Saturday, November 16, 2019

Giving Up on Someone's Life


Some time ago, we had a female patient in her 40s, came in with respiratory distress into ED.
She was just discharged from the medical ward for some pneumonia and with advanced chronic kidney disease.
She was already advised for dialysis, but her husband and she were not happy with the diagnosis, they took an AOR discharge and defaulted follow up.
She came back in a bad shape; creatinine >4000 and urea >60 and a face and body full of uraemic rashes - wet and angry lesions.
She was intubated in ED, suffered a cardiac arrest and arrhythmia - CPR and defibrillated and brought into ICU.

We treated her for hospital-acquired pneumonia and an array of complications of kidney failure.
Strong antibiotics pumped into her with many other life-sustaining drugs to keep her heart pumping well.
Few days later, her blood parameters improved but her general condition didn't - she wasn't waking up and her breathing effort was minimal.
I met the husband and explained about the current condition and introduced him to tracheostomy - while exploring her social support.

Two days later we managed to extubate her and put her on NIV machine - a machine to help with breathing but without the tube in the patient's mouth.

However, she became weaker and weaker as the hours pass.
We had to re-intubate her after a few hours. She managed to speak to her husband on that day.
We told the husband she might deteriorate further.

A few days later, she still wasn't making a good recovery. She was still very fragile and perhaps demotivated.
She cries and appears gloomy.
She understands us, but she was so weak she can only lift her fingers and perhaps some nodding or shooking.
We implored again the husband's thoughts on tracheostomy, and he adamantly refused it.
He refused tracheostomy, he doesn't want to discuss it.
But he also refuses to withdrawal of care, he wants the wife to be kept ventilated but refuses both tracheostomy and CPR.

It was perhaps a good decision, if we perform a tracheostomy on her, the woman will now be very dependant on the husband.
Not only she needs a carer for her tracheostomy (I wrote about tracheostomy before here), but she also needs dialysis 3x a week.
The whole family needs to be really dedicated and invest time and effort and energy and emotion.
Perchance, this is the best choice for her.

But we were bitter with the husband's verdict.
We felt like the husband gave up.
He refuses active intervention, he wants to wait until the patient recovers, but that is a far cry from reality.
That is a hope that might never come true.
I remember my colleagues thinking "Men, they will bail out if they can. Who want to take care of a sick and dependent wife?"
We wondered will the decision be different if we have asked the mother instead?
Will a mother give up?

But deep down I know, or perhaps I hoped - this man just did not want his wife to suffer longer.
That he loves her, and enough means enough.
Perhaps it was just his way of expressing his decision that made us disturbed - he was almost rude, he questioned and blamed our decisions, he questioned all the interventions done to his wife during all her previous admissions (which we the ICU team can't really justify as we do not know the situation then).
And his wife was young! 40s!
Her daughter is still in primary school - and she is going to lose her mum.
It was very frustrating to let a young woman die. We know if there is no active intervention, she won't make it.

Why did she default all her treatments?

Why did she take an AOR discharge then?

Why did the husband and her waited until she was very severely ill before bringing her back to the hospital?

Why even bring her to the hospital if they trust traditional medicine more than the doctors?

All these questions kept playing in my mind - unanswered.

At last, we managed to extubate her but she was so weak she can't even cough out her own sputum herself.
The nurses did vigorous chest physio and suctioned her sputum frequently.
And after a day, we discharged her to the general ward.
And she succumbed to her illness.

I see this kind of patient very often.
Every time, it breaks my heart to make that kind of decision.

-Because life is a test-

Monday, November 4, 2019

OT Call: Sampai Dua Failed Spinal in A Day

-warning: Entry ni banyak jargons. Maybe susah for non-medical persons to understand-

Starting this year, we MOs are divided into pools ie OT pool and ICU pool.
Everyone will remain in the pool for the whole month and then we either rotate or stay in the pool, depending on our boss.
I was in OT pool in Sept, then Oct in ICU pool - which explains why I had so many thoughts on critically ill patients in mind.
I am now in OT pool until next January - that is 3 months yeayy.

2nd Nov was my first OT call after switching pool. Dah lama x buat spinal wey.
But thankfully I had L, a floating MO to tag with me for 24 hours.
He does most of the work, I was there mostly to supervise and decide some minor things.
And he had two failed spinals that day. No, this entry is not to bitch about him, it is just for me to read back in the future about some of my cases I experience during oncalls.

