Man, I wish this recommendation had come out years ago.
The one & only time I've ever done mouth-to-mouth resuscitation to a real-life human being was several years ago in my first month of work in a downtown GP clinic. Security had called up to inform us that someone had fainted & they were bringing up the lady. This was at lunchtime when I was one of two doctors on duty, the other one having gone out to lunch, & we were operating on a skeleton crew of clinic assistants.
As soon as I saw the patient's condition, I knew this was not a simple case of syncope, but that she was in cardiopulmonary arrest. She was blue, no pulse, no respiration, & probably had been in this state for at least 15 minutes judging from what the security guard told us.
Adrenaline kicked in immediately as I called for one of the nurses to help me give CPR & look for the crash cart which no one could find as the assistants in charge of "taking care" of the cart had gone out to lunch...so much for being prepared.
Anyhoo, given the urgency of the situation, I had no choice but to give direct mouth-to-mouth resuscitation while the nurse did chest compressions. Fortunately, the patient had a relatively dry mouth (could have been bad - use your imagination). Unfortunately, given that she had probably been down for at least 15 minutes, despite our continued attempts at CPR, there was no response. The ambulance medics continued CPR as they brought her to the nearest hospital.
Alas, this was not a happy ending.
Showing posts with label Docs Life. Show all posts
Showing posts with label Docs Life. Show all posts
Tuesday, April 01, 2008
Monday, October 22, 2007
Tough Calls
How does one make such a decision?
Oct 22, 2007
Weigh options when saving premature baby
I REFER to the article, 'Saving tiny tickers' (ST, Oct 11).
It is indeed heartening that medical advances allow the babies mentioned to enjoy a new lease of life.
Infant mortality has been reduced drastically because of the excellent medical care and services provided by Singapore's health-care workers.
However, we should not use the plain vanilla number of initial infant survivals as the basis of a job well done by health-care professionals.
This holds true, especially for extremely premature babies.
With advances in medical treatment, younger and younger 'premmies' are able to survive.
However, some will have disabilities, from minor to major, because of their early arrival and subsequent damage to their brain and under-developed organs.
If a baby is severely brain-damaged, where his quality of life in future is likely to be almost non-existent, should the doctor go all out to save the baby, just so he is alive for another painful day?
Or should the doctor let the baby die with dignity, through compassionate inaction?
Who should be the one to make such an important judgment call on the treatment (intensive, moderate and just enough to prolong the life, letting go) for the tiny patient?
For parents, this dilemma can be very much be like that of the relatives of a brain-dead patient.
It is therefore important that a clear standard set of rules and guiding principles be provided and adopted for extreme premmies' treatment, as this is a sensitive and grey area where emotions, and personal and religious morals and convictions play a big part.
It is important that the parents have a say in the premmie's treatment and can make informed decisions.
This is because, as parents, their decisions will be based on what is best for the baby.
Doctors should not be biased against their young patients' parents, even when the parents' views and opinions differ greatly from theirs.
Doctors should also respect parents' decision on treatments offered to the baby, even if they disagree with the parents' decision.
At the end of the day, it is the parents, not the doctors, who will have to care for the disabled child.
Thus, treatment options should be scaled towards what the informed parents want.
As a resident working in the NICU, I grappled with such dilemnae almost daily. Why save the premature, especially the severely premature, when the child eventually develops disabling conditions like cerebral palsy, bronchopulmonary dysplasia, ROP, all requiring long term medical care, with questionable quality of life. And the caregivers, having had to deal with the heartbreaking situation, are now saddled with a huge hospital bill, & look forward to a life time of probably repeated hospital stays & visits & seeing their child suffer.
But as a resident, one sworn to save lives, we pretty much did our damnedest to save even the most premature of babies until we knew that there was nothing much else we could do for him. I don't remember any one of the parents trying to stop us from doing so. I sometimes wondered why.
But then I became a parent. I then realized that the love one has for one's child, even unborn, is undescribably all-encompassing. I understand now, why these parents would want the doctors to try their damnedest, no matter how disabled or how much suffering their child might end up with. In a way, it's a selfish kind of love.
In any case, it's a tough call to make. To save or not to save. You tell me.
Oct 22, 2007
Weigh options when saving premature baby
I REFER to the article, 'Saving tiny tickers' (ST, Oct 11).
It is indeed heartening that medical advances allow the babies mentioned to enjoy a new lease of life.
Infant mortality has been reduced drastically because of the excellent medical care and services provided by Singapore's health-care workers.
However, we should not use the plain vanilla number of initial infant survivals as the basis of a job well done by health-care professionals.
This holds true, especially for extremely premature babies.
With advances in medical treatment, younger and younger 'premmies' are able to survive.
However, some will have disabilities, from minor to major, because of their early arrival and subsequent damage to their brain and under-developed organs.
If a baby is severely brain-damaged, where his quality of life in future is likely to be almost non-existent, should the doctor go all out to save the baby, just so he is alive for another painful day?
Or should the doctor let the baby die with dignity, through compassionate inaction?
Who should be the one to make such an important judgment call on the treatment (intensive, moderate and just enough to prolong the life, letting go) for the tiny patient?
For parents, this dilemma can be very much be like that of the relatives of a brain-dead patient.
It is therefore important that a clear standard set of rules and guiding principles be provided and adopted for extreme premmies' treatment, as this is a sensitive and grey area where emotions, and personal and religious morals and convictions play a big part.
It is important that the parents have a say in the premmie's treatment and can make informed decisions.
This is because, as parents, their decisions will be based on what is best for the baby.
Doctors should not be biased against their young patients' parents, even when the parents' views and opinions differ greatly from theirs.
Doctors should also respect parents' decision on treatments offered to the baby, even if they disagree with the parents' decision.
At the end of the day, it is the parents, not the doctors, who will have to care for the disabled child.
Thus, treatment options should be scaled towards what the informed parents want.
As a resident working in the NICU, I grappled with such dilemnae almost daily. Why save the premature, especially the severely premature, when the child eventually develops disabling conditions like cerebral palsy, bronchopulmonary dysplasia, ROP, all requiring long term medical care, with questionable quality of life. And the caregivers, having had to deal with the heartbreaking situation, are now saddled with a huge hospital bill, & look forward to a life time of probably repeated hospital stays & visits & seeing their child suffer.
But as a resident, one sworn to save lives, we pretty much did our damnedest to save even the most premature of babies until we knew that there was nothing much else we could do for him. I don't remember any one of the parents trying to stop us from doing so. I sometimes wondered why.
But then I became a parent. I then realized that the love one has for one's child, even unborn, is undescribably all-encompassing. I understand now, why these parents would want the doctors to try their damnedest, no matter how disabled or how much suffering their child might end up with. In a way, it's a selfish kind of love.
In any case, it's a tough call to make. To save or not to save. You tell me.
Thursday, September 20, 2007
White Coats No More
This is a great move by the UK Department of Health.
White coats off, UK docs told
LONDON — British hospitals are banning neckties, long sleeves and jewellery for doctors — and their traditional white coats — in an effort to stop the spread of deadly hospital-borne infections, according to new rules published yesterday.
Hospital dress codes typically urge doctors to look professional, which for male doctors, has usually meant wearing a tie. But as concern over hospital-borne infections has intensified, doctors are taking a closer look at their clothing.
"Ties are rarely laundered but worn daily," the Department of Health said in a statement. "They perform no beneficial function in patient care and have been shown to be colonised by pathogens."
A 2004 study of doctors' neckties at a New York hospital found nearly half of them carried at least one species of infectious microbe.
Last year, the British Medical Association urged doctors to go without the accessories, calling them "functionless clothing items".
The new regulations, which will take effect next year, mean an end to doctors' traditional long-sleeved white coats, Health Secretary Alan Johnson said.
Fake nails, jewellery and watches, which the department warned could harbour germs, are also out.
Johnson said the "bare below the elbows" dress code would help prevent the spread of Methicillin-Resistant Staphylococcus Aureus, or MRSA, the deadly bacteria resistant to nearly every available antibiotic.
Popularly known as a "superbug", MRSA accounts for more than 40 per cent of in-hospital blood infections in Britain.
Because the bacteria is so hard to kill, healthcare workers have instead focused on containing its spread through improvements to hospital hygiene.
