One morning, I just completed my night call and on my way to our CME room. We were having our weekly departmental CME and naturally the emergency physician would chair the session. I called one of the senior resident who worked with me that night and asked him to attend.
During the lecture, I noticed that he didn’t show up. So I sent him a text message…
“Sometime I wonder kenapa kau tak suka dtg CME. Dtg la. Belajar aje.” (Sometimes I wonder why you don’t like to attend our CME. Please come for the sake of learning).
For those who don’t understand Malay, it is consider a slap on the face if a student got this kind of message from a teacher/consultant.
I made a big mistake. Actually I did not notice that I mistakenly sent this message to my senior consultant.
He replied:”Tq for reminding…sya d Putrajaya” (Thanks for reminding, I’m in Putrajaya).
This text message when from a very junior emergency physician to a respectable senior consultant. The content should be considered as something rude.
The way he replied my message showed his maturity and why he is the “respectable senior consultant”.
I regretted I sent him the message, but I’m glad it happens. Without that incident I would have not learn a valuable lesson from him… To be humble.
It is a real blessing in disguise…
Thursday, November 11, 2010
Tuesday, October 19, 2010
Dear Doctors – Are we guaranteed enough to be saved in our own grave??
We, Muslims believed that everything that we did during our lifetime will be questioned back, the moment we have been put in our own grave. All these while, it involves good deeds and of course the negative sides of our own mistakes that we have done.
In fact, we will receive punishment in our grave prior to the “judgement day” in which life in the hereafter.
Do bear in mind that all the things that we did will either help us or punish us. I don’t think I need to explain more regarding the duty on how to perform prayers, fasting, paying zakah as well as performing haj. These can be referred directly to our pillars and all Muslims will say that they knew about it.
Moving on to the next agenda on the matter of our duty as doctors? Well, let’s talk about what we did all these while. Believe it or not, we will definitely be asked in our grave and yet, Islam has always being the way of life as it practices equal judgement. Hence, I would like to highlight once again about what we do in our lifetime will be asked in later life.
The medications that we gave to our patients, various investigations that have been carried out and others will be taken into account. Thus, this is for sure that we will be asked either it has been justified or not.
So, let’s ask ourselves, “Have we caused harm to our patients?, Do we really care and allow our patient with peritonitis to just lay down on bed at 2am and plan to do laparotomy at 8am?, Can we say that all emergencies CT with contrast need a renal profile and let them wait?. Did we fight for our patient's right or simply keep our mouth shut letting things be?
Can we answer all these questions comfortably in our grave? Perhaps, almost all of us will say a big NO. All of us must have done something during our career timeline thus that will lead us to answer it as such. I would say that nobody’s perfect in this world and we all did mistakes. But then, mistakes can be very subjective based on different views of people. It can always be intentionally or unintentionally.
In this blog entry, let us focus on the “Big Intentional Mistakes”. Big Intentional mistakes may be seen and overlooked by some of us as it is small and perhaps some may be saying that it is not a mistake at all.
An example of this big intentional mistake will be a surgeon who is preaching everyone during lectures, seminars, and conferences regarding an urgent exploratory laparotomy in an unstable intra-peritoneal bleed. Surprisingly, in his own department, it has not been done. Patients will undergo CT Abdomen to rule out other things. When they have been asked whether this “other things” can change the management or not, they will keep their mouth shut. As a matter of fact, even a surgeon in training will answer in his examination that an urgent laparotomy is needed in an unstable intra-peritoneal bleeding. But then, in real life, he would waste valuable time ordering repeating ultrasound and CT abdomen prior to the procedure. This kind of person has no insight in answering and supporting his statement yet this is the person among some people who might have hard time in their grave answering all these questions.
But, do think twice. We are “The Doctors”, the one with high ethical value. We have been taught and trained well. I personally can’t remember the exact number of various ethics’ lectures that I’ve attended. But then, think again…. I’m not talking about coming late to work. I’m talking about the simple life saving procedure and simple way to ease patient’s burden.
