Incompetency

Today is a weekend off.

I’d finished the last oncall of this month on tuesday. it was really a bad oncall, and i would said it got worst from the previous one. an incident happened during the oncall (but i didn’t realized it till tomorrow afternoon).

dr zanariah’s geriatric patient complained that he had a fall. he claimed it happened on the night of my oncall. however, it was not reported to the staffs nor did they witnessed the fall. to complicate matters, i did not record anything from the patient because i didn’t do the night round …. nice eh?

hey, i was really busy ok! i got down to a&e after taking my bath at 9 pm and stayed there till 12 am. who on earth want to wake up the patients for night round at 12 am when they already sleeping? in fact, dr siti had already made the specialist night round earlier around 730 pm. why must the MO make another round? gila ker apa?

so the incident had been reported as official incidence. so, i may need to answer to the incidence commitee later.

hah… whatever lah. shit happened.

Hospital Kuala Lumpur

I finishned my oncall for the month of January 2009 yesterday. Today is the first day of 2009′s year of the ox CNY and I’m starting my self-proclaimed study week till 2nd Feb, and that’s a whole long week.

I’ve already been in HKL psychiatry department for nearly two months now. It’s a lot different compared to either Sg Petani or even UMMC. The most prominent is the high workload, number of patients and fast turn over of bed. Then the varieties of cases and the types and class of patients you see there. Then later, it’s about the style of managements and the availability of pharmacological agents to choose.

Let me talk first about the patients. There is sure whole lot of patients there. I was only managing up to maximum of 5 or 6 in-patients at any one time in UMMC, but here in HKL there will be at least 11 to be cared of, and if you are not lucky (either you are alone in your team or you have to cover your colleague in the same team) the number can rise up to 18 or even 20 patients at a time, and they must be seen daily. Luckily, I’m managing the team with one of my colleague so we managed to split up the allocation of patients but that didn’t spare me the tension when I need to cover her up during her leave. Luckily also for me, as I used to see 15 to 18 in-patients/day when I was in Sg. Petani. This way I can tell myself that it’s not THAT bad in HKL. We see mostly low to medium class of people in HKL. Mostly are in social class II and III, but there are those in social class V. They comprised of Malaysians and also international ‘customers’ and majority of them are foreign workers either legal or illegal ones. Somedays, they can also be some tourists who turned psychotic on their ‘visit’ to Malaysia. Majority of admissions are re-admissions and majority due to poor compliance. We see same cases of schizophrenia, mood disorders and organic psychoses, but the presentations (especially the content of the thought disturbances) are quite different from UMMC. The patients can present with very bizarre delusions and their disorganized behaviours can be very very psychotic (maybe we saw these much more as staffs in HKL has higher level of tolerance towards these behaviours compared to UMMC where the staffs will always call the doctor when the patients started to be agitated and apporaching the counter).

Ok, I think I’ll continue later about the people there and their approaches to psychiatric illness.

never take a leave without cover

It is only 2 months before I leave UMMC for HKL to continue my master’s programme. I got a senior in my team who is supposed to take his final exam in November. He was thinking of finishing his leaves all in a go before his final exam, but then was told by the HOD to take it in between working days. I’ve been covering him since before Hari Raya and has been doing much of his unfinished works (just like what all the other seniors did for him previously). I has to face and manage his unsettled patients, and took care of his lecturer’s patients who was admitted.

I really thought the covering for him will be over 3 days after I came back from my Hari Raya leave. But, instead, he put up my name to cover him until the end of the week. I don’t say much because, thanked God, he didn’t leave any unsettled or partially managed patient for me. But, I don’t think putting up my name as the one who’s covering him till the end of the week is correct.

I hate A&E duty!

I finished my A&E duty for this month yesterday. Although it was only once a month duty, I really feel happy to get over it. I never like to be doing the A&E duty. I rather be doing more ECT duty than to be stucked for 8 hours in a consultation cube at the green zone listening mainly to complaints about URTI and getting full medical examination etc etc.