Doctors and nurses who do not adequately wash their hands pose a far bigger risk to patients warns Dr James Steinberg, an Emory University infectious disease specialist. — AP
When I was an intern, then an MO doing hospital postings, we had to follow a dress code, which meant ladies had to wear skirts (no pants allowed unless on night call), & covered shoes (meaning court shoes, not thongs or Croc-like sandals!) while the guys had to wear ties or bow ties. It was a pain especially when, as an intern, you had to do all the scut work, running around the wards, doing multiple rounds a day, setting drips, taking blood (no such thing as phlebotomists in my day :( ).
I don't know about other doctors, but I find it less of a strain on my back to squat next to the patient's chair or bed when setting drips or taking blood (& also less risk of exposing my chest to the male patients!!!). Try squatting in a skirt. If it's a slim cut one, damned difficult. If it's a flare skirt , you end up sweeping the floor with it. And the shoes...OMG, talk about plantar fasciitis & bunions!
I used to envy the docs I saw on TV wearing those oh-so-comfortable scrubs. I wonder why doctors in Singapore can't change into scrubs when they get to the hospitals (even if they are not working in the OR), & at the end of the day, leave them for the hospital laundry to wash so that they don't bring home all those nasty hospital germs.
Besides, I think scrubs are sexier looking than street clothes.
:)
White coats off, UK docs told
LONDON — British hospitals are banning neckties, long sleeves and jewellery for doctors — and their traditional white coats — in an effort to stop the spread of deadly hospital-borne infections, according to new rules published yesterday.
Hospital dress codes typically urge doctors to look professional, which for male doctors, has usually meant wearing a tie. But as concern over hospital-borne infections has intensified, doctors are taking a closer look at their clothing.
"Ties are rarely laundered but worn daily," the Department of Health said in a statement. "They perform no beneficial function in patient care and have been shown to be colonised by pathogens."
A 2004 study of doctors' neckties at a New York hospital found nearly half of them carried at least one species of infectious microbe.
Last year, the British Medical Association urged doctors to go without the accessories, calling them "functionless clothing items".
The new regulations, which will take effect next year, mean an end to doctors' traditional long-sleeved white coats, Health Secretary Alan Johnson said.
Fake nails, jewellery and watches, which the department warned could harbour germs, are also out.
Johnson said the "bare below the elbows" dress code would help prevent the spread of Methicillin-Resistant Staphylococcus Aureus, or MRSA, the deadly bacteria resistant to nearly every available antibiotic.
Popularly known as a "superbug", MRSA accounts for more than 40 per cent of in-hospital blood infections in Britain.
Because the bacteria is so hard to kill, healthcare workers have instead focused on containing its spread through improvements to hospital hygiene.
Doctors and nurses who do not adequately wash their hands pose a far bigger risk to patients warns Dr James Steinberg, an Emory University infectious disease specialist. — AP
When I was an intern, then an MO doing hospital postings, we had to follow a dress code, which meant ladies had to wear skirts (no pants allowed unless on night call), & covered shoes (meaning court shoes, not thongs or Croc-like sandals!) while the guys had to wear ties or bow ties. It was a pain especially when, as an intern, you had to do all the scut work, running around the wards, doing multiple rounds a day, setting drips, taking blood (no such thing as phlebotomists in my day :( ).
I don't know about other doctors, but I find it less of a strain on my back to squat next to the patient's chair or bed when setting drips or taking blood (& also less risk of exposing my chest to the male patients!!!). Try squatting in a skirt. If it's a slim cut one, damned difficult. If it's a flare skirt , you end up sweeping the floor with it. And the shoes...OMG, talk about plantar fasciitis & bunions!
I used to envy the docs I saw on TV wearing those oh-so-comfortable scrubs. I wonder why doctors in Singapore can't change into scrubs when they get to the hospitals (even if they are not working in the OR), & at the end of the day, leave them for the hospital laundry to wash so that they don't bring home all those nasty hospital germs.
Besides, I think scrubs are sexier looking than street clothes.
:)
Wednesday, October 11, 2006
DNR
Here is an interesting entry about CPR & DNR in response to a New York Times article, The Last Word on the Last Breath.
I was surprised that an actual analysis was done & published in the NEJM on survival rates in CPR on TV!
I remember how dismal the success rate was during my stint in A & E oh-so-many years ago. Most of the patients who were admitted collapsed had already been down for more than 15 minutes. At that time (I don't know about now), the paramedical staff in the ambulances did not do intubations on the field. So most of the time, our efforts in the department were basically "going-through-the-motions" for a reasonable amount of time, before pronouncing death. Most of these collapsed patients had pre-existing co-morbidities & elderly or were victims of severe trauma, so our efforts were not unexpectedly futile. I remember the sickening crunch of breaking ribs while I did chest compressions, especially in the elderly & frail.
The only time I managed to bring back a patient was a gentleman in his 50's suffering from an acute exacerbation of COPD, who, right in front of my eyes, desaturated & went into ventricular fibrillation. Immediate CPR was instituted, & he was successfully resuscitated & immediately sent up to the medical ICU (whose MO was not terribly happy with accepting this very ill patient, but hey, what to do, A & E in those days were not equipped or staffed to monitor patients requiring close monitoring).
Even in the wards, many family members still insisted on going all out for the patient in spite of how gravely ill that patient was. Perhaps they didn't realise how traumatic CPR can be on an already weakened body. I can certainly understand why letting go is hard.
When my time comes, I will make sure that my family understands my wishes & let me go in peace. I admit I have yet to sign an AMD nor have I made a living will. It's one of those things which one keeps putting off, thinking that one still has time to do it. I really should get off my a** & get it done...
I was surprised that an actual analysis was done & published in the NEJM on survival rates in CPR on TV!
I remember how dismal the success rate was during my stint in A & E oh-so-many years ago. Most of the patients who were admitted collapsed had already been down for more than 15 minutes. At that time (I don't know about now), the paramedical staff in the ambulances did not do intubations on the field. So most of the time, our efforts in the department were basically "going-through-the-motions" for a reasonable amount of time, before pronouncing death. Most of these collapsed patients had pre-existing co-morbidities & elderly or were victims of severe trauma, so our efforts were not unexpectedly futile. I remember the sickening crunch of breaking ribs while I did chest compressions, especially in the elderly & frail.
The only time I managed to bring back a patient was a gentleman in his 50's suffering from an acute exacerbation of COPD, who, right in front of my eyes, desaturated & went into ventricular fibrillation. Immediate CPR was instituted, & he was successfully resuscitated & immediately sent up to the medical ICU (whose MO was not terribly happy with accepting this very ill patient, but hey, what to do, A & E in those days were not equipped or staffed to monitor patients requiring close monitoring).
Even in the wards, many family members still insisted on going all out for the patient in spite of how gravely ill that patient was. Perhaps they didn't realise how traumatic CPR can be on an already weakened body. I can certainly understand why letting go is hard.
When my time comes, I will make sure that my family understands my wishes & let me go in peace. I admit I have yet to sign an AMD nor have I made a living will. It's one of those things which one keeps putting off, thinking that one still has time to do it. I really should get off my a** & get it done...
Tuesday, September 26, 2006
Duh Moments
Duh Moment #1
Patient needs PAP Smear done. I tell her to undress & lie on couch while I prepare the equipment. I return to the examination couch & notices that she still has her underwear on.
Me: "Er...you need to remove your underwear in order for me to do the PAP Smear."
Patient: "Oh, is it? I need to remove my underwear?"
Me: "Er...yeah" (Inner Me: "Duh")
Duh Moment #2
Patient complains of headache. After taking history, I tell her I am going to check her blood pressure.
Patient: "Do you want me to take off my watch?"
Me: "Er...no." (Inner Me:"Duh")
Patient needs PAP Smear done. I tell her to undress & lie on couch while I prepare the equipment. I return to the examination couch & notices that she still has her underwear on.
Me: "Er...you need to remove your underwear in order for me to do the PAP Smear."
Patient: "Oh, is it? I need to remove my underwear?"
Me: "Er...yeah" (Inner Me: "Duh")
Duh Moment #2
Patient complains of headache. After taking history, I tell her I am going to check her blood pressure.
Patient: "Do you want me to take off my watch?"
