Odysseys of George

This time the rounds is hosted by Dr Joe Anthony of cochinblogs. He has featured two cases, one of posterior cruciate ligament ganglion and the other a post of mine about perforated gastric ulcer.

Thanks.

I could never understand this. It has been happening since the days of internship. It happened again today as a surgeon and again I had to insist and scream my way through!

In my years of service, one of the things I hate is when you refer dire emergency cases to another department. However, I also notice my own colleagues doing the same. No doubt non emergency cases should be referred with details of necessary relevant points. However, emergency cases do not allow for such in depth details. Time is of the essence and when the primary team calls then one should respond by being at the ER quick. Another issue is that when the ED doctors call to refer, ( well in Malaysia, most ED doctors consist of post intern doctors)why do some harass them for hours over the phone. They call because they are not sure. Of course, there are some ED doctors which I have come across that called me for an abdominal mass in a lady when the poor lady had a gravid uterus. If such blatant mistakes can be made, then it is more so that one should just move their butt and see the patient upon referral. Would asking more questions to such an ED doctor ease your irritable and already tired self? But I digress, that was ED to primary team.

So how about primary team to other speciality colleagues, especially when the person who made the call is a specialist? Am I angry, oh yes I am?

I was doing upper endoscopy today, when the endoscpic nurse informed that there was a case for urgent upper endosccopy(OGDS). I was at my last case and the other surgeon was doing a colonoscopy. So after preparing the patient, we proceeded with the OGDS. She was having a fast pulse and her blood pressure was at the lower limit of normal. She was obese and had two lines. She is a diabetic and presented to the orthopaedic department with gas gangrene and a fast spreading infection reaching the upper left thigh and her right hand till forearm. For this, the had to disarticulate her at the hip joint and and amputate one or two of her fingers. She had an episode of upper gastrointestinal bleed about three weeks ago which revealed a duodenal ulcer with no active bleed and was treated with proton pump inhibitors. Of all days, she bleed again this morning and was rushed to the scope room. A scope was introduced and at the same ulcer site which now looks bigger and had an active spurter. However, before anything could be done, she desaturated and her blood pressure started to fall.I withdrew the scope and sadly found that all her lines were bunked. Though dazed and confused, she managed to put some resistance when I tried to place an oropharyngeal tube. With that I requested assistance from the anaesthetic department. The anaesthetic medical officer was asking my doctor a hundred questions before telling her he would like to speak to me – like I had the time for this nonsense – I took the short cut – I shouted from across the room so that he could hear me through the phone! Damn! The things I do to get the message across their thick skull! The reason – well he and his specialist have discussed the case early in the morning and decided that she is not to be intubated due to her poor quality of life and poor outcome! My issue is I have a lady bleeding away and I can confidently stop it! Shouldn’t I push it?!! So angry I may be, I asked this obtunded anaesthetic medical officer whether the present scenario ever crossed their discussion! I can understand that decision if she worsens from infection or her heart weakens or as such but bleeding that I can stop – never! He timidly said they never discussed this. We got her lines and intubated her and subsequently I clipped the bleeder. The bleeding stopped but she lost the battle to infection.

Don’t you think? Why waste precious time but just come and assess for yourself rather than trying to assess the validity of the referral over the phone? A call in an emergency means ones assistance is needed. Drop your ego, show some sense of urgency and come to assist. Then if one has an issue then the discussion is a more valid one, rather than hearsay, don’t you think?

Misfortunes were pouring during the week just like the rain that poured in after a stretch of hot summer time. Then again, we in the tropics don’t really have summer well not actually. The tropics only have two seasons well actually three seasons – the hot dry season when draught is a common, the cool wet season when floods are a definite event especially in a country going through modernisation in a haphazard way with greed as the background and the third is the transitional phase that occurs between the first two season around the months of April and October when climates can be unpredictable just like the politicians we have, with strong winds and high tides rushing angrily towards the peninsular.
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This is a question that frequently crosses my mind. I never dwelt on it as with the passing days, time took to the better of that. However, today was different. I finished my call and tired, unable to produce an article for the blog. I remembered what Shireen used to ask me, “Why blog?” Then, I realised that it is Chinese New Year eve and I haven’t wished one of my closest friend, Bernard yet. Lately, the sms, IM, emails and the blog has evolved to a level that made it so easy to convey a message. But, I felt a loss of that human touch, the voice, the intonation, the rhythm and the depth of a human voice. So, I quickly reached for my handphone and called Bernard but sadly it was unanswered. Later, I find out his battery died from messaging him on IM. My post call hangover continued till the late evening and despite me trying to write an article, I was numb.
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Well we know how important helmets are for our safety. However, a friend of mine sent me these pictures, made me wonder — many things. True as ridiculous as this may appear, it is still important because what if they do survive at least their brains and skulls may be saved. Compare this with us Malaysians. We still find people going around without helmets even in the city. That is the attitude we Malaysians have difficulty changing. The third world mentality!

Welcome to Grandrounds No.10.

As I,was thinking on how to get around this honour which was set upon me by my buddy and our friends, so this is what I decided to come up with. Well initially, it was suppose to be a sing along to a song and the round had a theme but… next time maybe.

I start this grandrounds with a cheer,to Jimbo and his friend, who won first prize for his poster presentation.

Swee Kheng from Taiping, starts a well written article with “one year on, the pain and hurt has been replaced in its acute form, by a dull and aching sensation, always present in your soul, always present in the things that you do every day.”

As I browsed the blogs, many wrote about work and medicine. You name it had a picture of an abdominal xray which she called coffee-bean, as she continues to examine the elderly lady with a partial? per-rectal examination! I wonder how far her finger would go in a full per-rectal!!

Stormyformydoctors had a stormy locum practice after an intense quiet day but managed to do his bit to make him and all of us proud.

Talking about a stormy day, Sbanboy wrote to us why things ( in his case – bad calls), just don’ change despite changing hospitals. Well, a wise man said, you can never run from fate. Saw Ling adds to this as she describes her tough life in one of her worst days ever. No! I thought I was bad! Three horrors in 2 hours, you beat me to it Saw Ling.

I also realised that Sbanboy was not the only one to have changed hospitals. Shah, also rambled his way to new place but seem to be enjoying himself so much that he forgot to blog for a week!
Hope you are happy,Shah!

Before I leave work in medicine, I thought I would highlight an article where the owl after feeding his nocturnal life decides to advocate research especially among the medical students.

Life treats us in many ways. Shellgal makes an interesting article when she claims love is a paradox just after she realises that working is not about taking instructions blindly. Work is a paradox too sometimes!
Yap in his tent, tried to recall what friendship is all about and what kind of a friend he is. But what attracted me the most is the failure vagus felt as many of us have felt as such one day or another in our own lifetime about life and death.

With that, I end my grandrounds with this :