Reprieve!

Just started a week of annual leave. S-weet. :)

Congratulations In Order

For a good friend and A&E colleague, who just welcomed his baby boy into the world. Poor wife had a tough time though, but thank goodness everyone pulled through okay. Now if only he'd find the courage to pick the little neonate up! :)

Good wishes also go out to Hugh Laurie, who won his first Golden Globe for Best Actor ( TV Drama "House" ) 4 days ago. Did you catch his hilarious acceptance speech, where he stuffed a fistful of more than a hundred names on little strips of paper into his left pants pocket then randomly drew 3 out like a lotto? Think he thanked his hairstylist and a caterer, before moving on to his agent ( "Hmm, this isn't my handwriting." ). One of the best I've heard since Emma Thompson's Oscar speech for "Sense & Sensibility", Cuba Gooding Jr's for "Jerry Maguire", Matt Damon and Ben Affleck's for "Good Will Hunting" and Adrien Brody's for "The Pianist" ( although the kiss took up >50% of that one, heh ).

Surprise of the evening? Sandra Oh's win for her supporting role on "Grey's Anatomy" ( which, incidentally, also got nominated for Best Actor - Patrick Dempsey - and Best TV Drama ( no "House"! horrors! )). She looked equally stunned too. Not sure if she really deserved it, but heck, something for me to write about in my review.

American Idol 5

More of the same, but amazingly, still as entertaining as ever.

Loads of deluded tone-deaf Idol wannabes, with the occasional manic / effeminate ( bordering on transvestite ) / foul-mouthed character.

Can you guess who I've picked out?

2 fellows.

Both 17.

Both cute.

Both fans of the jazz genre.

One - Zachary Smits, who did a beautiful version of "I'm In The Mood For Love". Lush tenor vibrato, bedroom eyes, winsome smile, dark brown curls. No wonder Paula Abdul was drooling.

Two - David Radford, who sang "Summer Wind" ( one of my favourites, and Simon Cowell's too ). Sounded a little forced and bland, but he was trying to imitate his idol, Frank Sinatra, so it's hard to tell at this point. Definitely shows promise, especially when he crooned Dream A Little Dream in his car ( his friends listen to jazz as well, which is great ). He just needs to loosen up a bit.

Patrizio Show

It's confirmed! 22 February at the Esplanade Concert Hall. Tickets go on sale next week ( direct info from the record company ). Well worth the time and money. Don't miss!

ER Issues

Here's where I may shoot myself in the foot. :)

First, the less controversial stuff.

I saw a few "live cadavers" recently. Not exactly the Chinese New Year Dumping Syndrome as yet, but they're starting to trickle in, and it may really pour this coming week.

The lady I saw was in her 80s. Paramedics called in just before 8am at the tail end of my night shift as a standby for "drowsiness and low BP".

She was in one of THE worst states I've ever witnessed ( and I've seen my fair share of gross neglect in the elderly ). Absolutely parched, sandpaper tongue, skin that remained tented after a gentle pinch, sunken eyes and temples.

BP on arrival 60/40. Patient was gasping at a rate of maybe 10 breaths a minute. Man, she didn't look like she was going to last very long.

Good thing resus was empty at the time, so my 2 MOs and I ( plus a whole army of nurses ) went straight to work. Quick IV access, oxygen 100%, concurrent ECG and hypocount.

"Sugar's LOW," the nurse hollered.
"How low?" I asked.
"LOW, as in 'LO' on the hypocount machine. Unrecordable."

Aha! At least there was something we could treat! IV Dextrose 50% 40 ml stat, a pint of normal saline fast, and before we knew it, she turned pink, opened her eyes and nodded her head when we called her name. Respiratory rate 18 per minute. BP 100/65. She was even starting to move her upper limbs.

"Remember the old lady we saw the other day?" one of the MOs involved with the case asked me last night. "She's been discharged back to her family. But I can bet we'll see her again soon."

Or maybe her family won't call the ambulance next time.

Second, a pseudo-controversial issue.

Seems a patient got VERY worked up over some public comment made by a certain government official in the local paper, and shot in a lengthy essay detailing why s/he thinks this official's opinions are WRONG, WRONG, WRONG.

Something about a botched admission. Psychological distress caused by anticipation / anxiety / venepuncture. S/he even brought up an incident which occurred ONE YEAR AGO to further illustrate the point.

That's where I kena.

So I checked up this person's records on the computer. S/he made some sweeping statements about things I said, and turns out I remember this person quite well ( s/he has a rather unusual condition ). And besides, I'm quite paranoid where case-notes documentation is concerned, so I practically transcribed every conversation word for word.

In a word, I'm APPALLED.

The complaint pertaining to the ER experience makes up only a tiny part of the overall complaint ( which mainly pinpoints the ward ), but I managed to pick out a huge number of lies within a single paragraph.

Apparently, 20 minutes qualifies as a "long waiting time". An "urgent referral" from a GP warrants quick attention, I agree, but what s/he left out is that fact that s/he opted to wait FOUR ENTIRE DAYS before coming to the ER. S/he was so "sick" s/he managed to celebrate the Chinese New Year! ( By the way, this was the reason given when I asked why s/he didn't come to see us sooner. And yes, I typed it all in. Whew. )

Wait, there's more.

This is an educated young adult. Works in the civil service. Respected job.

But get this: I fully explained the management plan to him/her, after personally speaking to the specialist-on-call, who didn't think anything further needed to be done and requested an early outpatient review, which I thought was completely reasonable given the situation.