Me: "Er...no." (Inner Me:"Duh")
Thursday, August 17, 2006
A Doc's Life - More Memorable Moments (P.S. 8)
Scenario: 4th year Med School; infectious disease rotation
At that time, the infamous Middle Road Hospital was still around (this is about 20 years ago). Patients with skin problems or STD’s were managed there. (I've always wondered about this strange combination ☺).
As part of our posting, we were supposed to go on a field trip to a red light district to see how prostitutes are “managed”. There were 3 main districts: Johore Road, Desker Road & Geylang. I think most of us were hoping to see Geylang, where it is supposed to be the most “high class” of the 3, with specially designed beds & other contraptions in the brothels (whether this is true or not, I have no idea ☺).
Anyway, my group was sent to Desker Road with a social worker. Basically, what the medical social worker needed to do was to make sure that the “workers” had been keeping up with their regular visits to Middle Road for tests to ensure that they were “disease-free”. Those who were cleared were given green ID cards, which they had to show to the MSW who did spot checks.
There is a widely held misconception that prostitution is illegal in Singapore. Well, that’s not true. As long as the sex worker worked in his/her registered brothel & was holding a valid green card, it was OK. However, if they solicited their services on premises other than the brothel, they could be arrested. I am assuming that this, or a system similar to this, still holds true.
Desker Road is in a not too great area of the city. The brothels were located in old pre-war shophouses. Inside, the space was subdivided into spartan looking cubicles each containing a bed & a sink. Each brothel had its own “type” of sex workers:
a) Women
b) Old women – and I mean old. The lady whom we saw there looked like someone’s grandmother. In fact, she was wearing a traditional sam-foo type of outfit. We later found out that she REALLY WAS someone’s grandmother. When we asked her why she was still doing this kind of work, she said that she needed the money to support her (useless, IMHO) son who was already in his 30’s, and toddler grandson. Sad, really.
c) “Women” – transvestites, who looked more female than the real women; they were beautiful with gorgeous slim & toned bodies. They also tended to have exaggerated feminine gestures, & dressed in extremely revealing clothing (think: blouse made of some kind of net-like material, with no undergarments). One of them told us that "he" was saving up for gender reassignment surgery.
Surprisingly, the highest rate for service was for category c. At that time, it was between S$30 to S$40 per session. The poor old lady only earned $5 to $10 per session, while the “regular” women earned about $25 per session.
On leaving the brothels, we walked through the alleyway behind the shophouses, and there were vendors with tables set-up there, selling different kinds of devices supposed to enhance one’s erotic experiences! We were really quite surprised to see these things being sold openly although we (innocents that we were * GRIN*) couldn’t figure out how some of those things worked or where they were supposed to be fitted/worn!
An eye-opening experience.
At that time, the infamous Middle Road Hospital was still around (this is about 20 years ago). Patients with skin problems or STD’s were managed there. (I've always wondered about this strange combination ☺).
As part of our posting, we were supposed to go on a field trip to a red light district to see how prostitutes are “managed”. There were 3 main districts: Johore Road, Desker Road & Geylang. I think most of us were hoping to see Geylang, where it is supposed to be the most “high class” of the 3, with specially designed beds & other contraptions in the brothels (whether this is true or not, I have no idea ☺).
Anyway, my group was sent to Desker Road with a social worker. Basically, what the medical social worker needed to do was to make sure that the “workers” had been keeping up with their regular visits to Middle Road for tests to ensure that they were “disease-free”. Those who were cleared were given green ID cards, which they had to show to the MSW who did spot checks.
There is a widely held misconception that prostitution is illegal in Singapore. Well, that’s not true. As long as the sex worker worked in his/her registered brothel & was holding a valid green card, it was OK. However, if they solicited their services on premises other than the brothel, they could be arrested. I am assuming that this, or a system similar to this, still holds true.
Desker Road is in a not too great area of the city. The brothels were located in old pre-war shophouses. Inside, the space was subdivided into spartan looking cubicles each containing a bed & a sink. Each brothel had its own “type” of sex workers:
a) Women
b) Old women – and I mean old. The lady whom we saw there looked like someone’s grandmother. In fact, she was wearing a traditional sam-foo type of outfit. We later found out that she REALLY WAS someone’s grandmother. When we asked her why she was still doing this kind of work, she said that she needed the money to support her (useless, IMHO) son who was already in his 30’s, and toddler grandson. Sad, really.
c) “Women” – transvestites, who looked more female than the real women; they were beautiful with gorgeous slim & toned bodies. They also tended to have exaggerated feminine gestures, & dressed in extremely revealing clothing (think: blouse made of some kind of net-like material, with no undergarments). One of them told us that "he" was saving up for gender reassignment surgery.
Surprisingly, the highest rate for service was for category c. At that time, it was between S$30 to S$40 per session. The poor old lady only earned $5 to $10 per session, while the “regular” women earned about $25 per session.
On leaving the brothels, we walked through the alleyway behind the shophouses, and there were vendors with tables set-up there, selling different kinds of devices supposed to enhance one’s erotic experiences! We were really quite surprised to see these things being sold openly although we (innocents that we were * GRIN*) couldn’t figure out how some of those things worked or where they were supposed to be fitted/worn!
An eye-opening experience.
Wednesday, August 16, 2006
A Doc's Life - More Memorable Moments (P.S. 7)
Scenario: Pediatric Surgery Department of a large local hospital
This was where I did a 6-month rotation. This is where I:
• found out I was pregnant with my first son; had hyperemesis gravidarum due to aforementioned pregnancy, resulting in my having to run out during ward rounds to throw up, asking the nurse to jab me with IM Dramamine during one of my calls, and almost throwing up on a patient when I was assisting the on-call consultant in a laparotomy. The sight & smell of gas-filled loops of ischemic, necrotic intestines which popped eagerly out of the neonate’s abdominal cavity was not a pleasant one, pregnant or not;
• saw my first (& only) omphalocele;
• learnt how to do laser circumcision. And I am proud to say that my handiwork was pretty good too. Thing about using lasers is that you have to have good hand-eye-foot co-ordination. Hand because you have to target the laser, eye because you have to see what you are doing (duh) & foot because that’s how you turn the laser beam on & off (or shoot the laser, as a layman would say). There was a fellow from another Asian country who wasn’t terribly good with his hands, & one time, when I was assisting him, I saw him inadvertently “shoot” the laser at the glans penis – he didn’t lift his foot off fast enough. My eyes widened in horror & I cringed in empathy (although I am female, I could still imagine how sensitive that area is). Fortunately, it was a very small, very superficial burn.
• was taught how to differentiate between abdominal guarding & voluntary rigidity (in babies & children, who tend to be more sensitive to being palpated, this can be quite hard to do).
• developed a phobia of calling up radiologists on call to help confirm & manage intussusception. For some reason, certain radiologists were terribly unfriendly, and seemed to do the barium enemas very grudgingly. I often wished I could have told them: hey, I don’t like waking you up in the middle of the night either, but this kid is in pain, & signs point to a likely diagnosis of intussusception, you know!
• learnt that projectile vomiting in babies with pyloric stenosis is REALLY projectile, if you know what I mean;
• realized that many “head injury” patients tended to be admitted at night. I think the parents had no time to worry until after dinner, when fearsome thoughts & scenarios start flashing through their heads about the bump on their DDC’s* heads although the bump may have been sustained a week ago.
*DDC = Dear Darling Children
This was where I did a 6-month rotation. This is where I:
• found out I was pregnant with my first son; had hyperemesis gravidarum due to aforementioned pregnancy, resulting in my having to run out during ward rounds to throw up, asking the nurse to jab me with IM Dramamine during one of my calls, and almost throwing up on a patient when I was assisting the on-call consultant in a laparotomy. The sight & smell of gas-filled loops of ischemic, necrotic intestines which popped eagerly out of the neonate’s abdominal cavity was not a pleasant one, pregnant or not;
• saw my first (& only) omphalocele;
• learnt how to do laser circumcision. And I am proud to say that my handiwork was pretty good too. Thing about using lasers is that you have to have good hand-eye-foot co-ordination. Hand because you have to target the laser, eye because you have to see what you are doing (duh) & foot because that’s how you turn the laser beam on & off (or shoot the laser, as a layman would say). There was a fellow from another Asian country who wasn’t terribly good with his hands, & one time, when I was assisting him, I saw him inadvertently “shoot” the laser at the glans penis – he didn’t lift his foot off fast enough. My eyes widened in horror & I cringed in empathy (although I am female, I could still imagine how sensitive that area is). Fortunately, it was a very small, very superficial burn.