I’m not a locum-oriented doctor. So, having me sit there just like those doing locums at private clinics really stressed me up. Then the downside is that you don’t get immediate payment after doing the A&E duty! You are being considered to be doing your daily job; except that you are doing it at the casualty level rather than your own ward and specialist clinic!

I don’t know why and whose idea was it to put those in the so-called 2nd line team into the green zone duty at the A&E. Why must we be doing those kind of jobs? We are not the one whose being trained as first liners to see acute emergency cases. What if there are really acute emergencies in the green zone; patients who suddenly fall uncomsciously there etc? How are we supposed to react?

I’m really not comfortable in the A&E green zone. To be honest, I rather being put into the resuscitation zone at the A&E to full fill my 8 hours requirement. I feel I might be more usefull in helping to resuscitate those dying; helping to insert IV lines in a stressfull situation, inserting chest tubes or CVPs – that are what emergencies are all about. Not sitting in the consultation cube listening to lame complaints about minor illness that shouldn’t have come to the A&E at all.

However, to all A&E doctors – keep up the good works. I salute your commitments!

I just hate sick lawyers!

There’s always something big about sick professionals. In my case, it’s a mentally disturbed lawyer.

He was admitted to the ward during the weekend with manic symptoms and sudden suicidal ideation, and was put under my care since Monday. He had already causing some displeasured among the staffs (or maybe the other patients also) when he started became lovey-doey with his girlfriend who was with him all along the weekend. Another problem was his reluctancce to take the prescribed oral medications- his reason being that he’s not sure what they were for and wanted to wait for the consultant to brief him on Monday.

 

I managed to get history from him, and completed the first interview session with the cognitive evaluation on Monday morning. He looked cheerfull and was forthcoming during the interview, and even took the medications after being explained by me regarding their purposes.

I stepped on the wrong foot that afternoon, when I inocently walked to him to ask whether his colleague was coming. He started scolding me about the number of doctors who came to see him, with everyone telling him confusing plan of managements, especially about the duration of his stay. He was also upset that the consultant that he hope so much to look after him only came to chat with him for 5 minutes and told him that the trainees will be directly be in-charge of the care. Things were getting out of hand when he started demanding to be discharged (even against medical advice) and wanted to be cared by his personal GP doctor, who he claimed has psychiatric training (I even spoke to that doctor who claimed that he was a psychiatric MO sometime ago). He was arrogantly said that he lost confidence in my way of treating him. He was asking that a consent paper regarding his agreement for admission be shown to him, or else he would walked out of the door without anybody stopping him because it was his rights. He was saying how everything in medical need consent and he knew that because he handled some medical negligence cases. It was difficult to explain that only invasive procedures need consent. Sometime I felf as I was talking to a stone or a wall and it was ‘ibarat mencurah air ke daun keladi”. The ever present girlfriend also added some salt to the ‘cooking’ saying that doctors should be taking care of him all along the time, being around him most of the time because he was not yet put on a formal diagnosis etc etc. As if we don’t have other duties to do for the day!

 

The parents also (the mother especially) were saying that their son should not be kept in ’this’ kind of place because he was already toned down and more lucid about his surroundings, and was talking something logical. But at least thay backed off after seeing their son banging into the room and behaving irrationally and demanding excessively regarding his plan of managements.

 

I really thanked God, that the problems were fully settled today. He was calmer and able to except our explaination today (that was after IM Clopixol Acuphase 100 mg yesterday + oral antipsychotic + mood stabilizer + benzodiazepine). I just told myself not to take heart of what being told to me during the long 2 hours yesterday, and to take them in my stride. At the end of the day, he was in a high mood yesterday, and was quite paranoid, and these were characteristics of the disease.

I am tired.

