ICU Oncall Diary

Assalamualaikum.

Disclaimer: This post is going to be very medical-jargons studded. It's my MO Diary anyway. 😆😆

Nisaq, Insyirah, Me, Diana on our way back from peri rounds. 

Yesterday I had a tiring ICU call.

My First Lumbar Puncture

I did a lumbar puncture for a suspected meningoencephalitis patient and truth be told, this is the first time I performed a lumbar puncture for a non-surgical patient.

Yes, I can do spinal anaesthesia with one eye closed, and anatomically spinal anaesthesia and a lumbar puncture are the exact same thing.
But for spinal anaesthesia, the patient is sitting up straight and I have the luxury of it being in a controlled situation although at times I really need to be quick (eg in fetal distress cases) while in a lumbar puncture, patients are in the lateral position (imagine lying down by your side, cuddling your own knees). Obviously, the challenges are different.

I attempted twice at the lumbar puncture - first using the 22G Spinocan that the Medical team already has. I can't feel the give classically described as I pierce the layers using the Spinocan hence I requested the Pencan needle I've always used from the OT.

I succeeded in my first attempt with Pencan; but since the needle diameter is smaller ie 27G; the Medical MO had to stay longer to collect adequate CSF samples into small bottles to send to the lab. Haks, sorry pal.

The Difficult Ventilation Patient

My first referral of the day was at around 4.30pm.
It was a gentleman with severe pneumonia; and the ED instead of the usual Medical team referred him to me. They could not ventilate the patient - that shows just how bad the lungs were. The highest saturation was only 93% despite 100% oxygen.

We brought the patient into ICU and then my nightmare started. It was so difficult to maintain his saturation - this basically means the lung condition is so bad that we have to tailor our machine to give such high pressure to make sure adequate oxygen reaches his lungs so that it can then go into his brain, heart, and kidney. If we can't oxygenate him, we worry about the effects on his brain. He might not be able to wake up even if he survives this ordeal.

I did not sleep at night, kept requesting for ABGs, listening to his lungs, monitoring his urine output and cracking my brain on what to do. While fighting my tiredness and sleepiness at night, I then remembered my night houseman. Anaesthesia don't have many house officers and consequently, they are not available all the time. Sometimes when they are on leave, post night, etc, only the MOs are working and we are okay with that - we are independant like that.

My Houseman

But that night, my houseman slept through the night while I wake up every hour to check on my most critically ill patient. He was sleeping in another room and really there was not much I can ask him to do even if I wake him up. So I just let him be. Even the nurses did not call him to inform any abnormalities, they called me straight away and I prefer it that way.

That got me thinking, I used to spend the night sleeping too during my time as an Anaesthesia house officer. And the nurses did not call me too.
Did my MO also sleep through the night that time? They didn't call me at night either.
Did they think I was useless as well? Were the patients during my one month in ICU stable most of the time or did I not recognise they were ill and ignorantly went to sleep?

I shudder to think if it was the latter one.
Sorry, my MOs.

Shattered 

I went home after brunch, slept and woke up 5 hours later 😅😅
But despite this tiredness, I enjoyed the call - because I passed over to Dr Rey 😍 and she always made my day brighter even it was a tiring day.

'til then

The 2019-nCov

Assalammualaikum.

[Source]

As a doctor, I can't help but keeping myself updated with the progress and spread of this newly found coronavirus.

I am not one who loudly and consistently advocates people on social media, unlike the big names in the country like Dr Amalina, Dr Rafidah, Dr Ben Rusani, Dr Rusyainie Ramli, Dr Musa Nordin, and many others. You can search for them on Facebook and Twitter and I strongly urge you to follow at least one of them on social media to get accurate and reliable information and sometimes, advice.

Even so, I can't stand irresponsible people creating fear, spreading fake news and belittling the Ministry of Health (MOH)'s effort in curbing this outbreak. The media is also not helping. They purposely put very catchy headlines, which may sometimes be misleading. They need you to click these headlines because when you click, they earn money.

Don't Worry, Malaysia IS Prepared

Even if you are not particularly proud of how Malaysia is doing in terms of media transparency or corruption rate or educational ranking or any other issue people might find with Malaysia, be it politically motivated or not, our healthcare system is actually something we can and should be proud of.

Did you know that Malaysia is ranked as one of the top countries when it comes to preparedness for a pandemic? Yes, a study was published in 2019 and they termed this "Epidemic Preparedness Index (EPI)". We are in Cluster 1; the highest possible cluster.

BMJ Global Health 2019

Another reputable assessment is by the Nuclear Threat Initiative (NTI) called The Global Health Security Index (GHSI) 2019 . It ranked Malaysia number 18 out of 195 countries; even beating Japan (21st) and Singapore (24th).