• was taught how to differentiate between abdominal guarding & voluntary rigidity (in babies & children, who tend to be more sensitive to being palpated, this can be quite hard to do).
• developed a phobia of calling up radiologists on call to help confirm & manage intussusception. For some reason, certain radiologists were terribly unfriendly, and seemed to do the barium enemas very grudgingly. I often wished I could have told them: hey, I don’t like waking you up in the middle of the night either, but this kid is in pain, & signs point to a likely diagnosis of intussusception, you know!
• learnt that projectile vomiting in babies with pyloric stenosis is REALLY projectile, if you know what I mean;
• realized that many “head injury” patients tended to be admitted at night. I think the parents had no time to worry until after dinner, when fearsome thoughts & scenarios start flashing through their heads about the bump on their DDC’s* heads although the bump may have been sustained a week ago.
*DDC = Dear Darling Children
Tuesday, August 15, 2006
A Doc's Life - More Memorable Moments (P.S. 6)
This letter to the papers today reminds me of the naivete of some of the patients when it comes to matters related to their health or bodily functions.
Scenario: 3rd year Med School - Community health project for SMPH (Social Medicine & Public Health, now known as COFM - Community Occupational & Family Medicine). My clinical group did a project on hypertension & obesity; to gather data, we had to go to various units in HDB estates to measure BP, take height & weight etc.
Head of this particular family was a gentleman in his 40's with 4 daughters. As we were about to leave after gathering the neccessary info, he pulled me aside & asked: "I only have daughters. Is it because I only eat fish & don't eat meat?"
Me: "Er, no."
Him: "So what kind of diet should I take so that I can have a son."
Me: "Er, doesn't matter, what you eat won't affect the sex of your child. But for your health, please eat a balanced diet."
Not sure if he believed me or not.
Scenario: 3rd year Med School - Community health project for SMPH (Social Medicine & Public Health, now known as COFM - Community Occupational & Family Medicine). My clinical group did a project on hypertension & obesity; to gather data, we had to go to various units in HDB estates to measure BP, take height & weight etc.
Head of this particular family was a gentleman in his 40's with 4 daughters. As we were about to leave after gathering the neccessary info, he pulled me aside & asked: "I only have daughters. Is it because I only eat fish & don't eat meat?"
Me: "Er, no."
Him: "So what kind of diet should I take so that I can have a son."
Me: "Er, doesn't matter, what you eat won't affect the sex of your child. But for your health, please eat a balanced diet."
Not sure if he believed me or not.
Wednesday, July 26, 2006
A Doc's Life - More Memorable Moments (P.S. 5)
Subject: East is East and West is West?
In a society where a large proportion of the population still ascribes to traditional (or, in a more currently used term, alternative) medicine, I would get asked questions that, as a Western-trained doctor, I found difficult to answer.
A typical exchange:
Me: ”I’ll give you some medicine to help with your sore throat & phlegm. This is probably due to a viral infection, & you should get over it in a few days.”
Patient: ” Is it heatiness*? I ate a lot of chocolates yesterday.”
Me: “Er, I’m sorry, I really can’t say if it’s heaty or not, as I was not trained in Chinese medicine. This is probably a viral infection.”
I usually don’t brush it off as nonsense, as I like to keep an open mind. I occasionally even agree with the patient if I am too tired to explain, & the patient goes away happy that he/she has self-diagnosed the cause of his/her symptoms.
Another example involves a patient who is either recuperating from surgery or from an injury. He/she would ask me to confirm the “fact” that they should abstain from food like chicken & prawns as they are ”toxic”, & also from dark soya sauce as it would result in a hyperpigmented scar. I try to give them my opinion, but I usually don’t protest too violently, as I know that no matter what I say, these beliefs, which have been handed down through God knows how many generations, will persist; and they would abstain from those food items anyway.
*The concept of ”heatiness” & “coolness” is one held in Traditional Chinese Medicine to cause a variety of illnesses. Eg. Sore throat, phlegm, cough are attributed to one’s body being too “heaty”, often due to “heaty” foods like chocolates, anything fried, durians etc (the list goes on). Hence, “cooling” remedies like herbal teas are used to treat the symptoms.
In a society where a large proportion of the population still ascribes to traditional (or, in a more currently used term, alternative) medicine, I would get asked questions that, as a Western-trained doctor, I found difficult to answer.
A typical exchange:
Me: ”I’ll give you some medicine to help with your sore throat & phlegm. This is probably due to a viral infection, & you should get over it in a few days.”
Patient: ” Is it heatiness*? I ate a lot of chocolates yesterday.”
Me: “Er, I’m sorry, I really can’t say if it’s heaty or not, as I was not trained in Chinese medicine. This is probably a viral infection.”
I usually don’t brush it off as nonsense, as I like to keep an open mind. I occasionally even agree with the patient if I am too tired to explain, & the patient goes away happy that he/she has self-diagnosed the cause of his/her symptoms.
Another example involves a patient who is either recuperating from surgery or from an injury. He/she would ask me to confirm the “fact” that they should abstain from food like chicken & prawns as they are ”toxic”, & also from dark soya sauce as it would result in a hyperpigmented scar. I try to give them my opinion, but I usually don’t protest too violently, as I know that no matter what I say, these beliefs, which have been handed down through God knows how many generations, will persist; and they would abstain from those food items anyway.
*The concept of ”heatiness” & “coolness” is one held in Traditional Chinese Medicine to cause a variety of illnesses. Eg. Sore throat, phlegm, cough are attributed to one’s body being too “heaty”, often due to “heaty” foods like chocolates, anything fried, durians etc (the list goes on). Hence, “cooling” remedies like herbal teas are used to treat the symptoms.
Tuesday, July 25, 2006
A Doc's Life - More Memorable Moments (P.S. 4)
Scenario: GP Clinic; patient previously diagnosed with hypertension.
Again, this doesn't refer to one isolated case, but is a description of a commonly encountered situation involving hypertensive patients. Oftentimes, the patient comes in, not with the intention for follow-up of high blood pressure, but for another complaint, eg URTI, GE etc.
Me (after handling the presenting complaint): "By the way, I notice that you are on Drug XYZ for high blood pressure. Let's check your blood pressure & see how well controlled it is."
Patient:"I stopped taking the medicine already."
Me:" Why?"
At this point, there are two possible answers which illustrate misconceptions that patients have regarding the condition of hypertension:
a) Patient:"I finished the whole course already, so I thought I am cured."
b) Patient:"My friends told me that I shouldn't keep taking the medicine otherwise I will never be able to stop." (For some reason, some patients think that anti-hypertensives have some kind of addictive effect on their bodies).
I have lost count of the number of times where I have had to explain the chronicity of hypertension & the need for close follow-up & medication to keep BP under control. Yes, I have even resorted to expounding scary complications of uncontrolled hypertension like stroke, heart problems, kidney failure etc. to get the point across.
I don't know if this ignorance is a local phenomenon, or whether my overseas colleagues also encounter the same misconceptions.
Again, this doesn't refer to one isolated case, but is a description of a commonly encountered situation involving hypertensive patients. Oftentimes, the patient comes in, not with the intention for follow-up of high blood pressure, but for another complaint, eg URTI, GE etc.
Me (after handling the presenting complaint): "By the way, I notice that you are on Drug XYZ for high blood pressure. Let's check your blood pressure & see how well controlled it is."
Patient:"I stopped taking the medicine already."
Me:" Why?"
At this point, there are two possible answers which illustrate misconceptions that patients have regarding the condition of hypertension:
a) Patient:"I finished the whole course already, so I thought I am cured."
b) Patient:"My friends told me that I shouldn't keep taking the medicine otherwise I will never be able to stop." (For some reason, some patients think that anti-hypertensives have some kind of addictive effect on their bodies).
I have lost count of the number of times where I have had to explain the chronicity of hypertension & the need for close follow-up & medication to keep BP under control. Yes, I have even resorted to expounding scary complications of uncontrolled hypertension like stroke, heart problems, kidney failure etc. to get the point across.
