Perinatal Mortality Meeting

While I'm glad it was all over, I consider myself fortunate to be part of the team to be presenting on the statistics of labour room for this year. It sort of gave me a few insights as to the importance of data collection and analysis and how we can improve and benefit from statistics and its interpretation.

Perhaps I am an academician at heart.

The meeting was a quarterly effort done with the pediatrics team.

I presented mostly on the number of deliveries and birth rates, including modes of deliveries, number of multiple gestations, preterms, and most importantly in the meeting, stillbirths. The pediatrics team had their own presentation on NICU admissions and mortality rates. Later a few selected cases were brought up for discussions as to how to improve things.

I expected blame games and bashings between department but what I saw was a rather pleasant discussion without too much hostilities.

Some of the data I wished I had included:

1. Rate of success of ECVs

Success of ECVs would reduce CS rates for indication of breech. This would be a big help in preventing maternity risk posed by CS as well as risk to fetus during breech delivery vaginally.

2. Shoulder dystocia

The data would be helpful in seeing what could have been done for prevention and anticipation of similar cases.

3. Cord prolapse

This is potentially preventable. Response time could be assessed and discussed as well.

 4. Outcomes of instrumental deliveries

Success although may not very well indicate justification of the procedure, it may provide insight as to the baby's outcome. Many factors come into play here.

As a person with pediatric surgical interest, my interest in connection to O&G would be antenatal screening of congenital disorders, such as gastrochisis, congenital diaphragmatic hernia, duodenal atresia, and spina bifida. Outcome of baby's are greatly increased with antenatal diagnosis and subsequent deliveries in a equipped tertiary center with pediatric surgeons.

I do intend to do my part to make data collection more bearable and simple. A simple template may help perhaps.



"Those who do not learn from the past are doomed to repeat it"
Winston Churchill

EXIT - Enter O&G

Post housemanship.

I thought I won't see O&G ever again after I finished the posting during my housemanship.

I was SO wrong.

I was placed to O&G, just a stone throw away from the department of my choice, Peds Surgery. What was initial dread, fear of screwing-up, almost alternate tagging calls, incompetencies, morning prayers and high-octane action, turned out it's not too bad at all. For now.

Anyways, we had a first-ever EXIT (EXtrauterine Intrapartum Treatment) done quite recently, organized by the O&G team involving Peds Anesthesiology, Peds medical, Radiology.

It was a case of a baby diagnosed with a huge neck mass antenatally by our fetomaternal medicine specialist. Then he thought, "Hey, why not organize an EXIT for the the baby so he won't come out gasping from airway obstruction?". So he did. And it was a historical success for Hospital Wanita dan Kanak-kanak Sabah.

Pasar di OT

An LSCS was performed only the baby was only delivered halfway. Continuity of the uteroplacental-fetal circulation is the main objective of the procedure. During that time, I was the cameraman for that monumental moment. The O&G team made way for our anesthetist to secure an airway for the child. At first, attempt to intubate the child failed. Only after aspirating the cyst a bit did the anesth team manage to put in the tube. And the baby was delivered and transfer of care to peds medical team was performed.

The kid is still in level 3 while peds surgery team, attempts to shrink or if possible excise the mass so the kid could be weaned off his tube and ventilator.

While in O&G, I am growing in a way. Mistakes happens but that's how we grow. Sure there are ups and there are downs. Alot of downs. But we just have to keep getting up. Because that's the way to proceed.

In O&G I am learning sonography. I am learning surgery. I am learning mother and child. All requirements for Peds Surgery.

I'll stay for awhile to further grow then perhaps... I will become a better Pediatric Surgeon.

Link:
bcdecker.com/SampleOfChapter/550092359.pdf

We Need Guidance, Please

What we don't need are insults. We just need guidance. One of my favourite teacher was Pang Chee Hoong, physician whom took care of male medical acute and HDU 1 during my time there. And that was when I learned how to put in the central lines.

I was in my 5th posting and I still haven't done any central lines yet! But Dr Pang showed me the way and now I'm more confident. I came out of medical with almost 10 central lines and quite a few on my own with assistance from nurses.

Coming to anesthesiology, CVL are mostly done by MOs in the OT. I assume that even they want that bit of practice.

Last night though I had my chance of putting in 2 on my own. But shit did I panic when I realized that I haven't pulled out the guide-wire when I inserted the triple lumen! My heart pounded like hell and I thought I would end up in IJN instead of the poor patient with the thyroid storm.

Fortunately the wire was still there when I pulled out the triple lumen. Booyah! Still a good flow!

Setting up central lines is one of my favourite procedures as a houseman. Haven't tried it on peds yet but would like the experience. Hell I still need the practice to set up regular lines in peds. Still suck at it. Learning from them experienced nurses is not a bad thing. I still have much to learn. As always.

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Tips to CVL insertion:

- Success is assured when patient and your position is correct. Failure is guaranteed when positioning and exposure is sub-optimal.