So, here are some questions to be pondered about:
Why each time during examination, you answer exploratory laparotomy, but in practice you delay the definitive treatment with investigations…?
Patient with meningeal signs: Why for patient A you will do CT with contrast urgently but for patient B you let him wait for hours wanting to see the renal profile first?
So, What is our answer?. Are we guaranteed enough to be saved in our grave?
Perhaps, let us start correcting these “Big intentional mistakes” and then start focusing on the small ones.
In fact, we will receive punishment in our grave prior to the “judgement day” in which life in the hereafter.
Do bear in mind that all the things that we did will either help us or punish us. I don’t think I need to explain more regarding the duty on how to perform prayers, fasting, paying zakah as well as performing haj. These can be referred directly to our pillars and all Muslims will say that they knew about it.
Moving on to the next agenda on the matter of our duty as doctors? Well, let’s talk about what we did all these while. Believe it or not, we will definitely be asked in our grave and yet, Islam has always being the way of life as it practices equal judgement. Hence, I would like to highlight once again about what we do in our lifetime will be asked in later life.
The medications that we gave to our patients, various investigations that have been carried out and others will be taken into account. Thus, this is for sure that we will be asked either it has been justified or not.
So, let’s ask ourselves, “Have we caused harm to our patients?, Do we really care and allow our patient with peritonitis to just lay down on bed at 2am and plan to do laparotomy at 8am?, Can we say that all emergencies CT with contrast need a renal profile and let them wait?. Did we fight for our patient's right or simply keep our mouth shut letting things be?
Can we answer all these questions comfortably in our grave? Perhaps, almost all of us will say a big NO. All of us must have done something during our career timeline thus that will lead us to answer it as such. I would say that nobody’s perfect in this world and we all did mistakes. But then, mistakes can be very subjective based on different views of people. It can always be intentionally or unintentionally.
In this blog entry, let us focus on the “Big Intentional Mistakes”. Big Intentional mistakes may be seen and overlooked by some of us as it is small and perhaps some may be saying that it is not a mistake at all.
An example of this big intentional mistake will be a surgeon who is preaching everyone during lectures, seminars, and conferences regarding an urgent exploratory laparotomy in an unstable intra-peritoneal bleed. Surprisingly, in his own department, it has not been done. Patients will undergo CT Abdomen to rule out other things. When they have been asked whether this “other things” can change the management or not, they will keep their mouth shut. As a matter of fact, even a surgeon in training will answer in his examination that an urgent laparotomy is needed in an unstable intra-peritoneal bleeding. But then, in real life, he would waste valuable time ordering repeating ultrasound and CT abdomen prior to the procedure. This kind of person has no insight in answering and supporting his statement yet this is the person among some people who might have hard time in their grave answering all these questions.
But, do think twice. We are “The Doctors”, the one with high ethical value. We have been taught and trained well. I personally can’t remember the exact number of various ethics’ lectures that I’ve attended. But then, think again…. I’m not talking about coming late to work. I’m talking about the simple life saving procedure and simple way to ease patient’s burden.
So, here are some questions to be pondered about:
Why each time during examination, you answer exploratory laparotomy, but in practice you delay the definitive treatment with investigations…?
Patient with meningeal signs: Why for patient A you will do CT with contrast urgently but for patient B you let him wait for hours wanting to see the renal profile first?
So, What is our answer?. Are we guaranteed enough to be saved in our grave?
Perhaps, let us start correcting these “Big intentional mistakes” and then start focusing on the small ones.
Saturday, September 25, 2010
Spice-up “Impression” and/or Diagnosis
The Emergency Department is the place where most diagnoses are made.
Quite frequently, patients in the Emergency Department will be admitted without a firm diagnosis. Not being able to give an exact diagnosis is not in itself a failure of management. It is a matter of simply describing the patient’s current illnesses
I’ve always emphasized to myself and other medical officers to clearly state their diagnosis/impression. Lets face it, how often do you think doctors in the ward will read the whole documentation once patients have been admitted? Most of time they will just read our Impression: e.g., Acute Inferior MI.