I don't know if this ignorance is a local phenomenon, or whether my overseas colleagues also encounter the same misconceptions.
Saturday, July 22, 2006
A Doc's Life - More Memorable Moments (P.S. 3)
Subject: Sex Ed for Dummies – I know it is impolite to call someone a dummy, but after you have read this encounter, you’ll know where I’m coming from…
Patient is a female of child-bearing age. This is not an isolated case but a fairly commonly encountered experience.
Patient: “ Dr, there’s something wrong with me; my menses is late. It was supposed to come 2 weeks ago. It’s usually very accurate.”
Me: “Are you married?”
Patient: “Yes,”
Me: ”Do you or your husband use any form of contraception?”
Patient: “Er, no.”
Me: “Do you have symptoms like breast tenderness, nausea, loss of appetite…?”
Patient: “Er, ya, actually my breasts have been feeling a bit tender & my appetite is not so good.”
Me: “Well, you may be pregnant. Let’s do a urine test to check, shall we?”
Patient: “But it cannot be! We just got married last month & we were not planning to have a baby till one or two years later!”
Me: “Err…you don’t use any contraception…?”
Patient: “No.”
Me (patiently): “OK, then you may be pregnant. We can confirm it with a urine test.”
Patient exits room with a doubtful expression on her face…
Pregnancy test comes back Positive.
Me: “Congratulations! You are pregnant!”
Patient: “How did this happen? We were not planning for a baby……..” etc. etc…
Sigh…I sometimes wished that I could have told these patients that mind-control & will power are usually not terribly effective methods of contraception....
Patient is a female of child-bearing age. This is not an isolated case but a fairly commonly encountered experience.
Patient: “ Dr, there’s something wrong with me; my menses is late. It was supposed to come 2 weeks ago. It’s usually very accurate.”
Me: “Are you married?”
Patient: “Yes,”
Me: ”Do you or your husband use any form of contraception?”
Patient: “Er, no.”
Me: “Do you have symptoms like breast tenderness, nausea, loss of appetite…?”
Patient: “Er, ya, actually my breasts have been feeling a bit tender & my appetite is not so good.”
Me: “Well, you may be pregnant. Let’s do a urine test to check, shall we?”
Patient: “But it cannot be! We just got married last month & we were not planning to have a baby till one or two years later!”
Me: “Err…you don’t use any contraception…?”
Patient: “No.”
Me (patiently): “OK, then you may be pregnant. We can confirm it with a urine test.”
Patient exits room with a doubtful expression on her face…
Pregnancy test comes back Positive.
Me: “Congratulations! You are pregnant!”
Patient: “How did this happen? We were not planning for a baby……..” etc. etc…
Sigh…I sometimes wished that I could have told these patients that mind-control & will power are usually not terribly effective methods of contraception....
Friday, July 21, 2006
A Doc's Life - More Memorable Moments (P.S. 2)
Scenario: ER in a small hospital on a Saturday evening. Patient is a Chinese gentleman in his 40’s, who came in with his hand wrapped in a bloodied handkerchief.
He had been trying to catch an iguana (to eat. The Chinese are notorious for having an appetite for any creature that crawls, walks, swims….basically anything under the sun that is not toxic to the system). I guess the iguana was not too keen on being a dish on the dinner table.
On examination, his hand had multiple (& I mean multiple!!!) smooth edged lacerations on both palmar & dorsal surfaces which looked like razor cuts.
Looking at the pattern of injury, it looks like what had happened was that as he reached out to try to grab the lizard, the creature clamped down on his hand (I honestly didn’t even know that lizards had such sharp teeth). And as he reflexively tried to withdraw, it refused to let go, hence resulting in said lacerations ranging in length from half an inch to 3 inches.
Fortunately, there weren’t any tendinous nor nerve injuries although most of the lacerations were deep enough to warrant stitches. Took me a good hour to suture him up (must have been about 15 to 20 lacerations in total).
Oh, and the lizard got away ☺ ….go lizard!
He had been trying to catch an iguana (to eat. The Chinese are notorious for having an appetite for any creature that crawls, walks, swims….basically anything under the sun that is not toxic to the system). I guess the iguana was not too keen on being a dish on the dinner table.
On examination, his hand had multiple (& I mean multiple!!!) smooth edged lacerations on both palmar & dorsal surfaces which looked like razor cuts.
Looking at the pattern of injury, it looks like what had happened was that as he reached out to try to grab the lizard, the creature clamped down on his hand (I honestly didn’t even know that lizards had such sharp teeth). And as he reflexively tried to withdraw, it refused to let go, hence resulting in said lacerations ranging in length from half an inch to 3 inches.
Fortunately, there weren’t any tendinous nor nerve injuries although most of the lacerations were deep enough to warrant stitches. Took me a good hour to suture him up (must have been about 15 to 20 lacerations in total).
Oh, and the lizard got away ☺ ….go lizard!
Thursday, July 20, 2006
A Doc's Life - More Memorable Moments (P.S. 1)
After completing my mini-series on “A Doc’s Life – Memorable Moments” last year, I have recently recalled further anecdotal tales of more similarly memorable moments. And since people, for some reason, seem to enjoy such stories, I’ve decided to add a post script to this series, named, quite unimaginatively: “A Doc’s Life – More Memorable Moments”.
Here is my first P.S.
Scenario: My first day of work in a GP clinic in the heart of town. Patient is a tall good-looking gentleman (his appearance is totally irrevelant to the topic at hand, I know, but what the heck, I am of the female persuasion, such things do leave a lasting impression - GRIN -), a backpacking tourist from somewhere in Europe.
The patient entered my room, carrying a backpack with him.
Me: “What can I do for you today, Mr. ____”
Patient: ”I think I have worms.”
Me: “Er, how do you know?”
Patient: ”I found it in the toilet after I did No. 2.”
(OK, OK, he may not have quite put it in exactly that way, but I figured it would be easier on the sensibilities of some of my readers if I paraphrased it).
Me (apprehensively): “Sure…”
He then proceeded to take out from his backpack a small plastic jar covered by a piece of (clean) toilet tissue secured by a rubber band, & placed it on my desk.
(Sidenote: I have a phobia of all things that creep & crawl; spiders, cockroaches, worms, lizards etc etc. I have debrided necrotic ulcers, helped remove ischemic bowels, amputated limbs, seen & handled partially amputated /crushed limbs, but I still CANNOT touch creepy-crawlies....such is the nature of phobias)
I stared at the bottle, half expecting the worm to spring out of the jar, through the tissue paper, and on to my person (hey, phobias are illogical fears. Note: ILLOGICAL).
The patient must have seen the look in my eyes & very kindly said: “It’s dead. Would you like me to remove the cover?”
I nodded & apologized & explained my phobia.
He then removed the cover, & true enough, there was a very dead worm of the Ascaris spp. (better known as the roundworm to laymen) about 6 inches long. The patient must have picked up the infestation during his backpacking journey through Thailand or Vietnam.
The last time I had seen the Ascaris was during our Parasitology module in Medical School (I think it was in 3rd year) & the ones we were shown had been preserved in formaldehyde for God knows how long. Doctors here (at least GP’s in town practices) hardly ever see such infestations, since Singapore, being the developed country that she is, has high standards of hygiene & sanitation. So this was the first time that I had actually seen a “fresh” specimen, & I called my colleagues into my room to view it as well. I think the patient must have thought we were a bunch of “swaku”* doctors for being so fascinated by a worm.
Anyway, I gave him a prescription to get anti-helminthics.
And, oh yeah, he very kindly threw away the jar & worm for me.
*Swaku = local slang to describe someone who is unaware of, or oblivious to, what would be considered common knowledge - quite hard to define, actually, if you are not Singaporean.
Here is my first P.S.
Scenario: My first day of work in a GP clinic in the heart of town. Patient is a tall good-looking gentleman (his appearance is totally irrevelant to the topic at hand, I know, but what the heck, I am of the female persuasion, such things do leave a lasting impression - GRIN -), a backpacking tourist from somewhere in Europe.
The patient entered my room, carrying a backpack with him.
Me: “What can I do for you today, Mr. ____”
Patient: ”I think I have worms.”
Me: “Er, how do you know?”