I ALWAYS inform the patient, or at least the patient's relatives, of the plan on discharge. I documented this in my notes ( "patient informed and agreeable" ), but s/he turns around and says I told him/her to consult the specialist on his/her own instead! Making it sound like I was totally bo-chap and negligent in some way!

Argh, my blood boiled for a full 5 minutes.

Anyhow, I submitted my reply ( no choice, since the official got a direct email and needed our answers ). But thanks to my obsessive-compulsive scribing, my ass is covered. Yay me.

Moving on...


Alex, this bit's for you. :)

So I had an interesting email exchange about the merits of direct admissions from ER to the ward versus reviews by the ward teams in the A&E prior to accepting cases.

Bottomline: There's no perfect, win-win scenario. Rather, it depends on how we adapt to whichever system we're working under.

After all, what's the use of having referrals from the ER prior to admission, if the ward teams either can't or won't review patients, or worse, refuse to accept clear-cut cases into their care, thus causing major problems for the ER and the patients themselves.

Admitting directly to the ward also has its drawbacks. I once did an Internal Med call as a house officer where I got swamped with 5 extremely sick patients at one go. There was an allergic reaction which progressed to anaphylactic shock, a severe asthmatic attack, one pulmonary oedema, another haemorrhagic stroke ( no scan in the ER, yeesh ), and a septic shock.

My MO and registrar were already mobilized, but we were hanging by a thread, and still had a whole string of other cases waiting to be seen. Details are blurry ( it happened 7 years ago ), but I probably saw the last patient of the night maybe 4 hours after s/he was sent up to the ward. Thank goodness everyone else after that nightmare bunch was stable and remained so till morning.

The ideal situation, of course, is to have all patients either reviewed by the ward teams in the ER itself, OR have them admitted directly upstairs and seen within the hour, BEFORE anything untoward happens.

What I suggest: document ER notes METICULOUSLY, call the ward teams if you're worried, maintain good relations with the various specialties, and put your foot down once in a while if it's warranted.

Here's the kicker:

True stories related by a consultant and a senior medical officer respectively.

Incident #1:

Patient has condition A. Scan done, awaiting bed in observation.

Unexpectedly, patient develops condition B. Wheeled back to resus and intubated.

Specialist A called because patient originally presented with A, so by right should go to ICU A.

But specialist A says "the nurses in ICU A cannot handle condition B", and wants the ER to call specialist B.

Specialist B, however, agrees that condition A should be treated by specialty A. Doesn't accept case to ICU B.

Specialist A called again, this time requested by the ER to come down to see patient personally ( original consult conducted via phone ). So s/he comes down, still doesn't take the case, then suggests admitting to specialty X, which has no real jurisdiction where conditions A and B are concerned!

However, specialist A speaks to specialist X and the latter takes the patient to ICU X ( will wonders never cease ).

There's a punchline though - because ICU X is full, the patient has to overflow to ICU A! So the ICU A nurses end up taking care of the same patient they're supposedly "incapable" of handling!

Har har har :)

The other case is under specialty D. An outpatient investigation is done, during which the patient develops an adverse reaction resulting in condition E.

Specialist D considers routing the patient to the ER for admission to specialty E, but admits to ward D first to expedite the process, refers to specialist E upstairs, hoping the case will be taken over.

Unfortunately, specialty E will have nothing to do with the case, preferring instead to drop in every other day to check the patient's progress.

One fine day, the patient gets condition F. VERY serious, gets intubated and sent to ICU F, managed by specialists F for 2 weeks before improving and getting sent back to general ward.

However, specialty F doesn't accept the case under their care, so specialty D asks if specialty E can take over, since condition E was the presenting problem, triggered the other complications and hasn't resolved as yet.

Specialty E says no, keep the patient under specialty D. Orders this and that, but to be carried out by specialty D, okay?

So the medical officer tells me the next time something like this happens again, don't be surprised if we end up seeing the patient in our ER.

Dude, I usually don't enjoy entertaining this sort of thing, but in view of what you've told me, I say do what you have to do. Whatever's best for the patient.

But please call ahead first. So I won't blow my top ( I scolded an oncology MO for the same thing before. Don't mess with me. ).


Ahh, I love unloading. :)


Miscellaneous

Have you heard of Bill and Barbara Pease? Some psychologist couple that wrote a bestselling book pretty similar to the "Men Are From Mars, Women Are From Venus" prototype. The Pease's effort is "Why Men Don't Talk and Women Can't Read Maps" ( I think ). Flipped through it at a salon and was pretty nauseated by some of their "statements".

Man's need to spread their seed is an evolutionary trait - ie. they can't help it! You can't blame them for wanting to sleep with everything in a skirt!

Err, yeah, right.

Equally demeaning views about women somewhere in there too. But I switched off at some point so don't ask me for examples.

I do remember what they wrote about "the perfect partner" though. Apparently a woman is safest with a "Chinese man who listens to classical music" and should stay away from "hardworking jazz pianists".

Obviously, the Peases haven't met Singaporean men before.

Hey, you could consider that a compliment of sorts. Heh. Heh.

Looks like I'm going to get set up no matter what. But I do find it interesting that this fellow's name got mentioned by 2 different people, both of whom think I'm a prime candidate for "matchmaking" purposes.

Ah well. We'll see what happens. But don't place any bets yet. :)


Photos For The Day

Just doing my part to publicize Patrizio Buanne's upcoming concert. This was taken at his showcase at the Grand Copthorne last August. LOVELY guy. :)

The rest are random pictures left over from the Italy trip. Thought they'd add some colour. Also runs with the overall Italian theme, haha.


Time for a juicy Mandarin orange. Enjoy your weekend.