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Sunday, February 19, 2006

A story

When I was on-call on Wednesday for the elderly wards, I was called by one of the elderly teams to help them out with some of the day jobs, as they were still on their ward round (this was at around 5.30pm). As I was not doing anything that day, I went to help them out.

And there, the house officer asked me to review 2 of his patients, as he did not know what to do with them. The first one was for a patient who was tachycardic at 140bpm, but asymptomatic, and wondering why in the world were us doctors fussing over him. He has a history of AF and was rate-controlled on low-dose digoxin, but didn’t have a precipitant of the new AF, so I gave him a stat dose of digoxin and up-ed his maintenance dose, in the meantime, for the main team to review the next morning to review the new ECG and his digoxin dose, and also check the digoxin toxicity.

The second patient (Mr DB) I reviewed was quite sickly. His oxygen saturations had dropped, and he was tachycardic as well. On examination, he had a raised JVP, tachycardia, bilateral crackles at the lung bases, and he had a soft but tender abdomen without guarding, no masses palpable. Investigations for a septic screen had been done prior to me seeing him. Looking at the ECG, there was slight worsening of the LBBB which he had on the previous ECGs. His ABG showed metabolic acidosis. While I was settling him in terms of fluids/Abx, oxygen, catheterization, asking the surgeons to see him and awaiting the CXR/AXR, the HO and his SHO just left. That befuddled me, and what made me fuming mad was that they had actually just left, without handing over anything, and went to a house party at my residence instead (which I found out when I came home from on-call later that evening). The moment I stepped into the house, I saw them and they asked me how that patient was. I mean, the cheek of them to!

On Thursday, I was on-call again for the elderly, as I covered for another of my colleagues who was sick. The same house officer from the night before bleeps me, asking me to sort out 2 patients, of which he has no idea what to do, plus he was on-call on the cardiac bleep that day. So I said I’ll go. It’s the same 2 patients from the night before! He had not reviewed the digoxin dose of the patient in AF that morning. Apparently he says that he had spent 3 hours managing the other sick patient (Mr DB), of which when I went to look at what has been done, nothing apart from aggressive fluid resuscitation, and he didn’t even go back to check on the patient later that day!
And therefore, the patient had 4.5L of gelo + bicarb (as he had severe metabolic acidosis), urine output was only 450ml for the past 24 hours, the patient sounded distressed on examination, bilateral crackles heard throughout the lungs, he was tachycardic, and his abdomen was tense, distended and had generalized tenderness + guarding. The surgeons had seen him the night before and said that though it was likely to be intra-abdominal sepsis, he was not fit for surgical intervention. To me, he was not likely to last long, and my main aim was to keep him comfortable even as the sepsis overwhelms his body defences. However, it’s not supposed to be the on-call’s decision to start someone on ICP (Liverpool Integrated Care Pathway), but the main team’s.

And so, I tried to contact the main team – the SHO who was also on-call that day. No answer to both bleeps. Tried the HO’s as well. No answer. Maybe because they recognize the number but aren’t covering the wards, so therefore they don’t answer, I don’t know. And then I bleeped the on-call SHO for the wards and told him the story and what I intended to do, he was agreeable, but said I had better discuss it with the SHO as she was around and she would know better. I said I tried bleeping her, but there was no answer, and he said that she was right beside him! @#%#$ And so, I explained the whole story to her, and she was agreeable to it. Duh….

After starting ICP for the patient, the nursing staff placed the patient’s contact information in front of me, saying that I had to inform the family that the patient was going to die, and it’s not the nursing staff’s duty to. (strange, coz nurses from other wards do that though).

I have never had to break bad news before, what’s more over the phone. But I did, when I called the patient’s son in Norfolk and urged him to come down quickly, and he was asking me to predict if his father would last the night, which I said was difficult to, but it was crucial that he comes down to the hospital quickly. Thinking that was all I had to contend with, little did I know that the patient’s sister was standing in front of me, waiting for me to finish the phonecall and tell her what was going on with her brother.

I wasn’t prepared for it at all. Breaking bad news face-to-face is different from over the phone. You have to watch your facial expressions, your voice tone, your body language, your words of expression. Not to mention, I was not the main doctor looking after that patient, and therefore it was not my place to inform them that their relative/sibling was dying. But at that moment, I had to make a decision. I could either bleep the SHO from the main team (who most probably was busy as well) to discuss with the relatives, or I could tell them what was happening. And so, I bit the bullet and did the deed. Thank goodness I was on-call for those few days, and at least I knew what was happening with the patient and what was done and what was decided. They were grateful for my explanations of what was happening and what has been done, and they were thankful that they can refer back to the team any time they had questions. Then they went to see the patient.

Breaking Bad News

After telling them and the son that their brother/father is going to die soon and right now, we’re just keeping them comfortable now, is very draining, mentally. It was depressing. I just sat in the day room (where I had brought the patient’s sister and partner in to inform them). I could not let loose. I could not cry. I had to be composed. I still had a job to do. I still had other patients who needed the care they deserve. I can’t do any more for this one patient. It’s disheartening.

You can never prepare yourself for breaking bad news, no matter how much notice you have. You can psych yourself up for it. You can mentally rehearse what you are going to say to the relatives. It is just not adequate. All those times in medical school where we have sessions on breaking bad news and how half the year won’t turn up to those sessions. You don’t realize the importance of them till you’re actually in the situation yourself.

Observation is different from actually doing the deed. It is never an easy thing to break bad news. The question arises: whose duty/obligation is it to break bad news? The lowest rank in the team? Or the consultant? Ideally it should be the consultant, but at the end of the day, the relatives just want to hear that you have done the best for the patient and there is nothing more you can do apart from keeping them comfortable.

Personally, it’s so frustrating that when I feel so helpless at that point.

Death & Dying

I am just a youngster, barely out of school, and yet dealing with the dying and the dead day in day out (thankfully not that often). What do I know about deciding if a patient is not fit for resuscitation? What makes me think I know what’s best for the patient?

At the end of the day, you’re a doctor to the nurses and family all around, and so you have to act like one (even though you sometimes wonder if you actually are one), and in a way, you have the ‘power’ to make a life-altering decision, and that is mind-boggling.

I have seen cadavers at medical school. The first time I saw a recently-dead person was when I was called to certify a death. We learn the theory of how we know when a person is dead. But, it doesn’t prepare you for actually seeing a recently-dead person, still warm when rigor mortis hasn’t set in yet. You have to examine them to certify that they are dead. On Wednesday, I was called to certify 2 deaths, one of which when I was clerking in someone in the next cubicle. You never actually really think of it till it happens: ‘This person died while I was talking to and examining someone in the next cubicle? Oh my…’

When people say that in the medical profession, you will get used to death and dying, that may be true, but for me, it is absolute rubbish. Although I may look as if it is an everyday occurrence for me, with a calm but expressionless face, death still affects me. I’m sure it affects all of us. We just don’t show it. We can’t afford to. Death sucks.
Handing over of patients

Just a rant here about the handing over of patients. I appreciate the fact that most, if not all, of us would like to get away by 5pm, when work is officially over. But isn’t there work ethics whereby you shouldn’t leave routine day jobs for the on-call docs to do? I know I don’t. I know most of us don’t. But there are just some who do so, perpetually. And that is very annoying, especially if it repeats itself.

Do not do unto others what you don’t want to do unto yourself. I believe in that, and I work by that. If only others work this way as well.