Patient: ”I found it in the toilet after I did No. 2.”
(OK, OK, he may not have quite put it in exactly that way, but I figured it would be easier on the sensibilities of some of my readers if I paraphrased it).
Me (apprehensively): “Sure…”
He then proceeded to take out from his backpack a small plastic jar covered by a piece of (clean) toilet tissue secured by a rubber band, & placed it on my desk.
(Sidenote: I have a phobia of all things that creep & crawl; spiders, cockroaches, worms, lizards etc etc. I have debrided necrotic ulcers, helped remove ischemic bowels, amputated limbs, seen & handled partially amputated /crushed limbs, but I still CANNOT touch creepy-crawlies....such is the nature of phobias)
I stared at the bottle, half expecting the worm to spring out of the jar, through the tissue paper, and on to my person (hey, phobias are illogical fears. Note: ILLOGICAL).
The patient must have seen the look in my eyes & very kindly said: “It’s dead. Would you like me to remove the cover?”
I nodded & apologized & explained my phobia.
He then removed the cover, & true enough, there was a very dead worm of the Ascaris spp. (better known as the roundworm to laymen) about 6 inches long. The patient must have picked up the infestation during his backpacking journey through Thailand or Vietnam.
The last time I had seen the Ascaris was during our Parasitology module in Medical School (I think it was in 3rd year) & the ones we were shown had been preserved in formaldehyde for God knows how long. Doctors here (at least GP’s in town practices) hardly ever see such infestations, since Singapore, being the developed country that she is, has high standards of hygiene & sanitation. So this was the first time that I had actually seen a “fresh” specimen, & I called my colleagues into my room to view it as well. I think the patient must have thought we were a bunch of “swaku”* doctors for being so fascinated by a worm.
Anyway, I gave him a prescription to get anti-helminthics.
And, oh yeah, he very kindly threw away the jar & worm for me.
*Swaku = local slang to describe someone who is unaware of, or oblivious to, what would be considered common knowledge - quite hard to define, actually, if you are not Singaporean.
Monday, April 10, 2006
Weirdos
Today's letter in the newspaper from a patient requesting a waiver for the need of a chaperone for her acupuncturist during treatment, triggered memories of certain kinds of patients which left me (& my female colleagues) rather uncomfortable.
The need for a chaperone when a male doctor does an examination on a female patient is pretty much standard practice, not only to protect the patient, but also to protect the doctor from allegations of inappropriate behaviour. However, when it comes to chaperoning a female doctor examining a male patient (specifically if said patient has a complaint related to his genitals), there hasn't been much discussion over this issue.
Usually a male patient who has a complaint like urethral discharge, or penile rash or testicular swelling would request to see a male doctor, especially in the local context where Asian sensibilities tend to be more conservative. Hence, when I get a male patient who specifically asks for a FEMALE doctor to examine him for such complaints, alarm bells start to go off! Fortunately, such encounters are rare. But my female colleagues & I have compared notes & each of us had our own "Penis Guy" (different patients but similar complaints, each time requesting to see us specifically)who would come in complaining of a rash or some other malady that has affected his organ. And when you examine the affected area, there really is nothing obviously wrong with it. When the same guy comes in repeatedly for the same problem, we would try to redirect them to our male colleague to handle. This usually would put a stop to further unneccessary consultations for non-existent problems.
We have been fortunate that these patients did not exhibit any drastically inappropriate behavior during our non-chaperoned consults (although there was a case that was publicised fairly recently about a male patient who masturbated in the presence of the female doctor while consulting her for a supposed traumatic injury to his groin). Worst that ever happened to me was my Penis Guy trying to invite me out to dinner DESPITE the fact that I was wearing my wedding ring, & did not give him any indication whatsoever that I would even remotely be interested! The gall of some people...
The need for a chaperone when a male doctor does an examination on a female patient is pretty much standard practice, not only to protect the patient, but also to protect the doctor from allegations of inappropriate behaviour. However, when it comes to chaperoning a female doctor examining a male patient (specifically if said patient has a complaint related to his genitals), there hasn't been much discussion over this issue.
Usually a male patient who has a complaint like urethral discharge, or penile rash or testicular swelling would request to see a male doctor, especially in the local context where Asian sensibilities tend to be more conservative. Hence, when I get a male patient who specifically asks for a FEMALE doctor to examine him for such complaints, alarm bells start to go off! Fortunately, such encounters are rare. But my female colleagues & I have compared notes & each of us had our own "Penis Guy" (different patients but similar complaints, each time requesting to see us specifically)who would come in complaining of a rash or some other malady that has affected his organ. And when you examine the affected area, there really is nothing obviously wrong with it. When the same guy comes in repeatedly for the same problem, we would try to redirect them to our male colleague to handle. This usually would put a stop to further unneccessary consultations for non-existent problems.
We have been fortunate that these patients did not exhibit any drastically inappropriate behavior during our non-chaperoned consults (although there was a case that was publicised fairly recently about a male patient who masturbated in the presence of the female doctor while consulting her for a supposed traumatic injury to his groin). Worst that ever happened to me was my Penis Guy trying to invite me out to dinner DESPITE the fact that I was wearing my wedding ring, & did not give him any indication whatsoever that I would even remotely be interested! The gall of some people...
Thursday, March 30, 2006
Sometimes You Just Have To Listen To Your Gut
You wake up & have this bad feeling in your stomach (& you know it’s not the curry you ate last night). Things just go downhill from there. The car has a flat. Or the traffic is horrendous. You’re late for work. The F-O-N patient you usually try to avoid turns up & ends up in your consultation room. The waiter gets your dinner order messed up.
You also read about people with close calls who didn’t get on a plane because of a “bad feeling” & the plane ends up crashing with everyone on board losing their lives.
This sixth sense (no, not the I-see-dead-people variety) that you get sometimes is inexplicable, and unexplainable. I don’t know if it’s a gender-biased characteristic (the so-called “women’s intuition”); maybe the guys have a different name for it.
Whatever you may want to call it, this gut feel that you get can sometimes be a life-saver for your patients. I remember a few cases I encountered…
Patient A was a Malay gentleman in his early 40’s, who presented to me with mild gastric pain. Medical history & physical examination were unremarkable & he had only had the symptoms for a few weeks. Usually, I would prescribe an antacid and/or a H2 blocker with some lifestyle advice & review the patient again after a week or two, depending on the severity of symptoms.
However, in this case, something made me feel the need to refer him to a tertiary center for further investigations. 2 months later, I received a reply letter from the specialist who saw him at the specialist clinic giving me an update on his condition. Turns out that endoscopic examination revealed a gastric ulcer with very early malignant change. Fortunately, it was early enough that the patient did not need a total gastrectomy & just needed the affected area to be resected. I can’t begin to describe the feeling of relief (& some incredulity) I felt that we had caught this in time, thanks to my gut feel.
Patient B was a Chinese gentleman in his early 30’s who complained of a persistent cough of 2-3 weeks’ duration. He was not a smoker, & had no significant family or medical history of note. He had previously been prescribed cough mixture & lozenges by another doctor in the practice, without any relief. When I saw him, there were no physical signs to suggest any infection or malignancy. But again, gut feel made me order a chest x-ray…and to my horror, I saw a suspicious looking mass in the right lung. The radiologist report had daunting words like “suggestive of malignant change” & “infiltration”.
I referred him to a tertiary center. He returned to see me two months later to let me know that after undergoing a bronchoscopy & biopsy, the mass was not malignant, neither was it tuberculous (tested negative for acid-fast bacilli); even the specialists were puzzled by the diagnosis & thought that is was some unusual mycobacteria strain that had caused the infection. They ended up treating him empirically with what I believe to be a combo of Rifampicin & Streptomycin (patient was unclear as to the name of the drugs used). Happy ending – the treatment worked, & the patient was eternally grateful that number 1, the illness had been picked up, & number 2, it was NOT cancer.
Patient C was a Chinese lady in her early 20’s whom I saw as a health screening patient. During history taking, she revealed that she had a history of colonic cancer (!!!)& had a partial colectomy done. Apparently, she had seen her personal GP for (get this) epigastric pain (!!!), & the GP became suspicious & immediately referred her to a specialist for further investigations. Colonoscopy revealed early Ca Colon. I suspect that this GP had a gut feel too, that something was not quite right in this patient.