- Always have help around.

- The hardest part is getting the needle in the vein. Once that's done, the rest is a breeze.

- Know the potential complications.

- I know consent is important in the event of complications, but most of our folks, if we explain to them in details regarding the possible complications of CVLs, they would consult the whole kampung before agreeing. From Dr Pang: Do first, ask later. Save life first. (Up to you which you want to believe).

- Always pull out the guidewire first!!! Having a guidewire in the heart is equivalent to putting in wrong group match to a patient.

Have fun!

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Interlude

I'm writing way too much on O&G!

I promise Pediatric experience next!

(bukan ada orang baca pong)

O&G Revisit: The Bully

I had an MO (name with held but you'd know whom I'm talking about). He was a bully.

He would deliberately find excuse to 'kenakan' new HOs in the department (seriously!). His mood is like a playground see-saw, happy at one spectrum and a nuclear bomb at the other! He even admitted his mood swings and sometimes apologized for it.

My first incident with him was when I had my case note flung to the floor in PAC. I think he was angry with me for not writing well (I don't really remember now).

My second, when I scrubbed up for an emergency C-sec and I couldn't get through to the Peds MO oncall for standby. Baby came out flat, blue alert was called and he was furious with me throughout the whole closing of the patient's ab.

I've seen him calling up HOs for not filling in certain forms or writing in a style he didn't like. There was a time he told us he would find faults in the case note just so that he could find an excuse to scold a HO.

Well that was the worst of him.


On the bright side, after the blue-alert event, he did tell me nicely what I did wrong after I approached him and told him how sorry I am and that it was a mistake. He advised me not to take it personally as he just can't control himself at times and to learn from my mistakes.

He also thought some stuff in the labor room like what to look for in the CTG and during vaginal exams.

During my last few days of O&G, he gave me a chance to do a C-sec with him thus getting a very much needed C-sec performance in my logbook.
 

Much of the scoldings and the bullyings though unwarranted most times do sometimes provide the much needed eye-opener. And bad guys are not always bad (though they may be on the bad side of the spectrum).

He is still in the department and from what I hear from other HOs he is still the time-bomb he was when I was in O&G. But I do hope he does well and cool down a bit.

Well that's life.


Tips: Ambil yang baik, buang yang buruk, bersyukur.

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ps: I am so glad to be out of that department! =)

Final Posting: Anesthesiology

I remembered Prof Arif, my dear, Anesthesiologist lecturer in IIUM telling us how we should advise patient's going for op to pray as when the patient sleeps, it might be his last.

Undergoing anesthesiology rotation, I now can appreciate that anesthesiology is not a department where the anesthetist just 'intubate and extubate' or 'spinal' and just sit around in between.

Putting patient's to death with medications , maintaining airways and heart regulations while the patient is unaware, and reversing them back to life. Ventilator bag and machine replaces the patient's lungs, manipulation of his heart comes as easily with a push of the syringe plunger with the correct drug at the correct dosage.

My first impression of the anesthetist are that they control life itself!

Of course all this requires extensive knowledge on physiology and pharmacology to master this unique discipline. Just into my second month, I see that things do go wrong and shit happens and when it does, the patient's life can just slip from your fingers, and losing a patient on table is a horrible feeling when the patient (and family members) have entrusted you to keep him safe while surgery is on-going.

Things go wrong when you least expect them, ASA I patients, supposedly those undergoing short and routine procedures (I&D, CMR,  D&C).

Being put under is just damn scary. Putting someone under is just as scary. I have done a few successful intubations (20 is still considered few), and each time I still pray and hope that nothing goes wrong while I look for that vocal cords, epiglottis and put the tube in. This is by far the scariest procedures that I have to perform as a house officer.

Going through anesthesiology for 2 weeks in med school and 4 months as a HO is a very big gap. But that 2 weeks thought me a lot. Getting consent, RSI and inductions, MALESSS, holding a face mask properly and assembling the mask-valve-bag. And most important, the need to pray that things do not go wrong and the appreciation that life only belongs to Him and He is the controller of all life.


Lessons and Tips:

* It's OK to not be able to intubate. It's lethal to not being able to VENTILATE.
* MALESSS before intubating. It's a must!
* Label your medications.
* Check and check and check your blood products before giving them.
* Do NOT take things for granted.
* Remember that life is in GOD's hands. You are not god.

On the Table

I awake, only to die on the table
Pushed by bodies able
Through the door to the unknown
On my journey alone


Spark to those in need
Aiding best to those diseased
I greet him at the door
To push across the marble floor


Squeaky wheels turn
My inside burns
Fear of darkness
In a room brightest


My preparations complete
Although its no guarantee
My weapons to heal
Are those that might also kill


I am resigned to fate
This might just be my death bed
Again I'm put to sleep
I might never wake...