I’ve been working and traveling almost non-stop since the early of March. That also includes the time I commuted from Sg Petani and Kangar, and the period I spent taking care of our baby (wife going for her Induksi and BTN in short period of time in between). But the most tiring were our clinic days. Since the implementation of LIVE eHIS, the consultation time in the clinic has been a burden on me. We took a little bit longer to key in the information. I’m also not willing to let my patient see me just for seconds only. Pity those who came a long way, paid sums of money, took a long time for registration and then waited to see the doctor, but then when the time came, the patients only saw the doctor for a minute or less. If it was me,I couldn’t tell my respective patient if I’m just going to see him/her for a minute! What will be the feeling of the patients when they were told straight away to collect the medication after just warming up their seats in the consultation rooms?

That is why I took a few minutes to talk and explain to my patients. Follow up sessions are the time (although not so much time available) to psychoeducate and remind the patients and their families about their illness and the current managements. Doctors can always take the little time they have to check on compliance, social support, apart from checking on psychotic symptoms. But, that amount of time spent can cause backlogs of waiting patients, and the numbers allocated to each doctor will increase if less doctors are around. That is why I was trained not to take leave on clinic days (thanks to surgical, err .. especially mr rashide, yakhh!). I really want to take leave on Sundays and Mondays especially if I’m already having weekend free of oncalls. But, that will causes my colleagues that are around on that day to be swamped with patients! And now the MAs cannot help us to see patients after the launch of eHIS because of their limited access capability.

I don’t know how my friend can take leave on clinic days. He has conscience and insight about the workload, and how slow consulting times increase with eHIS, but still insisted on taking leave on that days because he’s not oncall and wants to finish his leaves before quitting the goverment post. I too can do the same thing. Just take my leaves because I’m gonna go for my master’s programme (insyaallah) because I might not have the chance to take long leaves when I start my study.

I know that this world can be a better place to stay if we are more considerate. On my part, things can be kept cooled if I just shut up and continue to do my routines. But, what about fairness? What about my or our chances to take our holidays? Do we have to bear, and suffer our mental and psychological exhaustion because of someone’s else? Do the person we sacrificed for, acknowledges our contribution? What do we get from it? : – body aches, psychological exhaustion …………………. ? Please, be rational to other people.

Call me, please ………..

  We always receive referrals during oncalls, especially from district hospitals. The referrals were mostly about admissions, and sometimes were just for consultation purposes. We are not supposed to be angry, more so scolded the persons who refer the case, because they too are busy during their oncalls. Referrals are akin to telling the host that you are coming to their house, or sending somebody to them, so that the hosts will not be surprised when somebody unknown to them suddenly appear on their doorstep, or worst in their house.

  That is why I usually remind the district MOs to give me a call first before sending the patients over for admission. Somethings can be solved just by phone consultation and don’t need admissions, whereas somethings need to be informed first, so that I can prepare my staffs for the arrival of the patients, and got hold of the accompanying PAP. I’m not a person who reject admission just like that, but I really need some reason about why the patient really needs admission; sometimes the patient was not at any fault, but was sent for admission because the family just didn’t like him being at home. This world is really a cruel place, isn’t it!

  However, what I got from my last 2 oncalls were utter dissappointment. 2 admissions were straight away put into my ward before being informed to me. Well, they were not informed at all – and the guilty party was the district MO. I couldn’t blame our Casualty MO because they will admit any referrals from district because most of the times, the cases were already informed to the respective MO oncalls. Both of the dissappointments were cases from Hospital Baling by the same MO: Dr Lailatul Azrah, and this is the 3rd time she bypassed me for admission. I don’t know what her problem is. I’ve already informed her last month to give us a call first when she suddenly sent an ‘unknown’ to us who was arrested by police in Pekan Baling. I didn’t scold her at all! I explained to her the importance of informing us first before sending the patient, and even asked her to spread this directive to her other colleagues. Obviously she couldn’t heed the advice, and maybe my ‘advice’ need to be upgraded to another level …..