By not reading the whole document, the team upstairs will not know some of the important things (why the diagnosis was made, findings, management and etc.) that happened in the Emergency Department.
Therefore during their morning rounds, the consultants will not be fully informed regarding the initial management and will assume most of the patients’ management has been done by their team rather than otherwise.
Once, I encountered a cardiologist that did not realize most patients with AMI in his center received their thrombolytic agent in the ED (without the presence of the cardiology team). In fact, patients’ complications will be fully managed in the ED as needed (central venous line, arterial line, inotropes, temporary pacemaker, etc.) and yet it is presumed that these things were done by the cardiology team.
So my suggestion is simple, we spice up the only thing that we are sure the receiving team will read, i.e., The Impression.
Here are some of the examples that I have started to write during my rounds.
Suggestion #1:
Imp: Acute Inferior MI
Change to
Imp: Acute Inferior MI with right ventricular involvement complicated by acute pulmonary edema (Killip II), reperfused post-Streptokinase
Suggestion #2:
Imp: Thyphoid
Change to
Imp: Clinical Thyphoid (Awaiting serology) in view of
1) Relative bradycardia
2) Constipation preceeding diarrhea
Suggestion #3:
Imp: Septic shock secondary to pneumonia
Change to
Imp:
1) Septic shock secondary to pneumonia (currently on single inotrope, SvO2 improving)
2) Intubated for respiratory distress with difficult airway (Comark Lehand III)
Suggestion #4:
Imp: AGE with severe dehydration
Change to
Imp:
1) AGE with severe dehydration - failed outpatient therapy
2) Hypokalemia secondary to 1 (K correction started)
3) Lactic acidosis secondary to 1 (improved after initial fluid bolus)
Suggestion #5:
Imp: MVA with left femur fracture
Change to
Imp:
1) Alleged MVA with close fracture of left femur
2) Complicated by Class II shock (Improve with fluid bolus and traction)
Quite frequently, patients in the Emergency Department will be admitted without a firm diagnosis. Not being able to give an exact diagnosis is not in itself a failure of management. It is a matter of simply describing the patient’s current illnesses
I’ve always emphasized to myself and other medical officers to clearly state their diagnosis/impression. Lets face it, how often do you think doctors in the ward will read the whole documentation once patients have been admitted? Most of time they will just read our Impression: e.g., Acute Inferior MI.
By not reading the whole document, the team upstairs will not know some of the important things (why the diagnosis was made, findings, management and etc.) that happened in the Emergency Department.
Therefore during their morning rounds, the consultants will not be fully informed regarding the initial management and will assume most of the patients’ management has been done by their team rather than otherwise.
Once, I encountered a cardiologist that did not realize most patients with AMI in his center received their thrombolytic agent in the ED (without the presence of the cardiology team). In fact, patients’ complications will be fully managed in the ED as needed (central venous line, arterial line, inotropes, temporary pacemaker, etc.) and yet it is presumed that these things were done by the cardiology team.
So my suggestion is simple, we spice up the only thing that we are sure the receiving team will read, i.e., The Impression.
Here are some of the examples that I have started to write during my rounds.
Suggestion #1:
Imp: Acute Inferior MI
Change to
Imp: Acute Inferior MI with right ventricular involvement complicated by acute pulmonary edema (Killip II), reperfused post-Streptokinase
Suggestion #2:
Imp: Thyphoid
Change to
Imp: Clinical Thyphoid (Awaiting serology) in view of
1) Relative bradycardia
2) Constipation preceeding diarrhea
Suggestion #3:
Imp: Septic shock secondary to pneumonia
Change to
Imp:
1) Septic shock secondary to pneumonia (currently on single inotrope, SvO2 improving)
2) Intubated for respiratory distress with difficult airway (Comark Lehand III)
Suggestion #4:
Imp: AGE with severe dehydration
Change to
Imp:
1) AGE with severe dehydration - failed outpatient therapy
2) Hypokalemia secondary to 1 (K correction started)
3) Lactic acidosis secondary to 1 (improved after initial fluid bolus)
Suggestion #5:
Imp: MVA with left femur fracture
Change to
Imp:
1) Alleged MVA with close fracture of left femur
2) Complicated by Class II shock (Improve with fluid bolus and traction)
Saturday, September 11, 2010
My first Eid Ul-Fitri as an Emergency Physician
Recently me and my family celebrated Eid Ul-Fitri. This is my first Eid as an Emergency Physician (EP). Here are some of the remarks I got regarding my profession (most of them translated of course…)
Aunt #1: So you can treat anything and everything???...
