Angry Doctor

Saturday, November 19, 2005

Recurring Nightmare 4

Please read Foreword first.


Recurring Nightmare – Internal Medicine

It’s been a good call so far. You managed to eat dinner, shower, AND watch the news while you eat supper before going to bed, so you are actually not annoyed when your pager beeps at midnight.

It’s a nearby ward. You decide to walk there instead of calling back.

When you get there you find the night nurse performing CPR on an elderly patient. Your houseman is at the head end of the bed, trying to intubate him. He looks up when he realises you are here.

'I can’t intubate him,' he says, his face a mix of panic and embarrassment.

'Don’t intubate yet. Just bag.'

He drops the laryngoscope and starts to bag the patient. You adjust his grip on the mask.

'Stop CPR.'

You watch the monitor as you feel for a pulse. No pulse, no rhythm. Pupils fixed and dilated. Doll’s negative.

'Continue CPR. What’s the story?'

'Er…'

'It’s OK.'

You pick up the casefile and begin to flip through the thick notes. You spot your own handwriting and remember you saw this patient during your rotation in this ward last month. Why is he still here?

You find the entry you need.

Not for active.

You walk over to the nursing counter to page the Reg.

'What are you going to sign up as?' he asks.

'The morning team wrote to sign as pneumonia.'

'OK.'

You call the time of death. The nurses start to clean up the mess. The houseman stands at the counter, not quite sure what to do. Second posting, but the first was in orthopaedics. You realise he is still in his shirt and tie.

'Give me your pager. Go take a shower. Page me when you are done.'

He obeys and runs off.

You sit down to write the death cert.

'Staff nurse, have you called the family?'

'Ya. They say they will come with the IC in the morning.'

You decide to write the casenotes instead. You flip through the old entries and begin to remember this case.

Came in last month with pneumonia, multiple co-morbid factors. Recovered after a course of antibiotics, but family refused to take him back. Five sons, lived with the youngest one, but when he was declared fit for discharge the son said he needed a few more weeks to get a maid and renovate the toilet to install a ramp. The other sons each gave their excuse. Social worker, Case Manager brought in, no progress. Weeks went by, no maid, no more visits, no news.

You remember him because at one point he was so well he would help the nurses hand out the afternoon snacks to the other patients. Why would he need a ramp in the toilet? You wonder what happened between him and his sons.

Then a few days back he fell sick again with pneumonia. Son finally came down when patient was put on 'Dangerously Ill List'. Decided not for active management.

You write your notes and walk back to the bed to hand the nurses the file.

'Page me when the family brings the IC. Thanks.'

You watch the staff nurse and the assistant nurse do their thing with a quiet efficiency. You never did find out where the hospital morgue is located.


The patient’s eyes are already glazed over, his toothless mouth open as if uttering a silent cry. The dead look ever so dead. You smile when you remember that you used to wonder whether it was possible to tell the exact moment when a person’s soul left his body.

The houseman’s pager beeps. You walk back to the nursing counter to answer the page.

24 Comments:

  • Social admission + Not for active

    sigh....

    By Blogger andrew, At November 19, 2005 9:43 am  

  • Very typical of medical calls. Worse is they clear the bed and then comes another sick case at 4-5am, need to review and maybe even resuscitate..... Whole night screwed.

    By Anonymous Anonymous, At November 19, 2005 10:40 am  

  • Haha one of the reasons why I didn't enjoy my internal medicine posting was because there were so many "not for active" cases.

    Was very depressing as a houseman. In my 4 months, I only resuscitated 1 case that collapsed. Most of the other 40 over collapsed cases, we just drew the curtains and looked busy behind them.

    The other thing about internal medicine, they loved to order blood tests every day. The more they did not know what was happening the more blood tests eg ds-DNA, ANA, RA factor etc etc....and guess who has to take the blood? Houseman. Guess who takes all the patient's "Wah everyday take blood I gonna die liao lah" complaints? It's ok for one or two, but when you get 20-30 patients complaining the same thing...

    That was my introduction to internal medicine.

    By Anonymous Dr Oz bloke, At November 19, 2005 11:06 am  

  • Wah lau, damn good all your stories. Daman sad, but so true.