  I can’t understand why some MOs are very lazy to inform us about psychiatric admissions. If they can inform other specialities’ MOs oncalls about their referrals, why is that different with us? Are we really second class service, that we will just swallow what others shove through our throat? Maybe the notion of psychiatry MOs being passives can be accepted in the past, but now psychiatry MOs are more ‘virulent’ and aggressives, and no more bullying around of us anymore. We also demand the same respect, and we only ask that our patients be taken seriously.

  If any referring MOs think that psychiatric patients are of lesser importance and can be pushed here and there, I would like them to properly manage the patients first before sending them to us, or even thinking about consulting us. I don’t like to scold, but don’t consider us, our staffs and even our patients as pushovers. I had scolded people when I was a surgical MO, and even being scolded by tertiary hospitals’ MOs, so I think we know the feelings of it in both situations. I just want to have a healthy relationships with district MOs, because at the end, we still need each other. To the above mentioned MO, kindly wait for my call to ‘advice’ you!!!   

there will be flaws here and there

There are flaws in everything – humans, animals, machines etc, except the God almighty. The flaws might make us angry and dissatisfied, or make us determine to overcome it towards near-perfection (I don’t believe in perfection though ….)

Now, we are starting to find loopholes, flaws, user-unfriendliness, breakdowns etc in our eHIS. That are things that can’t be avoided if you embark on a new system, or even personnel.

I really hate it when the times come for me to order Therapeutic Drug Monitoring (TDM) order from the system. The system flow of the TDM is very haywired until the pharmacist refused the samples, and requested a manual, form-filled request. My first experience with TDM was a disaster because the whole IT unit that was involved with it need to be called into my room – thank you to En Adam, Cik Ira and Miss? Janice because of your help in getting my sample processed after minutes of trial-and-error. I was really amazed that by afternoon, the result was ready for me to view without asking the PPK to fetch it. However, my second experience was terrible; 2 of my specimens were straight away rejected because the pharmacist said her computer already ‘pening’ and she couldn’t process the order. But, may I ask, whether if it was the pharmacist the one who was ‘pening’ at that time?

Then we have this problem about registering referrals, in my case, the concern is more towards the referral from Casualty Dept for mental state evaluation for admission. The referring doctors sometimes really missed out the referral portion, and straight away discharged the patient that need to be seen after giving a call to the doctor who was supposed to take the referral resulting the disappearance of the patient from the system thus blocking another doctor from viewing the initial clinical notes. It’s still ok if the Casualty Dept is making mistakes now, as mistakes are made to be learned. However, I must congratulate those like Dr Soo Choo Kong – a ‘veteran’ who still take the challenge to learn the usage of a system that’s really an alien to his generation, and those youngsters like Dr Dymna and Dr Wong, to name a few, who took the task of referring the patient to be seen electronically via a virtual clinical notes. Their contributions really speed up tracing of old notes and previous manual OPD cards, and making recalling pertinent matters regarding the patient easier.

 

All hail the brave ones!!!

There’s nothing to be scared and paranoid of!! But there will always be rooms for imrovements!

The problems with eHIS

We are still in the 3rd stage of the Hospital Informatiom System. As I mentioned in the earlier post, there were all sort of craps going on in the initial implementation of the Go Live! stage. I heard that most of the problems occured with the front line team, especially the Emergency Dept, and the specialist clinic.

I think the problems can be divided into several sources;

doctors – because majority of them were so ignorant and determined not to follow the system, thus abandoning the preparatory programmes

paramedics & other support staffs – these are also those who were too busy to equip themselves before the programme take off

patients – Malaysians are well known to lose their temper at the slightest inconveniences, whenever their demands can’t be met immediately etc etc. This more correct when we observe the ‘unique’ patient’s pool of Sg petani

eHIS – this is the first time a hospital with an already present pool of patients being equipped and told to embark on the eHIS. As I was being told, this is the first in the world. Whoah! Cayalah Sg Petani!

