Tuesday, February 17, 2004

Eucalyptus: Your question on the Forum Page complaints deprived me of some sleep yesterday. :) Yes, I cut the letters out. EVERY SINGLE ONE OF THEM. This is gonna be a long post, but hey, hopefully it'll be a fruitful discussion.

CASE #1 -- Mr. Lee Cheow Poon's father, August 2003

The complaint that started it all:

"On Aug 3 last year, my 79-year-old father fell at home. I didn't think much of it then as my mother called and said he was none the worse for it.
However, the next day, a staff member of The Salvation Army's Day Care Home for the Aged in Bedok where my father spent his day called to say that he might have suffered a stroke as he was not his normal self.
On hearing this, I rushed down to the Salvation Army and sent him Singapore General Hospital's A&E Department. He was very quiet and had a blank look. He also had difficulty walking.
After a rather long wait, we saw the doctor, who sent my father for X-rays of the hip area. I told the doctor about my father's unusual behaviour and also about what the staff at the home said about him possibly having suffered a stroke.
The X-rays showed no fractures and, for reasons that I still do not understand, the doctor asked me to take him back 3 days later for a scan to see if he had suffered a stroke.
I brought him home later int he afternoon, only to have him collapse in a heap at his bedside at about 4pm. He could not move at all.
I called for an ambulance, which sent him to Changi General Hospital where he was later diagnosed to have suffered a stroke.
He stayed in hospital for about a month, after which my family sent him to St. Andrew's Community Hospital for rehabilitation. His left limbs had been left immobile as a result of the stroke. Sadly, this did not improve his condition and he is now bedridden.
It hurts when I think about what mimght have been if the doctor had paid attention to what I said and ordered the scan immediately. My dad could have continued to lead a fruitful life.
Nothing can be done for him now but if highlighting this incident changes the attitude of SGH towards other likely stroke victims, I would have gained some measure of satisfaction from writing this letter."

-- Mr. Lee Cheow Poon ( 5 Feb 2004 )

The SGH Reply:

"We refer to the letter (above). We are sorry to learn that Mr. Lee's father suffered a stroke upon returning home from the hospital. We have investigated the matter and would like to clarify the medical management of the patient. Mr. Lee's father was examined promptly by the doctor at our Emergency Department last Aug 4. On presentation, he was conscious and able to give his medical history. His chief complaint was pain over the right hip as he had had a fall at home the day before and had injured his right hip.
During the consultation, the patient did not complain of any weakness and was able to walk. As there was no clinical evidence of a stroke, a CT scan was therefore not ordered at that time. He was thus treated for his fall.
However, in view of the patient's age, history of fall and Mr. Lee's concern about the possibility of stroke, the doctor scheduled a follow-up outpatient appointment for him. Mr. Lee's father was to be evaluated by a neurologist on the third day. Unfortunately, he suffered a stroke at home on the same day.
We empathize with the emotional distress experienced by Mr. Lee and his family. We will be glad to meet Mr. Lee to clarify any further concerns."

-- Assoc Prof Tay Boon Keng, Chairman Medical Board, SGH ( Feb 7 2004 )

Mr. Lee's response ( or more accurately, retort ):

"I refer to Assoc Prof Tay's reply. Some of his statements are very misleading.
Firstly, he said my father was "examined promptly" by the doctor. This leads one to think that my father was attended to immediately, or at least quickly, upon his arrival at SGH.
We waited for more than 1 1/2 hourse before being attended to. In between I had to leave Dad in a wheelchair at the A&E Department for a much-needed lunch, having skipped breakfast that day.
If I could afford to take time out to walk to a canteen, have my lunch, walk back to the A&E Department and continue to wait, I would hardly term it as "prompt".
Secondly, he wrote that my father could walk. From the time Dad alighted from my vehicle to the time he left the hospital, he was confined in a wheelchair.
At no time during the consultation with the doctor did my father rise to walk. Nor did the doctor instruct Dad to show him that he could walk. The doctor did not see my father walk, period. So how did Prof Tay conclude that my father was able to walk?
In fact, during the X-ray procedure, the attendant and I had a great deal of problem trying to get him out of the wheelchair and in position as Dad was complaining of pain.
Also, the procedure had to be repeated because the doctor, after seeing the results, said that the X-rays were not taken according to his instructions.
When the procedure was carried out a second time, I had to don a heavy lead jacket in order to go into the room and prop Dad up in an awkward position so that the X-rays could be taken.
Thirdly, Prof Tay wrote that my father was "conscious and able to give his medical history". I accompanied Dad throughout the consultation and never left him alone with the doctor at any time.
Dad never volunteered any information. I was the one who was answering most of the doctor's questions because Dad remained very quiet and had that glazed look throughout.
As I wrote in my earlier letter, I told the doctor about Dad's unusual behaviour and about what the staff at The Salvation Army said about the possibility of him suffering a stroke.l
How is it that The Salvation Army could diagnose Dad's condition so accurately and the good doctor could not?"