Me: No Aunt, just anything to do with emergency situation.. including finding a taxi and a coffin..
Cousin #1: You are an EP now, so when are going to be a specialist???
Me: … (Stunted)….
Cousin #2: So (since you are a specialist now) you are not seeing patients anymore.
Me: I’m responsible for hundred off them perday, review a handful of them, fought for some of them, conducting procedures and sadly pronounced death for a small fraction of them.
Cousin #3: Now that you have become a specialist, Life will be easier for us. Recently I was found to have an enlarged uterus for more than 6 months. I’m currently under gynecologist follow-up. May be you can help out….
Me: Please continue the follow up. In emergency department, we take care of acute illnesses. We will refer this kind of cases to the same person that you have seen.
Aunt #2: So you are specialized in Emergency Medicine… I just get to know about it recently.
Me: Thank God…Finally.
I’m not surprise with some of the remarks. “Emergency Medicine” and EP’s are still young in Medical Field. We still have a long way to go.
Selamat Hari Raya to all
Aunt #1: So you can treat anything and everything???...
Me: No Aunt, just anything to do with emergency situation.. including finding a taxi and a coffin..
Cousin #1: You are an EP now, so when are going to be a specialist???
Me: … (Stunted)….
Cousin #2: So (since you are a specialist now) you are not seeing patients anymore.
Me: I’m responsible for hundred off them perday, review a handful of them, fought for some of them, conducting procedures and sadly pronounced death for a small fraction of them.
Cousin #3: Now that you have become a specialist, Life will be easier for us. Recently I was found to have an enlarged uterus for more than 6 months. I’m currently under gynecologist follow-up. May be you can help out….
Me: Please continue the follow up. In emergency department, we take care of acute illnesses. We will refer this kind of cases to the same person that you have seen.
Aunt #2: So you are specialized in Emergency Medicine… I just get to know about it recently.
Me: Thank God…Finally.
I’m not surprise with some of the remarks. “Emergency Medicine” and EP’s are still young in Medical Field. We still have a long way to go.
Selamat Hari Raya to all
Tuesday, August 17, 2010
Treating patients as parents…. Should we???
We all have heard remarks that doctors should treat patients as their parents. Some of us accepted this view as it’s provided a firm practices of medicine.
I personally think this notion should be alter.
When my parent was admitted, I was able to stay up more than 36 hours, running from department to department, stand-sit-kneel and all of others. I managed to do this for one patient. We managed numerous patients per day and it is impossible if we would have to do the same.
Plus, when we managed our parents, we tend not to be objectified. First, we would think the worst possible diagnosis and doing unnecessary investigations. Second, some of us would even go to the other extreme as thinking there is nothing terribly wrong with our parent and asking them to sit tight in the house.
Belief me when I say I’ve seen doctors that wrongly treated their parents. Most of them regretted what they have done.
The best way is to get a second opinion. This not only shows the doctor’s maturity, it would directly give the best treatment to our parents.
So when you ask
“Should you treat your patients as you are treating your parents?”.. I’ll answer NO and alter to..
“We should treat our patients as we would like other doctors to treat our parents”
Does it sound fair???
I personally think this notion should be alter.
When my parent was admitted, I was able to stay up more than 36 hours, running from department to department, stand-sit-kneel and all of others. I managed to do this for one patient. We managed numerous patients per day and it is impossible if we would have to do the same.
