Archive for October, 2009

Unreasonable Relatives

It is most frustrating, when J. is working in a team that frequently updates the relatives of the patients under its care, to be informed via the nursing staff that the CEO of the hospital has received a complaint that the team is “not updating the family enough”.

The complaint came from the daughter of the patient. The team has never, ever seen the daughter in hospital. The wife and son (who are frequently in hospital ad actually take care of the patient at home) get updates on the patient’s condition and plans every day.

It’s a classic case of ‘guilt-syndrome’. The most unreasonable, unpleasant relatives, who demand the best impossible care for the patient are the ones who

(a) don’t live with the patient

(b) don’t take care of the patient

(c) haven’t seen the patient in months-years because work and gallivanting about the world takes precedence over filial piety.

Now that the relative is sick, it’s their chance to show that they care so deeply that they can be utterly unpleasant and impose their ridiculous demands on the healthcare staff.

There are sons who demand that their premorbidly wheelchair-bound parent, a resident of a nursing home, WALK before being discharged from hospital. Sir, if I could perform miracles, I would be curing AIDS with the power of my mind in Africa instead of listening to your arrogant, ignorant ramblings.

Bah.

Jumping to Conclusions

People are new. New people take time to catch up, and the first impression is often false.

He was on call with a new HO with a poor reputation for breaking down and almost being in a catatonic state on his first week at work. Most likely he was overwhelmed by being in a new country, in a new hospital, in a new system, in a new department with a horrendous workload for the inexperienced. Let’s say that frequent consultations were had and a couple of serious mistakes were made. J. was not happy.

Yet a couple of months down, said HO was the sole house officer on the same team as J., and having had experience in other teams, proved to be more than capable enough to settle all the changes of the admittedly rather complicated team. It’s a humbling experience for J. to be reminded that the conclusions we jump to about people are often unjustified.

Severe Abdominal Pain in a Woman of Childbearing Age = ….

It’s been over a year since J. started working, but he still remembers this experience from a student posting.

There was a 36-year-old lady who had come in with a 3-day history of abdominal pain, starting from the umbilical region, subsequently radiation to the right hypochondrium/flank region, bilateral shoulders and was exacerbated by lying down and relieved by sitting up.

Physical examination demonstrated tenderness over the areas of pain (including the shoulders) but no guarding or rebound tenderness, a low grade temperature of 37.6 degrees, BP 100/60mmHg, pulse 90 beats/min, SpO2 100% on room air. Initial investigations: Hb 11.6, TW 22.1, Plt 200, PT/PTT renal panel (U/E/Cr) liver function tests and serum amylase levels all normal.

She was admitted to General Surgery, who initiated basic cultures, fluids, antibiotics and ordered a CT abdomen/pelvis to look for any possible perforated appendix/viscus as she (as the registrar pointed out, “she doesn’t look too well…”). This lady was in sufficient pain that she needed IV morphine 2mg in order to lie down flat for the CT scan. Right before the scan, however, the registrar noted that her bladder was full and she had not been catheterised. He considered that her last reported menses was 1 month prior and lasted only 2 days (instead of her usual 5). He then flipped through the A&E notes and noted that the urine pregnancy test had been ordered but had not been performed (since the pt had not passed urine). The GS medical officer catheterised the patient in the CT scan room and ran the urine combur 9 and urine pregnancy test.

Positive.

CT scan withheld, O&G registrar informed, and the patient was wheeled to the labour ward immediately where a repeat pregnancy test was confirmed, and a transvaginal ultrasound demonstrated free fluid in the peritoneal cavity and a right adnexal mass – confirming the diagnosis of ectopic pregnancy. Care was handed over by the GS side to O&G who proceeded to prepare the patient for an operation. One life saved, thanks to an astute GS registrar.

That was the only case ectopic pregnancy J.’s seen… The UPT must always be checked for any woman of childbearing age. That’s what J. thinks when he sees a patient in the A&E referred to GS for abdominal pain.