-- Mr. Lee Cheow Poon ( Feb 11 2004 )

SGH's 2nd reply:

"We refer to the letter above.
We apologize if there had been any lapse in communication. As the incident took place more than six months ago, we seek Mr. Lee's understanding that we could rely only on the notes documented in the patient's case file for our reply.
We appreciate Mr. Lee's valuable feedback and have given him our assurance over the phone that we have taken his feedback to heart. We have always had clinical protocols in place for the diagnosis and management of stroke patients.
However, we are reminded through Dr. Wee Lee Loong's letter that it can be extremely difficult to diagnose a stroke the minute it happens. We have stepped up efforts to be vigilant at all times, especially when screening potential stroke patients.
We have given our contact person's details to Mr. Lee. We would like to extend our invitation once again, should he wish to meet us to further discuss his concerns."

-- Assoc Prof Tay Boon Keng ( Feb 14 2004 )

And here's Dr. Wee's letter, dated Feb 11 2004

" I refer to the letters on stroke patients. The practice of medicine is a science yet, in many ways, also an art. This is because illnesses do not always present themselves in either black or white; very often, they present themselves in shades of grey, eventually progressing to black.
While it is every doctor's aim to diagnose a stroke early, the difficulty lies in the fact that early manifestations of stroke -- within the hour or so -- may not always show the classical symptoms of weakness, numbness or change in mental state.
A comment was made that the early treatment of stroke involves lowering and controlling the blood pressure [ I will transcribe these in a separate post -- Jen Jen ]. There are actually two spectrums of stroke. The haemorrhagic ones which bleed, caused by a rupture of the blood vessels in the brain, and the ischemic ones, caused by a clot in the vessels, depriving brain cells of invaluable nutrients and oxygen.
Management of the former would involve judicious control of the blood pressure, and perhaps the option of surgery, while management of the latter would entail allowing a high blood pressure kept within safe limits. A precipitous drop in the blood pressure during an ischemic stroke can starve the brain of more nutrients, resulting in more detriment than benefit.
It is therefore unwise and potentially dangerous to expect paramedics to make a judgment call prior to a brain scan.
Presentation of illnesses in the elderly population can be extremely atypical at times. It is not always prudent to subject elderly patients to a battery of brain scans, chest X-rays, liver scans, and serial blood tests.
Ultimately, a high index of slinical suspicion, couples with a suggestive history, and appropriate tests are required to clinch the right diagnosis.
Therefore, it can be extremely difficult and perhaps even impossible to diagnose a stroke the minute it happens."

-- Dr. Wee Wei Loong ( Feb 11 2004 )

And if you're still with me after all that, here're a few points for FRIENDLY debate. ( Yes, key word in capital letters, ahem. )

1. Did the SGH A&E doctor miss the diagnosis?

From Mr. Lee's accounts, his father appears to have become aphasic after the episode. To the non-medical readers, this means he had problems with verbal communication ( in this case, he couldn't even speak, aka expressive aphasia ). Some people have receptive aphasia -- they can talk fine, but are incapable of understanding what you say. Some others have global aphasia, which is a combination of both. Aphasia is one of the so-called alarm bells in stroke patients, especially the elderly. It constitutes a change in mental state, together with other signs such as apathy, drowsiness, even agitation, confusion, visual and auditory hallucinations ( though these can also occur in cases of sepsis and electrolyte disturbances ).