Life then lands
His lungs in my hands
Heart beats on screen
First cut done clean


He lies still
As his insides revealed
Blood pours then restored
How long can this mortal body endure?


'Wake up' I hear
What's far sounds so near
My eyes open I see
Life, has been given back to me

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The Assessment

Started HDU today. Patient's are quite stable for now and not much movement. Things will be busier this Monday... Had a patient whom was tachycardic the whole day. Didn't think of it much till I noticed she had a temperature and BP was starting to drop. All after the relatives noticed.

I should have acted sooner. Fluid challenge and antibiotics stat. Because in sepsis, everything can change when you act just one few moments sooner...

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I passed my assessment with a 70% mark. For the more academic and curious I'll share the topics:

• ECG: Pulseless ventricular tachycardia
• ECG: Complete heart block
• CT brain: Hemorrhagic stroke
• CXR: Pneumothorax
• Gen Med: Diabetes mellitus
• Clinical: Organophosphate poisoning
• Resuscitation: Hyponatremia and hypokalemia
• Resuscitation: Neutropenic sepsis

I don't think I did great. What the assessment showed me was how weak I was in medicine and management and how unsystematic I am. I think that's what assessments are about. To assess what you don't know rather thank what you know. Identifying your weak points helps you realize your weakness so you can work on it and take it to the next level. The questions are all med school stuff. Yet I still fumbled with answering.

And this is on paper.

Real life is different. More factors are equated in. Staff, teamwork, patient's character, your own character, the ward environment, the hospital system, your superiors, and of course your cases. Some people manage well in-situ, under pressure. I am not one of those people. But repetition and practice helps. The more you experience the better you get. You don't turn super overnight. Heck, you don't become great after months of practice.

I shouldn't therefore be too happy that I'm already a few more steps to leaving medical. I might be leaving but still lacking in the necessary skills and knowledge. This could be dangerous. longer stay however may just provide that extra push to develop.

After all that said... No way I'm staying in medical more than I have to :p I'm stressed with the work, but enjoy it at times. It's one of the only postings where opportunity to learn and practice independently is abundant.

I hope I've learned something and continue to learn.

Monster Change

Now I'm posted to Hematology ward. My HO leader wants me in ID, but my MO doesn't want to let me go. She wants me to stay. I'll just have to wait, CM to see how it goes. I'm quite comfortable in Hematology ward already...

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After going through halfway through housemanship, I do notice changes. I think it's for the worse in some aspect.

I have become the monster that I despise most when I see the monsters (some of my MOs or specialists) that I dislike and hope not to be. In my struggle to perform for others, I have succeeded in slowly chipping away some of my past existence, revealing the ugly caterpillar one so much wished to hide. A reverse transformation of nature, that may only come with stress and power and greed and desire to self-preserve.

Wings that sprout to fly are made of leather and bones instead of soft, feathers. I may soar high but less than grace. My breath becomes fire all of a sudden that singes hearts if not burn outright.

Is this how the course of things go? Where one forgets the very being he once was and strive to improve or at least maintains?

I loath when my superiors act on impulse and emotions. Disregarding the feelings of others. Breeding only contempt and a vicious cycle of loathing. I today have succeeded in succumbing to anger from that irrational emotion. My mild, growing wrath licking like fire the hearts of my dear colleague, my co-working staff nurses.

For becoming a monster, I apologize.

I long for humanity once more. For humility that I should be.

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Sudden Death

Again I haven't blogged here in awhile. Updates: I'm currently in Medical posting, it's already been about 2 months. So far I'm enjoying the posting quite a bit but the amount of death I'm seeing weekly. Today was another except that this was an unexpected one...

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A patient was admitted into female medical extension for acute flare of rheumatoid arthritis. In casualty she was given PCM, tramadol, morphine and fentanyl but none seem to have helped. She was still in severe pain on admission.

We brought my MO to see the patient first when she came in to start her rounds. We thought we'd get back to her later to solve her pain issues at the end.

"She won't die from the pain."

Whether she died from the pain or not I'm not too sure, but she did die today.

Halfway through the ward rounds, the staff nurse informed me that the patient was not breathing. She was right. I called my MO and we initiated resuscitation. Oh how there were so many inadequacies at the moment when every second counts.

1. No crash cart in the ward
2. Patient's only IV line was blue and not functioning
3. Oxygen thank was not by the bedside
4. We couldn't open the patient's jaw for intubation; temporomandibular RA

We couldn't manage to revive her after 30 minutes of trying. She passed away.

Our impression was drug overdose from the amount of opioids given to treat her pain. I'm more inclined to believe it was hypoglycemia as her DXT showed LO value. Later we found out that someone from the A&E sent her blood for dengue serology IgM which turned out to be positive. Did dengue kill her?

Whatever her cause of death, it came swiftly, unexpectedly. We were caught unaware and unprepared. Death is like that. It comes when nobody expects it. But we can still prepare. We all know how. It's only a matter of implementation.