    By Anonymous sexy med student, At November 19, 2005 11:09 am  

  • "Decided Not For Active Management". In lay terms, I take it to mean "this is a no hoper so let's call it a day boys and girls". Heaven forbid that I should one day land up in a government hospital where the medical efforts are so cavalier. If I had a privately engaged internal medicine specialist attending to me,say in Mt. Elizabeth, probably, the outcome would have been quite different, no? For one, there would have been no pimply housemen fumbling with the tubes and looking clueless!

    By Blogger uglybaldie, At November 19, 2005 11:29 am  

  • Dear uglybaldie,

    The way it works in Singapore govt hospitals is that if the patient is dangerously ill and the doctors feel there is a chance that he/she might collapse and require intubation and subsequently mechanical ventilation and ICU care to sustain her life, we will call and discuss the case with the relatives.

    The issues are mainly the chances of the patient actually recovering from such an event and being discharge. If so, what the patient's quality of life would be and any possible morbidity and permanent disabilities.

    But in most cases, especially fraile elderly, the chances of them actually being able to be weaned off the ventilators are not good. These patients can be put on those machines for months and months and kept alive. Meanwhile your hospital bills in the ICU continue to pile up.

    Unfortunately for everyone, there is a financial cost involved.

    As a doctor I wish that I could just do my best to save every patient. But there have been cases where we tried our best and then the old lady died after staying in the ICU for 3 months. The bills came up to close to $70,000. The family subsequently charged the doctors with not educating them on the financial implications of "trying our best" to save the old lady and accused us of being "money suckers pretending to save a hopeless case".

    I believe that most doctors lay all the facts out openly and honestly. If the family insist on doing everything to save and prolong the life of the loved one and are fully aware and accept the financial implications, there is no problem for us.

    I am sure that is what the private hospitals do too. Except there is no subsidy from the govt, hence there is no need to answer to anybody except the patient's family.

    In govt hospitals sometimes administrators may ask some questions so there is another party to deal with and justify to.

    It's definitely not simple.

    By Anonymous Dr Oz bloke, At November 19, 2005 11:58 am  

  • Haha. Oz Bloke, uglybaldie’s setiments are exactly what you alluded to in your comment on different classes in hospitals: that if there exists more than a single class patients and their families will attribute any bad process/outcome to their difference in payment class rather than the patient’s condition!

    I think I will call it “Oz Bloke’s Law”

    uglybaldie, unfortunately money can’t buy you immortality (yet). People die in MtE too. But like Oz Bloke said, you can buy yourself a longer stay in the ICU before you die though, but you have to pay for it.

    By Blogger angry doc, At November 19, 2005 12:51 pm  

  • Thanks for the elucidation.

    It would appear therefore that in a government hospital, the prolonging of life is a money issue principally with the administrators asking whether the end justifies the means and if not, it is then "decided not for active management". Why? because there is a government subsidy.

    Is it any wonder then that Singaporeans are always money minded and the pursuit of material wealth is at the top of the agenda?

    Contrast this with the situation in say Australia where full medical benefits are extended to every citizen and AMDs are unheard of.

    I may agree with them that a welfare state is not desirable for this country but I do strenuously voice my concern that an act of prolonging life is weighed with dollars and cents. Medical science has as yet not dealt convincinly with the question of patients who apparently were hopelessly ill but later recovered despite all the odds stacked against them. Leaving it to medicine and the money man in the context of Singapore, to decide on the fate of a person's life is not justifiable nor conscionable.

    By Blogger uglybaldie, At November 19, 2005 12:55 pm  

  • uglybaldie said: "If I had a privately engaged internal medicine specialist attending to me,say in Mt. Elizabeth, probably, the outcome would have been quite different, no?"

    Yes, maybe you would have survived, but hooked up to tubes & life support systems for maybe months on end before eventually passing on, then your next-of-kin would then refuse to pay the bill (probably in the hundreds of thousands of dollars) & possibly then sue the hospital or doctor for trying to keep you alive in the first place knowing that the prognosis was so dim in the first place.

    Life (& death too, like it or not)happens, and occasionally, unpleasant choices have to be made.

    By Blogger aliendoc, At November 19, 2005 1:00 pm  

  • uglybaldie, I think you must draw the distinction between previously healthy patients who just need intensive care to get them through the bad patch, and patients who have had their run and won't get better despite the best of efforts and intentions.