 

  I has mentioned 3 human-related factors against a single machine-related factor. Is it clear where we can start to improve the programme? Ok Ok …. for those so dumb to evaluate the logic, here’s the answer:

We should start by improving the human-related factors. Not many will agree, because some will say it’s easier to change the programme, rather than corecting human’s perceptions. But, it will take quite a lot of money, time and working hours to correct something that’s already being implemented and accepted at the previous hospitals.

It’s the human touch that need to be improved. Things like whipping the hard ass of the IT illeterate doctors about the advantages of the system, teaching them to be more tech and IT-savy, giving confidence to them to explore the system, and not afraid of making mistakes etc.

What’s so hard of making a mistake, just press on Ctrl-Alt-Delete, then log off the system. Any takers? You can try it now!

Case study: our 1st ECT

Mr MN

Baling, Kedah
1^st admission:

Was shouting non-stop and talking irrelevantly on admission

Reason for admission: tried to harm family members, decreased appetite and sleep

Noted changes of behaviour 2005; social isolation – acquired traditional Rx

Condition deteriorated 2006; Talking To Self and Laughing To Self, wandering around, claimed being bullied by seniors at school, wanted to see ‘Tuanku Sultan Abdul Halim’, claimed people going after him, bringing ‘parang’ to go to war

seek Rx at psych department for 3 f/u, then refused to come back again

In ward:

+ Paranoid delusions with religious preoccupation:

Saying that Muslims are being victimized in Penang and Singapore

Wanted to chase ‘ghosts’

+ family history of mental illness: uncle-maternal side

Stopped schooling at 15 y/o

Used to take ganja

Started on haloperidol and changed to sulpiride

2^nd admission:

Readmitted around 1 month after discharged

Reason for admission: irrelevant speech, poor sleep, disturbing public

In ward:

Need to be restrained nearly 2 days, preoccupied, hostile

Was put on 2 days of IM Acuphase

Still not yet settled considerably after 3 days of admission; praying in a disordered manner around the ward, still need to be restrained on 4^th day of admission

+ Nihillistic delusison:

Claimed he was deaf and dumb during his childhood years because insects which were actually ‘syaitan’ flew into his ears, and currently being eaten up by dwarfs – ‘orang-orang kerdil’ which will be dancing on his pillow at the beginning before feasting on him

Crawling in the ward – claimed now being an ‘animal’

Still need to be restrained occasionally after more than 1 week of admission

Prominent psychotic symptoms still took place with gross thought disorder, hallucinatory behaviours and also some features of flight of ideas. Tangentiality developed after a initial short time of relevant answers during each interview

Slow response to haloperidol and developed EPS (Parkinsonism features and drooling of saliva)

ECT was started:

Better presentation after 6 course – came forward, calm but anxious to go home

ECT was continued until the 7^th course, then allowed home leave

Came back from home leave:

Manageable at home for first 2 days after came back home, then started talking irrelevantly again about silat etc

Wanted to be a silat master to teach others how to fight the ‘dajal’ in the big war

IM depot 200 mg

T.Risperidone 2 mg BD

T.Artane 2 mg BD

Came back from 2nd home leave:

Still wanted to be involved in silat to defend the village and country

Mother agreed there were improvements, but not yet fully stable – able to care himself, able to take Rx accordingly , still had bizarre/irrelevant answers and ideas

T. Risperidone 2 mg OM 3 mg ON

T. artane 2 mg BD

Clinic f/u:

Improves a lot, no TTS, no paranoid ideation

Clinic f/u:

Improving

Clinic f/u:

Continuous improvement; mother more cheerfull

Start to socialize back again, riding motorcycle to g/mother’s house, helping the house chores

Planned to cont schooling next year

Reactive affect, euthymic mood, orientated, no flavid psychosis