Plus, when we managed our parents, we tend not to be objectified. First, we would think the worst possible diagnosis and doing unnecessary investigations. Second, some of us would even go to the other extreme as thinking there is nothing terribly wrong with our parent and asking them to sit tight in the house.
Belief me when I say I’ve seen doctors that wrongly treated their parents. Most of them regretted what they have done.
The best way is to get a second opinion. This not only shows the doctor’s maturity, it would directly give the best treatment to our parents.
So when you ask
“Should you treat your patients as you are treating your parents?”.. I’ll answer NO and alter to..
“We should treat our patients as we would like other doctors to treat our parents”
Does it sound fair???
Friday, August 13, 2010
Inbreeding is a dangerous thing….
Genetic inbreeding has been going on up until now since the first it has been created. With regards to human inbreeding, I personally think that all of us agree that it does more harm. Well, if it’s not, I bet our parents will keep on asking us to marry our cousins without knowing about the consequences. It has not only scientifically proven that it carries genetics diseases, but it also slows human development.
If you accidentally made a silly mistake, people would even sometimes joke around and ask you if your parents are related. In a way, it implies that inbreeding produces a weaker (or slower) generation.
There is a concept of “Faculty Inbreeding” and this is the one that I would like to discuss more. Faculty inbreeding implies that the same student graduated and rejoins the same institution. It reduces the possibility of new ideas that are coming in from external sources, just as genetic inbreeding in which it reduces the possibility of new genes entering in to a population.
Let me simplify this concept for better understanding. A medical student graduated from university X became an intern in University X. He then later joined a specialist training in University X and became a specialist in University X and calling himself a world standard physician.
Try to imagine, a person that only drives a Proton Saga throughout his life, could not possibly commented much regarding Mercedes, BMW, Porsche and etc. This person can brag all he wants regarding proton fuel consumption, price on the road but until he has driven others, he might not know the smoothness, safety and reliability of other cars. If Proton is so good, people would not have bought other cars. There must be reasons behind it and until you have driven it, you might not see the whole picture of what I am saying.
Dr Ogren from University of Minnesota wrote “A high quality graduate training cannot be achieved if such inbreeding of ideas takes place”.
This statement did not surprise me. First, a student from the same institution was obviously has the same experiences and therefore ideas as others. Secondly, this student will always obey their “Master” no matter how old, ancients and disruptive the idea really is. Otherwise we will not have seen patients with unstable intra-abdominal injuries getting a CT Abdomen, patients with moderate to severe head injury getting X-ray cervical (AP, lateral, shoulder pull, swimmer’s view and etc) prior to CT cervical. All these happened and things are still happening because the “Master” is considered right even though he is clearly wrong.
These new inbreeding faculty members would have a narrow horizon. For them, the horizon is set and all that they have to do is just to continue to work as before. No new destination, no new technique, no new management and continue to breed a new generation that follows a very old captain. The worst thing is that they don’t even know what is new and the right thing to do. They act as in they are so smart and rejecting unheard ideas.
Inbreeding faculty members would want someone to stay with them and eventually those who have the same ideas like them (or the one that would not object). In turn, they will try not to hire people who try to introduce and invent new things. These new things might save more lives; transform the department to become more efficient and in turn it makes life worth living. But because it is not understand by these so called “Master”, it could not have been done.
This “Faculty inbreeding” product is very contagious. It can affect hospitals which are nearby and for those who depend on them as a tertiary hospital. Their management will have to alter according to this old, ancients rule prior to sending these patients.
I have always asked my students to compare their lecturers. Which one gives best, compact and informative lecture? Is it the one that inspires them most? Almost all gave me a lecturer who has been to a lot of places with lots of experiences.
Don’t get me wrong, I’m not trying to say that we should not buy proton cars. I’m driving a Proton car myself. After I have owned a Honda, Mercedes (a second hand car of course) and drives many others, I have decided to buy a Proton Saga because of its fuel consumption, cheaper taxes and maintenances. I know I have given-up some aspects in terms of comforts and safety but I try to compensate it by driving it carefully. All I’m saying is that I know what I’m driving rather than bragging that this is the best car ever.
