I found that I can live through this stage without that much negativity. So, one-by-one, I kick-started my hobbies.

I started off with my photography.

It's red in colour because it's hot commodity.

I snapped pictures on my smartphone regularly. I'm always on the lookout for those moving shots of hospital life. Only drawback is the medico-legal aspect of it. None can be revealed too much. 

Aside from snapping those pictures, I also look forward to the fun of editing, printing and scrapbooking my photos. You know, for my later years when I'm nostalgic and all.

Nostalgia looking at this picture and exclaiming how much hair I have back then.

For now, you'll have to be satisfied with still life. I'm still not comfortable showing pictures of sick people - especially those in dire conditions or pain.

Until then, here's pictures of dull Temerloh.

Happy Ramadhan, everyone!

The Tagging Experience

Salam.

It's been a hectic and strenuous two weeks of tagging as a first poster at the Medical Department, HoSHAS. As a tagger, I was required to work double shifts - come in at 7am and check out at 12am (but usually I finish work later than that).

Welcome to HoSHAS quarters, Block E.

The routine begins with morning HO review of patients. On the first day, I was given only one patient to clerk - AEBA secondary to UTI. I was scolded by the MO because I didn't put in any clinical plans - senior HOs were supposed to teach me the works but they were occupied that day.

Then, comes the MO review rounds. These are just refinement of HO management plans. It's during this time that I learn the most. I get to see how the MO's think and argue, and then manage.

The specialist review rounds comes later that morning. Specialist discussions are usually too deep to follow during the initial days of tagging, but slowly I caught on and asked questions.

Medical rounds usually last until lunch, stopped awhile for visiting hours, then continued in the evening.

 Hospital Information System (HIS) - berebut laptop dengan nurses untuk buat morning review.

After the rounds, it's time to work the clerical skills - writing discharge notes, calling clinics for appointments, writing referrals, tracing old notes.. stuff that will work itself out by trial-and-error over time. Here's the tricky part - all of these have to be done according to priority, some must be done before the end of the office hours.

Life in the Medical Department is a hectic one, compared to other departments. On an active day, admissions can go up to 25, ballooning up the ward, warranting transfer of old, stable cases to other wards.

My energy drink.

Here's a very brief summary of my tagging life:

On day 2, I was entrusted to cover one cubicle of 4-6 patients.

On day 3, I did CPR on 3 different patients.

On day 5, my post-HD patient developed ACS and died.

On day 8, I was reviewing 8 patients per day. Still slow.

On day 13, I pronounced the death of a patient. "Makcik, pakcik dah takde."

Death consists of five forms to be filled in.

On day 14, my newly diagnosed PTB patient absconded.

TB registry.

GETTING SCOLDED

I've been scolded a few times for my lack of sense of priority but it's an understandable fault - first timers usually don't have the same awareness, sense of urgency or responsibility.

I've been scolded for not reviewing fast enough.

"Tunggul kayu ke? Pegi la clerk new case tu."

I've also been scolded not being aware of the events in the ward, especially the acute beds.

 Items to prepare for femoral catheter insertion.

Everyone gets depressed after a scolding, especially if it's not your fault to begin with. But bouncing back is key. And also, saying sorry if you're wrong, saying sorry even if you're right.

 

Accompanying a patient's transfer to HTAA.

PROCEDURES

Things that were previously awkward to do are now staple.

"Doktor Yusoff, bed 6 cabut branula dia."

"Doktor, bed 18 tak pasang CBD lagi."

"Doktor, anaes call, cakap bed 26 tak repeat ABG lagi."

Gotta memorize what each tube is for by the end of the first week.

What hand hygiene?

But the most routine-disturbing phrase has got to be this:

"Doktor, bed 24 collapse!"

OFF TAG

Alhamdulillah, now that I'm finally off tagging, I have plenty of time to settle my unfinished business e.g. doing the laundry, stocking new supplies of food for sahur, Tarawih prayers, writing this blog, and recreational stuff.

It's a relief but a lot of responsibility at the same time. Some times, the night shift HO will be alone to take care of the whole ward. By merely hoping for the uneventful is wishful thinking; one has to prepare for medical emergencies. That's when you have to decide whether it's necessary to disturb the on-call MO.

If an ACS patient complains of chest pain, you take his vitals, do an ECG stat, give him sublingual GTN, compare the latest ECG with the old ones, review the latest blood investigations, then you decide whether to call the MO or not. If you're not sure, you can just inform him/her while giving her the important info.

That's just ACS. There's SpO2 dropping, hypoglycaemia, hypotension, fitting, etc.

But this level of clinical acumen will only improve by time. Until that time, you'll get scolded over and over again for not being able to prioritize or manage simple events.

 Blood culture company giving a talk, then freebies.

Oh, one more thing - night shift HOs have to take blood from the whole ward at 6am in the morning. If one starts at 5am, he/she will probably finish around 7-8am.

So medical students, do come and help, yes?