I'm trying to recall if I was ever taught the importance of baseline mental state in medical school. I don't recall it being covered, but if anyone can refute this, please inform me quickly so I don't end up giving the wrong impression. The importance of a person's premorbid status was only drummed into my head during my housemanship internal medicine posting at CGH. I was lucky, 'cos CGH Medicine isn't subdivided into Neurology, Renal, Gastroenterology, Haematology, Respiratory and the like. We got to care for everything from stroke to gastroenteritis to renal failure and asthma, so baseline mental state was frequently asked during initial clerking.

Perhaps the SGH doctor in question lacked this experience? We know ERs in Singapore are mostly run by medical officers, some of whom may have had only a year of housemanship and another as an MO ( doing who-knows-what posting ) under his/her belt, before being thrust into a warzone of medical, surgical, orthopaedic and paediatric emergencies, some of which require a very sharp eye and admirable clinical acumen in order to diagnose correctly. Qualified ER physicians are trained to develop the necessary skills for this vital task, but they usually cover the resus and critical care areas, not consult, where Mr. Lee's dad was examined. Not having adequate experience can result in missing a diagnosis, or inappropriate managment. The important thing is, WHEN IN DOUBT, ALWAYS CONSULT A SENIOR. This could not be stressed more in the ER setting. But of course, not every MO does this. Whether it's out of ignorance, arrogance, or an insanely busy shift in Mr. Lee's father's case, we will never know.

Bottomline: Stroke was not definite in this patient. But it sure was a possibility.

2. Why the discrepancy between Mr. Lee's account and the A&E documentation of events?

I have no insider knowledge, so I don't want to speculate. However, if we consider Prof Tay's explanation, it certainly seems as if the doctor's version is the total opposite of Mr. Lee's. Here's the deal: the A&E notes were entered at the time of consultation back in August 2003, while Mr. Lee's account is made 6 months after the fact. I don't see why Mr. Lee would give an inaccurate description, if indeed it is that. On the contrary, the memory appears to be etched in his mind forever. This is something I just can't put my finger on.

3. Why the delay in the complaint?

Incidents like this almost always have a trigger, and who can hazard any guesses here? A sudden surge of anger, a comment ( innocent or deliberate ) from someone, maybe reading an article in a magazine somewhere, or a similar experience recounted by a friend or relative -- anything is possible. Again, this is something we can't confirm, but the half-year delay, to me, makes this letter sound suspiciously incited by an outside force. If Mr. Lee was so disturbed and concerned, why didn't he lodge the complaint from the word go? Why wait 6 months? Why now? He never did say.

4. An incorrect statement

"... but if highlighting this incident changes the attitude of SGH towards other likely stroke victims, I would have gained some measure of satisfaction from writing this letter."