Even Prophet Muhammad (pbuh) himself preaches us to travel to China if necessary. Yet, some of us are feeling so comfortable in their “comfort zone” and rejecting this precious statement.
Once we “The Doctors” have seen other systems, departments, protocols, personnel and etc, then only we would appreciate how much lives that we have truly saved and how much that have died in vain.
If you accidentally made a silly mistake, people would even sometimes joke around and ask you if your parents are related. In a way, it implies that inbreeding produces a weaker (or slower) generation.
There is a concept of “Faculty Inbreeding” and this is the one that I would like to discuss more. Faculty inbreeding implies that the same student graduated and rejoins the same institution. It reduces the possibility of new ideas that are coming in from external sources, just as genetic inbreeding in which it reduces the possibility of new genes entering in to a population.
Let me simplify this concept for better understanding. A medical student graduated from university X became an intern in University X. He then later joined a specialist training in University X and became a specialist in University X and calling himself a world standard physician.
Try to imagine, a person that only drives a Proton Saga throughout his life, could not possibly commented much regarding Mercedes, BMW, Porsche and etc. This person can brag all he wants regarding proton fuel consumption, price on the road but until he has driven others, he might not know the smoothness, safety and reliability of other cars. If Proton is so good, people would not have bought other cars. There must be reasons behind it and until you have driven it, you might not see the whole picture of what I am saying.
Dr Ogren from University of Minnesota wrote “A high quality graduate training cannot be achieved if such inbreeding of ideas takes place”.
This statement did not surprise me. First, a student from the same institution was obviously has the same experiences and therefore ideas as others. Secondly, this student will always obey their “Master” no matter how old, ancients and disruptive the idea really is. Otherwise we will not have seen patients with unstable intra-abdominal injuries getting a CT Abdomen, patients with moderate to severe head injury getting X-ray cervical (AP, lateral, shoulder pull, swimmer’s view and etc) prior to CT cervical. All these happened and things are still happening because the “Master” is considered right even though he is clearly wrong.
These new inbreeding faculty members would have a narrow horizon. For them, the horizon is set and all that they have to do is just to continue to work as before. No new destination, no new technique, no new management and continue to breed a new generation that follows a very old captain. The worst thing is that they don’t even know what is new and the right thing to do. They act as in they are so smart and rejecting unheard ideas.
Inbreeding faculty members would want someone to stay with them and eventually those who have the same ideas like them (or the one that would not object). In turn, they will try not to hire people who try to introduce and invent new things. These new things might save more lives; transform the department to become more efficient and in turn it makes life worth living. But because it is not understand by these so called “Master”, it could not have been done.
This “Faculty inbreeding” product is very contagious. It can affect hospitals which are nearby and for those who depend on them as a tertiary hospital. Their management will have to alter according to this old, ancients rule prior to sending these patients.
I have always asked my students to compare their lecturers. Which one gives best, compact and informative lecture? Is it the one that inspires them most? Almost all gave me a lecturer who has been to a lot of places with lots of experiences.
Don’t get me wrong, I’m not trying to say that we should not buy proton cars. I’m driving a Proton car myself. After I have owned a Honda, Mercedes (a second hand car of course) and drives many others, I have decided to buy a Proton Saga because of its fuel consumption, cheaper taxes and maintenances. I know I have given-up some aspects in terms of comforts and safety but I try to compensate it by driving it carefully. All I’m saying is that I know what I’m driving rather than bragging that this is the best car ever.
Even Prophet Muhammad (pbuh) himself preaches us to travel to China if necessary. Yet, some of us are feeling so comfortable in their “comfort zone” and rejecting this precious statement.
Once we “The Doctors” have seen other systems, departments, protocols, personnel and etc, then only we would appreciate how much lives that we have truly saved and how much that have died in vain.
Friday, April 16, 2010
Coming Soon...
The blog will be oficially launch once I've completed my final Emergency Medicine exam.
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