    Like car mechanics, sometimes there's only so much we can do when the engine is broken.

    In the ideal world there would be a ventilator for every patient who needs one and the staff to take care of him, but in reality there aren't.

    In the meanwhile, we need to decide whether the old man with the minimal heart function who is unlikely to recover gets the bed, or the young man who has a pneumonia and just needs a few days of support to get him through. Sure the old man may recover miraculously, but tell that to the young man's family while he dies from a treatable cause.

    At the end of the day, money plays a part (it decides how big an ICU facility you have), but it's not a direct factor in deciding who gets the bed. I have never seen anyone denied ICU because he cannot pay, and I have seen rich men booted out of ICU when someone else needed the bed more.

    By Blogger angry doc, At November 19, 2005 1:30 pm  

  • huh? how can we compare a human being made up of cells and a soul albeit old and pass his prime with an old jalopy that has seen better days?

    Just joking! Your point taken but why are we spending such an obscene sum to build the gargantuan that is the National Library in town when we need more ICU and other facilities for an ageing population? Not your call of course but just a thought.

    If I were filthy rich, angry doc, I wouldn't even want to step within spitting distance of a government hospital. Unfortunately, since I am not,we should all seek a better health care system for the common populace and I hope they are listening.

    By Blogger uglybaldie, At November 19, 2005 1:45 pm  

  • "uglybaldie, unfortunately money can’t buy you immortality (yet). People die in MtE too."

    That was uncalled for. I apologise.

    By Blogger angry doc, At November 19, 2005 1:46 pm  

  • Dang! I want you to know I wrote the apology before seeing your latest post. Honest!

    I think the difference between civic projects like the library and end-stage medical care is that the former is an investment, and the latter a drain. Hence the emphasis on preventive care these days?

    I don't think we need more ICUs, but I do think we need to reassess our attitude towards death and dying.

    A lot of healthcare we consume now are being consumed just because it is there and we assume we should.

    Very few people seem to accept that we all have to go someday, and that it may be a better option than hanging on and suffering (or being in a state which you aren't even aware of suffering anymore).

    But I guess we need to hit the stage when living isn't fun anymore, or be the one taking care of a vegetative person before we can speak authoritatively?

    By Blogger angry doc, At November 19, 2005 1:53 pm  

  • No need to really because the truth is sometimes unpleasant!

    But I would say, the stay to the end would be much more pleasant for the unfortunate old man.

    I hope you blog more about your work and your thoughts. It's good to know that doctors are human beings too!

    I am not a doctor but I am what you call, a knowledgeable patient.

    By Blogger uglybaldie, At November 19, 2005 1:54 pm  

  • I think in our scenario the old man wouldn't have wanted to be on a ventilator for weeks before dying alone in the ICU.

    He would have wanted to die in his own bed at home surrounded by his children and grandchildren.

    And I think sometimes we as doctors have to give that option because family members want to feel that they took the option as an advice/order from a doctor to let their parent die and it's not because they were unfilial and didn't want to spend money for the ICU...

    By Blogger angry doc, At November 19, 2005 1:58 pm  

  • with regards to uglybaldie's comments:

    apologies, i've just come off post call, so i hvaen't been able to comemt earlier, and some of this alludes to your earlier comments.

    anyway, i'd just like to clarify that it's neither the doctors or the hospital administration who decides that the patient is not for active resuscitation - we have to explain to the family, they have to agree. of course, most of the time when they hear the odds of surviving, and the probable recoverable function, they do agee with us.

    also, you might not want to come within spitting distance of a government hospital, but i humbly beg to differ. even bearing in mind all the drawbacks of publiuc healthcare, i'd have to say that the standard of care in government hospitals is generally pretty good, evidence-based, and up-to-date.

    personally, i'd have more qualms with private hspitals, where the doctors earn directly from you, and (as i have it reliably from first-hand sources) frequently prescribe procedures and medications that don't help, but will make them money.

    not all, but enough of them.

    so, private doesn't necessarily mean better, unless good service and smiling staff mean more to you than the actual medical treatment.

    By Anonymous distinguished mediocrity, At November 19, 2005 5:09 pm  

  • Hi,

    Sorry about the comment on government hospitals. Apologies to you and Angry Doctor. My views were not meant to cast aspersion on the good work of our public health care professionals but rather to highlight the disparity between a business driven by profit (which also means good service and the requisite degree of professional competence) and a public service rendered as part of the government's responsibilities.