Caesar yg kena convert GA
First case yg failed spinal tu was for EMLSCS for an unstable lie in labour.
O&G post kt L - G2P1 unstable lie, os 2cm, contractions 1:10mins tapi last meal belum cukup.
Ada lagi sejam lebih before the fasting time (6 hours) complete untuk patient tu. For those who don't know, patient nak op akan kena puasa at least 6 jam.
Lagi lagi klo patient pregnant sebab nanti ada risiko tinggi untuk tersedak makanan, masuk paru2 and mati - senang cerita. Igt suka2 doktor nk suruh patient jangan makan?

That time I was doing appendix case, and ada lagi 2 appendix menanti..
And since surgical team dah ada dalam OR, and salah satu appendicitis tu in sepsis, TWC 26 - I called that one first.
So I rush the current surgeon untuk habiskan appendix tu cecepat.
Aleh2 dia bagi HO dia close the skin, I said "Okay tapi klo HO u lambat sgt, u hv to take over sbb I hv EMLSCS"
Obviously HO dia lambat la, tapi dapat la jgk stitch more than half of the wound.
Sekali patient ni pulak lambat banguuuun. 15 mins post reversal, the kid still hasnt emerge from anaesthesia - lalok lagi adik tu, x boleh extubate.
Last2 lambat jugak induce appendix yg sepsis tu.
I was already fidgety that time, kang tiba2 O&G post unstable lie tu as fetal distress, dah kena bukak second OT. Kan susah.

And I texted Farahin tnya - kenapa os baru 2cm and contractions 1:10 dah kira in labour?
And betul la apa Frhn ckp; os dah bukak, and dh ada contractions, in labour la tu.
I got confused between in labour and active phase of labour.
Seb baik tnya Frhn dlu, sbb klo tertanya O&G sini, maluuu.

Kena pulak appendix yg sepsis ni complicated, Masz x dpt nak release tip of appendix hence Mr I scrub in and korek keluar appendix nye.
At least mencepatkan lah, boleh la pggl caesar tu cecepat.

Pastu tengah2 L membagi spinal, tiba2 ada aspirate blood pulak.
In the middle of administering spinal drugs, usually we aspirate sikit nak tengok the CSF again. And we usually can see the "cloud" coming into the syringe - ie the CSF lah.
Tp yg L pnya ni, aspirate keluar blood la pulaaak. So ktorg betul2 kan, position balik etc, dpt balik CSF nye.
Tp by then dh mendak kot ubat spinal yg lain hence the block jadi patchy. Patient still sakit bila surgeon testing kt perut 😣

So terpaksa la call Boss John - discuss next step.
Boss kata GA je lah. Uhhhukss. Utk yg tak tahu, men-GA-kan perempuan mengandung adalah sesuatu yg seboleh2nye MO Anaest nak avoid.
Bahaya wey, banyak risiko nye. Paling menakutkan, klo hypoxic smpai mak tu brain damage. Kau nk jawab kt court?

Nasib baik tadi tggu utk last meal dia habis and siap ter lambat sejam lagi sbb buat appendix dlu.
Baby nurse terus call Paeds utk standby sbb mummy under GA kan.
And intubate la itu mummy - uneventful. Op pun uneventful.

Baby je lalok. Mula2 keluar menangis pastu lalok pastu kena PPV. Last2 admit NICU under CPAP for TTN 😞

Indian yg Failed Spinal
Ini memang nk ketok L.
Bunyi mcm rasis, but no. Not rasis. Patient ni memang India mari, barely speak Malay or English hence everything was translated by the Indian employer.
Nak debride wound di kaki nya, so L bagi la spinal.
Spinal tu nampak mcm smooth je - I wasn't really paying attention sbb by then mcm dh trust L, and I started documenting BP HR sume.
Nak test level pun susah sebab the patient mmg tak faham ktorg ckp. So suruh surgeon proceed je drape.

Sekali waktu surgeon test pkai forceps, meringkuk2 patient tu sakit. Alahai kesian.
Tapi kaki sebelah dah berat, cuma yg op side je still sakit and x berat sangat. Tilt tilt table, tunggu 15 mins pun sakit lagi.
Wktu tu dah 2 lebih pagi, mata dah berat - kes x habis lagi.
Nk convert GA alaaaaahai.
Last2 supplement Ketamine. Yeay wonder drug mmg do wonders.
Terus patient lalok and tak sakit. Tnya sakit ke (secara body language) - dia kata tak, sambil mata dia dh membesar dan bercahaya kerana Ketamine. Heee~
Terasa berjaya sangat.