To make it even more obvious, Malaysia's index is at 62.2/100 while the world average is at 40.2/100 and high-income countries' average is 51.9/100.
That means we are even higher ranked than the average of high-income countries.

We have successfully dealt with the SARS outbreak, MersCov, Ebola outbreak and our very own Nipah outbreak in 1998/1999. Nipah was likely the most deadly of all, almost half of the infected patients die. We dealt with it successfully that time, and learned from the experience and became more prepared.

Formal, dry statistics aside, as someone who works in a government hospital, I know we have really good guidelines on curbing these infectious diseases.
Every year before the season of people start coming back from Hajj, lots of courses and workshops are done to remind and re-train everyone what to do in a suspected MersCov case. We have very specific guidelines and standard operating procedures to ensure we do the best and provide the safest care for the patient, other people and ourselves.

Even now, doctors and other allied healthcare personnel are being sent to Hospital Permai in Johor Bahru to help with the workload. Our hospital's Bilik Gerakan has already been activated. All the staff in ED are required to wear a surgical mask all the time.

How To Spot Fake News

Well, for one - fake news won't have fine details. Today I received a forwarded article, supposedly on a 22-year-old Indian national who died in Malaysia due to 2019-nCov. But the article didn't mention any comments from our top MOH speakers, neither did it mention in which hospital did the patient die in. The people who regularly update true statistics and findings are Dr Dzul, our health minister and Dr Hisham, our DG of Health. In fact, anyone who speaks on behalf of KKM can be trusted.

I believe the news to be fake but our KKM has not responded to it yet - I'll be waiting for the rebuttal.

Always ask, WHO? WHY? WHEN? HOW? to any news you came across.
If the article can't answer these questions; it is most likely fake so don't go spreading them. We don't want to end up like Zed Zaidi.

What is 2019 n-Cov?

Coronavirus is a family of viruses commonly found in animals such as cattle, camels, and bats. They usually cause the common cold and flu. 6 types of viruses have been known to infect humans, and this 2019 nCov is the seventh. MersCov and SARS are also under the coronavirus family. Read more on them from the CDC website.

How Does It Compare with Other Coronaviruses?

Well, for one it definitely is very contagious, even higher than Mers-Cov and in the same range with SARS. But it is less fatal.

[Source]

As of now, the death rate is 2.2% compared to SARS 9.6% and Nipah almost 50%. 

Why Is It So Hard To Get The Correct Statistics?

This outbreak is fairly new, numbers change every day - the number of people infected tomorrow will surely be more than yesterday and not necessarily in a predicted manner. There are still some cases that might not yet be diagnosed as 2019 nCov. That makes the total number of infected patients not yet very accurate.

So whatever data we have now, have to be interpreted with caution.

Why Is This Flu Might be Harder to Control than SARS?

This is due to the human-human transmission and the fact that people can be spreading this virus even when they are seemingly healthy.

During the SARS outbreak, patients who spread the virus are the ones who are already starting to fall ill hence it is easier to identify these patients; look for those with fever, cough, cold and isolate them from the crowd.

However, with this 2019 nCov, people who are still healthy are already spreading the virus, and then only they start to fall ill. That means, if you and I were exposed to anyone from Wuhan, China but is still feeling healthy now, we might already be spreading the virus to everyone near us before we even fall ill. Hence it's hard to identify people that are spreading the viruses.

That is one of the main reasons the Government has started to ban the entrance of Chinese tourists and foreign students from Wuhan, Hubei. They might all be carrying the virus and spreading them everywhere even though they are all perfectly healthy.

How Worried Should We Be? Should I Start Wearing Surgical Masks Outside?

My advice will be yes you can be worried but don't be panicked.
As Dr Mike stated again and again in his video, you should be ALERT, but NOT ANXIOUS.

Be alert with people around you, stay away from sick people; 6m away from coughing and sneezing person is safe.
Be alert with yourselves, routinely wash your hands with soap and don't touch your mouth, nose, and eyes unnecessarily; these are the routes the virus enters our body.

And no, I don't think we have to wear surgical masks yet in Malaysia.
We have only 8 cases positive so far and all those are Chinese citizens.

That means, if you are not at the place where there are a lot of Chinese citizens, especially those from Wuhan then you are unlikely to be infected with the virus. If you think you might be infected, please see the doctor and inform them early because every Govt facility has its own separate facility to isolate people with a suspected contagious disease.

Having said all these, I have to reiterate that these numbers are correct only at the time of writing and otherwise stated in the images. Should the situation change or we find that the 2019 nCov is more deadly than we thought it was - the advice might change rapidly.

Please keep yourself updated - follow KKM Twitter, Dr Musa Nordin on Twitter, Dr Noor Hisham and Dr Dzul both on Facebook and Twitter.

Let us all keep calm, keep ourselves and the people around us healthy.

Good global reading sources:
[WHO]
Centres for Disease Control and Prevention (CDC)