So the moral of the story is: don’t ignore that niggling voice that comes from that gray area between your conscious & subconscious, which sometimes makes you do things which you otherwise would not do. That strange feeling in your gut may not be indigestion, but your intuition telling you that things may not be what they seem to be.
You also read about people with close calls who didn’t get on a plane because of a “bad feeling” & the plane ends up crashing with everyone on board losing their lives.
This sixth sense (no, not the I-see-dead-people variety) that you get sometimes is inexplicable, and unexplainable. I don’t know if it’s a gender-biased characteristic (the so-called “women’s intuition”); maybe the guys have a different name for it.
Whatever you may want to call it, this gut feel that you get can sometimes be a life-saver for your patients. I remember a few cases I encountered…
Patient A was a Malay gentleman in his early 40’s, who presented to me with mild gastric pain. Medical history & physical examination were unremarkable & he had only had the symptoms for a few weeks. Usually, I would prescribe an antacid and/or a H2 blocker with some lifestyle advice & review the patient again after a week or two, depending on the severity of symptoms.
However, in this case, something made me feel the need to refer him to a tertiary center for further investigations. 2 months later, I received a reply letter from the specialist who saw him at the specialist clinic giving me an update on his condition. Turns out that endoscopic examination revealed a gastric ulcer with very early malignant change. Fortunately, it was early enough that the patient did not need a total gastrectomy & just needed the affected area to be resected. I can’t begin to describe the feeling of relief (& some incredulity) I felt that we had caught this in time, thanks to my gut feel.
Patient B was a Chinese gentleman in his early 30’s who complained of a persistent cough of 2-3 weeks’ duration. He was not a smoker, & had no significant family or medical history of note. He had previously been prescribed cough mixture & lozenges by another doctor in the practice, without any relief. When I saw him, there were no physical signs to suggest any infection or malignancy. But again, gut feel made me order a chest x-ray…and to my horror, I saw a suspicious looking mass in the right lung. The radiologist report had daunting words like “suggestive of malignant change” & “infiltration”.
I referred him to a tertiary center. He returned to see me two months later to let me know that after undergoing a bronchoscopy & biopsy, the mass was not malignant, neither was it tuberculous (tested negative for acid-fast bacilli); even the specialists were puzzled by the diagnosis & thought that is was some unusual mycobacteria strain that had caused the infection. They ended up treating him empirically with what I believe to be a combo of Rifampicin & Streptomycin (patient was unclear as to the name of the drugs used). Happy ending – the treatment worked, & the patient was eternally grateful that number 1, the illness had been picked up, & number 2, it was NOT cancer.
Patient C was a Chinese lady in her early 20’s whom I saw as a health screening patient. During history taking, she revealed that she had a history of colonic cancer (!!!)& had a partial colectomy done. Apparently, she had seen her personal GP for (get this) epigastric pain (!!!), & the GP became suspicious & immediately referred her to a specialist for further investigations. Colonoscopy revealed early Ca Colon. I suspect that this GP had a gut feel too, that something was not quite right in this patient.
So the moral of the story is: don’t ignore that niggling voice that comes from that gray area between your conscious & subconscious, which sometimes makes you do things which you otherwise would not do. That strange feeling in your gut may not be indigestion, but your intuition telling you that things may not be what they seem to be.
Friday, October 07, 2005
A Doc's Life - Memorable Moments 10
This is my final installment in my mini-series of Memorable Moments. Note that these moments occurred over a span of over one & a half decades, and I hope that I haven't given the impression that a doctor's life is full of these "unusual" happenings :). In most cases, a doctor's life is usually routine, oftentimes mundane, and not as glamourous & "happening" as portrayed in most TV series & movies...
Scenario: GP clinic
I am sure that a lot of doctors out there have had the experience of meeting with rather ignorant patients not being terribly clear about their medical conditions & treatment. Eg, when asked about what kind of medication they are taking for diabetes/hypertension/arthritis/gout/heart problem, they reply "One round white tablet, half a blue oval one, & a small red one" like we are supposed to know what kind of medicine they are referring to just because we are doctors).
Patient was an elderly gentleman who was there for a medical examination for insurance purposes. He was accompanied by his wife & son. I took the usual medical history (nothing significant, according to the patient & his family).
When I exposed his abdomen, lo & behold, there was a mid-line abdominal laparotomy scar, at least 8 inches long! The following exchange ensued (note: patient's dialogue has been translated from a local dialect into English, so pardon the glaring grammatical mistakes):
Me: "I thought you said that you had no surgery done before? What was this scar for?"
Patient (grinning):" Oh, small thing only lah. 16 years already - not important!"
Me: "This is a very big scar. Didn't the doctor tell you what was wrong with you before you had the operation?"
Patient (gleefully): "No lah, doctor say cut so I go and cut lor!!!"
I was speechless.
Scenario: GP clinic
I am sure that a lot of doctors out there have had the experience of meeting with rather ignorant patients not being terribly clear about their medical conditions & treatment. Eg, when asked about what kind of medication they are taking for diabetes/hypertension/arthritis/gout/heart problem, they reply "One round white tablet, half a blue oval one, & a small red one" like we are supposed to know what kind of medicine they are referring to just because we are doctors).
Patient was an elderly gentleman who was there for a medical examination for insurance purposes. He was accompanied by his wife & son. I took the usual medical history (nothing significant, according to the patient & his family).
When I exposed his abdomen, lo & behold, there was a mid-line abdominal laparotomy scar, at least 8 inches long! The following exchange ensued (note: patient's dialogue has been translated from a local dialect into English, so pardon the glaring grammatical mistakes):
Me: "I thought you said that you had no surgery done before? What was this scar for?"
Patient (grinning):" Oh, small thing only lah. 16 years already - not important!"
Me: "This is a very big scar. Didn't the doctor tell you what was wrong with you before you had the operation?"
Patient (gleefully): "No lah, doctor say cut so I go and cut lor!!!"
I was speechless.
Thursday, October 06, 2005
A Doc's Life - Memorable Moments 9
Scenario: GP clinic in the heart of town.
Patient was a lady in her mid-40's complaining of a vague vaginal discomfort of 2 weeks duration. No significant medical history of note; menstrual history was also normal, with LMP 2 weeks prior to consultation.
After taking her history, I proceeded with an abdominal examination and then a PV during which I was surprised to feel a firm irregular mass in the posterior fornix of the vaginal vault. Thoughts of "tumor", fungating mass" etc ran through my mind, but I didn't want to say anything until I could visualise it. I proceeded with a speculum exam & saw a brownish colored FOUL SMELLING mass with a tail - it was a retained tampon (her LMP was 2 weeks prior, which allowed for Lord knows what kind of micro-organisms to proliferate in that very fertile medium...).
The patient was shocked when I told her what it was, & I could tell that until I actually showed her the offending object, she could not believe that she had forgotten to remove it.
My consultation room smelt like something had died and was decomposing, even after the patient had left; and we had to allow it to air out for several minutes, spray plenty of air freshener before it was fit for occupation again. The last time I had experienced something so malodourous was as a medical student doing the forensic path posting and had to undergo the "traditional" exposure to a decomposing body - that smell just sticks to your clothes for the rest of the day...
Patient was a lady in her mid-40's complaining of a vague vaginal discomfort of 2 weeks duration. No significant medical history of note; menstrual history was also normal, with LMP 2 weeks prior to consultation.
After taking her history, I proceeded with an abdominal examination and then a PV during which I was surprised to feel a firm irregular mass in the posterior fornix of the vaginal vault. Thoughts of "tumor", fungating mass" etc ran through my mind, but I didn't want to say anything until I could visualise it. I proceeded with a speculum exam & saw a brownish colored FOUL SMELLING mass with a tail - it was a retained tampon (her LMP was 2 weeks prior, which allowed for Lord knows what kind of micro-organisms to proliferate in that very fertile medium...).
The patient was shocked when I told her what it was, & I could tell that until I actually showed her the offending object, she could not believe that she had forgotten to remove it.
My consultation room smelt like something had died and was decomposing, even after the patient had left; and we had to allow it to air out for several minutes, spray plenty of air freshener before it was fit for occupation again. The last time I had experienced something so malodourous was as a medical student doing the forensic path posting and had to undergo the "traditional" exposure to a decomposing body - that smell just sticks to your clothes for the rest of the day...