Tapi bila dah kena supplement2 Ketamine ni, tak boleh la nak tinggal kan L utk jaga OT sesorg.
Patient sakit je which is about every 20mins, kena tambah 10mg Ketamine and so on.
And akhirnya berjaya habis op, tanpa perlu convert GA.

Ok habis sudah ceritera oncall.
Till next time :)

-Because life is a test-

Sunday, November 3, 2019

First Screening for Masters Programme


Alhamdulillah, I passed the first screening of the Masters programme for MMed Anaes.
The registration for the programme was in July this year.

The screening is just a formality to screen and filter out applicants who do not fulfill the requirements eg those that are not yet 3 years in service, or those with insufficient LNPT marks.
So as (almost) expected, it was smooth for me. Alhamdulillah.

eHLP - Permohonan Berjaya

I am not sure about last year, but this year the exam board created a blog / website for us applicants to register for the Entrance Exam.
The Entrance Exam fee is RM250. Initially, the closing date for the exam registration was 1st November but that doesn't make sense because the release of eHLP result of the first screening has not been announced. Thank God they postponed it to the 10th November 2019.

So today, I paid the RM250 and registered myself for the entrance exam which will be held in mid Dec this year.
Let's start studying again :)

-Because life is a test-

Saturday, November 2, 2019

Treating The Critically Ill


ICU settings

As an Anaest MO, I work in both the Operating Theatre (OT) and the Intensive Care Unit (ICU).
Needless to say, the patients I treat in ICU are all very sick patients. Most of the time, they are intubated, to allow oxygen being delivered to them so that they can breathe better, and easier and thus, relieving their bodies of the fatigue.

Often, we managed to save them.
They recover, extubated and then discharged to the general (normal) ward.
Sometimes they don’t do well, and we need to know when to stop, and when to say “OK, this is it. This is our limit and there is no more we human beings can do”. It is challenging to determine that point. I am always scared that I gave up too early. What if I just need to try a bit more to save him?

Give up? Or try harder?

Often, the line separating surviving from succumbing is grey.
And adding to the complexity - is the life after survival.
One might survive the ordeal but left with disabilities that render him / her dependant on others.
One might get through a severe infection of the lungs but the heart became weak and can't even stand walking to the toilet without feeling breathless.

I would often think - would the patient rather die of the infection or live with permanent disabilities? How can we know? Will the children know?

Jangan menambahkan penderitaan seseorang / tak nak dia menderita lama

So what if we can save the patient, but we know the outcome will not be good? Should we still try all out and get the patient to live - but only having his heart beating but without his brain and muscles functioning well?

And then comes miracle. How sure can I be that no miracle will ever happen?

Families cling to the word miracle like a stranded hiker clinging on her fingernails.
They need it, they desperately hope for a miracle. And I am there, shattering all their hopes.

No, please don't hold your hopes high. You need to understand, your father is not doing well and his heart might give way anytime soon. Please be ready.

Yes, I believe in miracles. But that is specifically why they are called miracles.
They rarely happen. And if they happen, no matter what we did, it will still take place.

ICU is a very specialised and thus, limited place.
Not all patients can be admitted to ICU - we need to choose our patients carefully, those who can benefit the most from an ICU admission and we have our own admission criteria.
Some patients who unfortunately do not meet the admission criteria; will be ventilated in the general wards. And it breaks my heart seeing these patients being outside in the normal ward, and die eventually. I usually hope the families will bring them home, so that they can die at home, surrounded by their family members.
But our society don't really do that.
They'd prefer their parents to die in the hospital, and most of the time, they don't agree to the withdrawal of care. They will agree to at most, limitation-of-therapy.

Every critically ill patients have a story of their own.
They might be healthy and fit last week, but a severe infection of the lungs, or perhaps disseminated infection of bacteria into their spleen and livers, causes them to be incapacitated and fighting for their lives.
Sometimes, it is a motor vehicle accident - injuring their intraabdominal organs, their brain and/or their bones.
Critically ill patients can be any of us in the future.
Have you actually thought about it?
Would you prefer being alive but disabled permanently and relying on your family members or die trying?
Is life, or quality of life more important to you?

p/s: No I am not trying to say people that are already disabled to be better off dead. No no not at all.
It's just so hard to imagine living but not really living. You aren't even yourself anymore.

-Because life is a test-