This is the only issue that I feel very strongly about. People who read Mr. Lee's letter may get the wrong impression that SGH A&E makes it a habit of not diagnosing strokes, whether obvious, likely or remotely possible. My reply to the non-medical readers, and especially the press, is that SGH does not have an "attitude" towards possible stroke victims, or any other type of patient.
At triage, the nurse is the first to see walk-in cases. If you're sent over via ambulance, you get pushed into critical care immediately, regardless of your condition or complaint ( ie. even minor infections or trivial trauma gets seen in there, AS LONG AS the paramedics bring you in ). Mr. Lee's dad was seen in consult because (1) he was brought by his son, (2) in stable condition, and (3) not exhibiting overt signs of a stroke. If the next thing you expect is for nurses to do the diagnosing, then you are being unreasonable. ER nurses are already among the most astute and intelligent of their cohort. I've met a few who can read ECGs and tell you when a patient "just doesn't look good" ( their way of saying s/he needs to be seen ASAP ). Most of the senior ones are well-trained in advanced resuscitation, and invaluable in assisting doctors as they handle heavy caseloads on a daily basis. If there had been a real need to up-triage Mr. Lee's dad to critical care, I'm sure the nurse would've done so.
Waiting times in consult are, of course, longer than those in resus / critical care. The queues at SGH are long, and patients often hail from the Renal, Haematology and Oncology departments, among others. These can have a long list of medical conditions with overlapping features. So a simple case of fever isn't "just the flu" anymore -- it could be neutropenic sepsis, peritonitis from the dialysis catheter, or a serious infection of unknown origin due to the patient's compromised immunity from chronic illness. Such consults require detailed history-taking and examination. In capable hands, the case can be disposed of in 10 minutes. In more junior ones, up to half an hour, +/- a senior consult. Throw your usual cough/colds, lacerations, fractures and foreign bodies in the eyes/ears into the whole mix, and you're talking an average waiting time of at least 30 to 60 minutes. Maybe 2-3 hours during very busy periods. 1 1/2 hours, to me, is already pretty decent.
Next, SGH's CT head protocols. Let me say right now that if a stroke had been suspected at all, and the senior doctor on shift made aware of it , the scan would most definitely have been done. Again, I repeat that Mr. Lee's father appears to have been seen by someone who was probably an MO, who DID NOT discuss the case with the ER physician, and thus dispensed with his own management as he saw fit. If a senior had been consulted, he may or may not have ordered the CT stat ( a change in mental state doesn't constitute a stroke, as mentioned earlier ). BUT Mr. Lee's dad would have been admitted, AT THE VERY LEAST. It all depends on the senior's discretion. I've had patients undergo CTs for much less -- a middle-aged fellow with no history of head trauma once presented with one episode of being unable to stop walking, and knocking against a wall because of it. No neurological deficit, fully alert, speech normal. I spoke to my consultant, who immediately approved the scan. The result? A subacute subdural haemorrhage.

I too empathize with Mr. Lee's predicament. My late uncle died from a haemorrhagic stroke in 2001, after being bedridden and tortured by contractures and pressure sores for more than a year. It's never easy, watching a loved one suffer. He was my favourite uncle, and my mother's favourite brother. We were extremely close, and his stroke came only days after he had just comforted me during my traumatic breakup. I thought I couldn't possibly take any more pain, and seeing him awake yet unable to speak, shedding silent tears as we stood at his side holding his hands, haunts me to this day. His diagnosis wasn't missed because he presented so dramatically -- sudden loss of consciousness then sinking into a coma -- but if it had been missed, I wouldn't have been happy either.

But let's not lose sight of the bigger picture here. Mr. Lee's putting the blame on the hospital is incorrect. Misguided, I'm sure, but still wrong. It's interesting that he chose this particular time to finally voice his concerns -- he says he gained "some measure of satisfaction", but doesn't he also realize that the delay may have put other stroke victims ( and their relatives ) at a disadvantage as well? 6 months is a long time, you know.
Non-medical people don't know how the system works. Heck, even doctors don't know how other hospitals work if they haven't rotated through them before. Making sweeping statements in a national paper is irresponsible. And not going through the proper channels ( ie. the hospital's clinical services / corporate affairs departments ) first is just plain jumping the gun.

Last but not least, The Straits Times could be more discerning with the missives it decides to publish. Considering it is an organization that prides itself on reporting the truth, the Forum Page editors are being frighteningly lenient with complaints involving medical personnel. If their aim was to get a major reaction, then bravo, they've succeeded brilliantly. But let's not forget the reactions from the doctors, nurses and paramedics as well -- people whose jobs are to save lives, sometimes putting their own at risk in the process. Public opinions of healthcare workers reached an all-time high during the SARS epidemic, but see how quickly the appreciation has dissipated less than a year later. Mr. Lee's letter even caused a sudden onslaught of similar complaints last week, which again the Forum Page editors opted to print, and which exhibited misconceptions about the diagnosis and proper management of stroke, misconceptions that the editors glaringly knew nothing about, or chose to ignore. I will transcribe and discuss these letters another day, after you've digested this lengthy entry of mine. :)

Anyhow, for your information, I will be emailing the Forum after this to direct them to my post. Thanks for reading.

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