Wednesday, October 05, 2005
A Doc's Life - Memorable Moments 8
Scenario - Labour ward of a teaching hospital
I had just helped bring into the world a healthy baby, and had delivered the placenta. I was repairing the episiotomy when suddenly, I hear a "PLONK" of something dropping on the floor behind me.
"Did you drop the baby???!!!" I yelled at the nurse in panic, in the middle of a stitch.
"No," the nurse replied calmly. "Daddy just fainted" she continued matter of factly (I guess it was a fairly common occurence for the men NOT be able to take the bloodshed, gore & trauma of childbirth).
I had to check Dad for head injuries (fortunately, he was fine) after finishing the repair.
I have always known that men are not as macho as they'd like you to think. Somehow, the sight of the episiotomy & the placenta being delivered are the things that tip them over...
I had just helped bring into the world a healthy baby, and had delivered the placenta. I was repairing the episiotomy when suddenly, I hear a "PLONK" of something dropping on the floor behind me.
"Did you drop the baby???!!!" I yelled at the nurse in panic, in the middle of a stitch.
"No," the nurse replied calmly. "Daddy just fainted" she continued matter of factly (I guess it was a fairly common occurence for the men NOT be able to take the bloodshed, gore & trauma of childbirth).
I had to check Dad for head injuries (fortunately, he was fine) after finishing the repair.
I have always known that men are not as macho as they'd like you to think. Somehow, the sight of the episiotomy & the placenta being delivered are the things that tip them over...
Tuesday, October 04, 2005
A Doc's Life - Memorable Moments 7
Scenario: Local teaching hospital - Internal Medicine ward
My first encounter with death. I was an intern, and medical school definitely did not prepare me for dealing with death, the dying & their loved ones.
The patient was a 40+ year old lady with advanced CA Breast that had metastasised to her lungs. Despite the oxygen mask, she was gasping desparately for air. Her pre-teen daughter was at the foot of the bed, crying; her husband was at her bedside, crying & pleading with his wife to "hang on, fight it, fight it..." Before our very eyes, she was being asphyxiated by the cancer cells that had taken over her lungs.
I wanted to yell at her husband to stop, to comfort his wife instead of asking her to struggle on, I wanted to cry with the daughter, but it was not my place to do so...I had to leave the room to compose myself before I broke down. I did not re-renter it until the patient had passed on. Fortunately, I had an understanding MO.
My first encounter with death. I was an intern, and medical school definitely did not prepare me for dealing with death, the dying & their loved ones.
The patient was a 40+ year old lady with advanced CA Breast that had metastasised to her lungs. Despite the oxygen mask, she was gasping desparately for air. Her pre-teen daughter was at the foot of the bed, crying; her husband was at her bedside, crying & pleading with his wife to "hang on, fight it, fight it..." Before our very eyes, she was being asphyxiated by the cancer cells that had taken over her lungs.
I wanted to yell at her husband to stop, to comfort his wife instead of asking her to struggle on, I wanted to cry with the daughter, but it was not my place to do so...I had to leave the room to compose myself before I broke down. I did not re-renter it until the patient had passed on. Fortunately, I had an understanding MO.
A Doc's Life - Memorable Moments 6
Scenario: Largest maternity hospital in the local scene; I did a 6 month rotation through the Neonatal ICU.
I saw and did things which I would never have imagined if I hadn't gone through this posting. Among the unforgettable are congenital abnormalities some of which I would be unlikely to see again in this lifetime.
SIRENOMELIA: Or the Mermaid Syndrome. This baby was a BBA (our acronym for Born Before Arrival), still birth, born to a Malay family. It (unclear of it's gender) had just one fused limb with a single toe. The upper half of the baby looked absolutely normal.
CUTIS APLASIA: The baby was literally born without any skin. According to literature, this rare condition usually affects part of the body, most commonly the scalp. However, in the case that was admitted, the ENTIRE baby had no skin. He was covered by a thin transparent glistening membrane. You could see his muscles, superficial blood vessels etc. We kept him as comfortable as possible; setting an I/V on him was a nightmare. He survived for 3 days before passing away.
ANENCEPHALY: This was an undiagnosed case, because of lack of antenatal follow-up. The baby was a stillbirth.
ACHONDROPLASIA: This was also undiagnosed antenatally, despite adequate follow-up. Understandably, the mother was depressed. We kept the otherwise healthy baby boy in the ward longer than normal to prevent the parents from doing anything "drastic" in the immediate post-partum period, and arranged for them to see a counsellor.
One of the most heart-wrenching, gratifying, stressful, tedious tasks we had to perform was the resuscitation and intensive monitoring of premature babies, some as small as 700 grams. Blood gases, electrolytes, parenteral nutrition all had to be closely watched to keep them alive. It became a bit of a moral dilemna for me after watching the effects of surviving prematurity: CP, BPD, developmental delays, mental retardation (some more severe than others). Was it worth saving their lives? I had to accept that the moral decision was not mine to make; as doctors, we were there solely to save lives when called to do so. There was even one instance of a mid-trimester TOP who called for the NICU MO-on-duty (moi) to go to the gynae ward to resuscitate the 23 week old fetus who had been expelled & was actually crying! This little life clung on for 3 days before letting go...It was hard not to weep with the mother, who, for whatever reason, had to go through this ordeal and live with her decision.
This posting was the most stressful and at the same time the most enriching one I had gone through. Not only did I learn so much about the resilience of babies (they are not as fragile as one might think), but it would later serve me well for my adventures as a new mom (I did not become one of those panicky moms who would call the pediatricians when Baby refused to stop crying/refused to suck/poo-ed too much/poo-ed too little). And in the rare free moments, the nurses taught me how to feed/burp/bathe the babies - this definitely was good practice!
I saw and did things which I would never have imagined if I hadn't gone through this posting. Among the unforgettable are congenital abnormalities some of which I would be unlikely to see again in this lifetime.
SIRENOMELIA: Or the Mermaid Syndrome. This baby was a BBA (our acronym for Born Before Arrival), still birth, born to a Malay family. It (unclear of it's gender) had just one fused limb with a single toe. The upper half of the baby looked absolutely normal.
CUTIS APLASIA: The baby was literally born without any skin. According to literature, this rare condition usually affects part of the body, most commonly the scalp. However, in the case that was admitted, the ENTIRE baby had no skin. He was covered by a thin transparent glistening membrane. You could see his muscles, superficial blood vessels etc. We kept him as comfortable as possible; setting an I/V on him was a nightmare. He survived for 3 days before passing away.
ANENCEPHALY: This was an undiagnosed case, because of lack of antenatal follow-up. The baby was a stillbirth.
ACHONDROPLASIA: This was also undiagnosed antenatally, despite adequate follow-up. Understandably, the mother was depressed. We kept the otherwise healthy baby boy in the ward longer than normal to prevent the parents from doing anything "drastic" in the immediate post-partum period, and arranged for them to see a counsellor.
One of the most heart-wrenching, gratifying, stressful, tedious tasks we had to perform was the resuscitation and intensive monitoring of premature babies, some as small as 700 grams. Blood gases, electrolytes, parenteral nutrition all had to be closely watched to keep them alive. It became a bit of a moral dilemna for me after watching the effects of surviving prematurity: CP, BPD, developmental delays, mental retardation (some more severe than others). Was it worth saving their lives? I had to accept that the moral decision was not mine to make; as doctors, we were there solely to save lives when called to do so. There was even one instance of a mid-trimester TOP who called for the NICU MO-on-duty (moi) to go to the gynae ward to resuscitate the 23 week old fetus who had been expelled & was actually crying! This little life clung on for 3 days before letting go...It was hard not to weep with the mother, who, for whatever reason, had to go through this ordeal and live with her decision.
This posting was the most stressful and at the same time the most enriching one I had gone through. Not only did I learn so much about the resilience of babies (they are not as fragile as one might think), but it would later serve me well for my adventures as a new mom (I did not become one of those panicky moms who would call the pediatricians when Baby refused to stop crying/refused to suck/poo-ed too much/poo-ed too little). And in the rare free moments, the nurses taught me how to feed/burp/bathe the babies - this definitely was good practice!
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