    It is undisputed that in government run hospitals, manpower in terms of doctors and nurses is stretched to a breaking point. I suspect that part of the reason why angry doctor is angry is because he is overworked, probably underpaid. LOL. In private practice, a doctor need only work at a pace that is commensurate with his earning expectations. So, the quality of health care he gives will be better. I must say I agree with the comment that sometimes proceduces are churned and medications prescribed unnecessarily but in itself, this may not be a bad thing. That is if you can afford the doc's skulduggery! I remembered some apparently unnecessary uroscopy done on a relative and it was later discovered that he needed immediate surgery to correct a medical problem.

    Whilst I do agree that the next generation of doctors needs to be trained, I do feel uncomfortable if I were to be attended to by a newbie who cannot even tell the difference between a gastric attack and an inflammed appendicitis! And you can find a lot of them in government hospitals.

    20 years ago, I had my gall bladder taken out by a surgical professor. That was when the procedure was still invasive. To this day, every time I look at my tummy, I still marvel at his surgical prowess. The surgical site is still as smooth as a baby's! But this came at a price. He was very very mercenary. And he will only do one maybe at most two similar type surgeries a day. Truly, what you get is what you paid!

    By Blogger uglybaldie, At November 19, 2005 6:56 pm  

  • I won't defend the restructured hospitals or condemn the private ones, because I don't think my breadth of experience allows me to have a balanced view.

    I think the most important facet is still the point of delivery. At the end of the day it's about whether the doctor/nurse/therapist has heart. Medical skills being equal, you want the guy who thinks that his best profit is your health.

    As for your surgical scar... it is probably more the result of your constitution rather than the surgical skills, which allows me to coin the 'Reverse Oz Bloke Law' at your expense. Haha!

    By Blogger angry doc, At November 19, 2005 7:29 pm  

  • Hi,

    I forgot to mention that the incision area is very small, hence the site looks like it has not been operated upon. You need exceptional surgical skill to take out the gall bladder with an opening smaller than the recalcitrant organ itself.

    How much of heart can you put in when you yourself is already under seige?

    At the end of the day, let's not kid ourselves. The whole of Singapore would opt for treatment at a private hospital if they can afford it.

    Also I do not agree that medical skills are equal. You have good lawyers and the less competent ones.
    There are good teachers and the really atrocious ones. I might agree that you need the same degree of knowledge to pass the examinations minimally but thereafter, the skills come in various shades but all enough to qualify that individual to practise medicine.

    By Blogger uglybaldie, At November 19, 2005 8:29 pm  

  • What I meant was: given two doctors who are equally competent to treat a condition, you will want to choose the guy who has your interest at heart rather than his bottomline, and I am not sure going private or public will guarantee either way.

    "How much of heart can you put in when you yourself is already under seige?

    At the end of the day, let's not kid ourselves. The whole of Singapore would opt for treatment at a private hospital if they can afford it."

    I would guess those statements are largely true.

    By Blogger angry doc, At November 19, 2005 8:44 pm  

  • Still using pager???
    I thought all the pagers were converted to handphones.

    Yr HO never read casesheet?
    DNR still resus & intubate?

    By Blogger eLAnee, At November 20, 2005 12:46 am  

  • Wow what a discussion! I was away for just a while and...

    Anyway good to see well balanced views from both patient and doctors :)

    I have written suggestions in a previous comment about having a socialist approach to govt hospitals and public health care.

    Angry doc now calls it the Oz bloke law? haha!

    But seriously, having a single class is the fairest way to go. I'm sure you can have no complaints from the patients. If they complain ask them to go private.

    As for doctors, those who say they want to earn mroe money, tell them to wait till their "LONG BOND" is up then go private too. We should have compulsory bonds of 6 years after attaining consultanct for our specialists trained with hospital funds. After they serve their bonds they can go where they want.

    By Anonymous Dr Oz Bloke, At November 20, 2005 12:59 am  

  • why call the reg ?

    By Anonymous Anonymous, At November 23, 2005 12:53 am  

  • He collected gold teeth...

    Plus it was departmental policy.

    By Blogger angry doc, At November 23, 2005 8:07 am  

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