The (Flat)Line Between Life and Death

Disclaimer: All characters depicted dead or alive are fictional. Any resemblance is purely due to your own imagination.

One of the first thing you learn as a medical student is that in Medicine, 1 + 1 is not always equal to 2. To put it simply, if the ah pek (whom I often abuse in my many stories) take two Viagra, he is not going to enjoy himself twice as much. This was not an easy concept to grasp for someone like me who liked hard concrete numbers and predictability. 

Eyes Wide Shut!

The fact is that things are never straightforward in Medicine. They are never black and white but shades of grey. Unfortunately these shades of grey applies to Death as well. How do we really know if someone has died? Is it after that last breath he took like in the movies? But what if his heart is still beating? What if his brain is still thinking? And what if his eyes are still looking?

Flatline - Asystole

To verify and pronounce death, the attending doctor has to first make sure that all resuscitative efforts have failed or the criteria of not resuscitating are met. There should be no pulse, no breathing, the pupillary reponse to light and corneal reflex are absent and there is no response to painful stimuli. In the hospital, an echocardiogram (ECG) has to be performed to show a flatline.

On call one day, I was asked to attend to an elderly patient who had collapsed. He had the DNR (Do Not Resuscitate) status and there was really nothing much I needed to do. By the time I was there, there were no pulse or breathing on auscultation, no constriction of the pupils when the torch light was shone on his eyes and no response on sternal rub or supraorbital pressure. I hooked up the ECG lead from the defibrillator but there were still wriggly lines and waveforms on the monitor. I needed that flatline and a printout to demonstrate asystole (complete stoppage of the heart) before I can pronounce death. The time indicated on the printout is also used as the time of death.

After waiting for a few minutes, the ECG did not looked like it was going flat any time soon. I instructed the nurses to keep the monitor on and to call me when there is a flatline as I had another emergency to attend to. In the middle of the night in the hospital, you are IT and I had no time to waste.

15 minutes later, I was back up in the ward. When I got to the bed, I was shocked to find the bed empty! I ran frantically to the nursing counter and one of the staff nurse told me that the patient had been pushed to another room to be with the family for mourning. I went, "What the fxxk! What about my ECG strip!"

The staff nurse reassured me that she had already printed the strip and proudly passed it to me. I took a look and went, "What the fxxk! This is not a flat ECG!"

My heart literally sank as this was not a flatline ECG and was STILL full of wriggly waveforms. The patient has technically not be pronounced dead and I needed to retrieve the patient / the body to get the proper ECG! I had no choice but to sheepishly enter the room where the patient /body was with an ECG machine. About 8 relatives were by the patient /body wailing loudly. I was a junior doctor then but I knew that approaching emotional relatives often resulted in catastrophic outcomes. I apologised to them for interrupting and asked if the relatives could excuse themselves for five minutes. Miraculously (yes in Singapore, nice relatives are miracles!),  they were kind enough to comply. I managed to get my ECG strip and quickly returned the room and the body to the relatives.

As I stared at the flatline on the ECG strip, I wondered if there WAS a distinct line between life and death.

Perhaps we will find out for ourselves one day...

or perhaps we won't...

Service Quality

Dr Og is still a bit sore over the fake 20% pay rise saga. You see, in a recent wedding I went to, a IT friend exclaimed loudly, "Wah! 20 % pay rise ar!!"

I took great pains to explain that "no lah", its at best 5% per annum, lest the bride and groom expect a corresponding increase in the ang bow!

Another issue that arise during the recent saga was the introduction of the Service Quality Komponent. Lets just say Dr Og is a great proponent of solid service. Some doctors don't seem to realise or they die die don't want to believe that medicine is basically just a service industry. Yes, doctors (of all grades) tend to have a messiah complex and think that they are doing what they are doing to save lives. But honestly, even saving lives is a form of service, is it not?

And it is not only the patients we are serving. We also serve our Bosses. These days things may have changed with Residency but when I was a Houseman, I was the biggest service provider since I served all the patients and was at the beck and call of everyone else in the team from the Medical Officer to the Senior Consultant. We had to buy coffee, run errants and play flower pot during meal times with Senior Cons who needed his ego soothed with a big entourage. More often than not, we also tio raped and kennah bwat guyou on our gluteus region by our seniors. At times, we had to go karaoke and it is rumoured that some female HOs also provide extra service. Hahaha...

You wouldn't blame me if I were to tell you that I felt like a prostitute as a HO, the similarity in that we had to service anyone and everyone, being the lowest life form in the hospital food chain. And when I became more senior, I often had to use this analogy to correct the attitude of some yaya papaya HOs or interns.

But on deliberation with one of my senior doctor one day, he concluded that the term prostitute may not be most appropriate for obvious reasons. He reckoned, "I think we are more like...... Geishas!"

卖 艺 不卖身！What wisdom :)

The Seventh Month

Someone asked me why I have not been blogging.


Simple truth is that sometimes when I blog, I feel like I'm writing to myself, or worse, to ghosts.... since there is hardly any response from whoever is reading (if any).....


But since its the hungry ghost month, its highly appropriate for me to at least make an entry for the ghosts out there supporting this blog. (My mother will surely scream choy! and hit me in the head if she saw this)

Source: http://asiaparanormal.blogspot.com/

For the Chinese at least, the seventh month can be a rather scary time. We were brought up to believe that the hungry ghosts will do us harm and going out late at night and activities such as swimming were frowned upon during this month. The seventh month this year has been somewhat unsual in that we celebrated NDP in a big way in Marina and will be having the presidential election soon! The pompous fireworks and wong hei (王气) will surely send all the ghosts into hiding!


But that is not true for our hospitals! There remain many scary and unnatural things that we have to look out for! 


The Ghost Whisperer


Technically not scary but suspected to be a spirit medium / tang-ki (乩童) of sorts who serves to bridge the living to the dead. He is usually a junior doctor who appears to be very busy and would disappear for a long time but not get anything done at all. When confronted he would insist that he has done a lot of work although not witnessed by any living patients. It is likely that he has an inert ability to see things that other normal house officers and medical officers cannot and was busy helping those poor souls still lingering the corridors of our wards. His disappearance can be explained by the fact that he transists between earth and the netherworld without really knowing. In actual fact, his colleagues all hope that he will go to hell too!

The real Ghost Whisperer looks nothing like this la!

The Lift

Frightful stuff inside!

Otherwise known as The Elevator. Super slow and often contains scary objects! The Lift in the hospital has a mind of its own having been possessed by the spirit of a nasty ward nursing manager who met an untimely death when the ECG leads, stationeries and paper she was hoarding fell onto her one day. True to her (mean) spirit, you will wait long long if you needed a ride to go to the upper levels. Worse, if you are really down on your luck, The Lift will  bring you down to Level -18 instead where you WILL bump into your CEO!!


The Zombies


Another breed of doctors. Unlike the Ghost Whisperer, the Zombies are doctors who specialises in KLKK (Kia Lai Kia Kee) and have no specific directions (be it in life or in their medical career). They are seen wandering and bumping into one another, often getting in the way of those doing real work. Occasionally, by brownian, these Undead Walkers will wander into the canteen and start having a nice cup of coffee while their fellow doctors continue to slough to their deaths in the ward. The Zombies can be identified by their lack of expression and of eye contact. (Compare this again to the Ghost Whisperer who is often anxious and frightened having seen things they shouldn't...) The Zombies come to work in crumpled clothes having have no motivation whatsoever! 

Blood stains from yesterday's surgery

The Gwai Lo (鬼佬)


Literally "ghost man" in Cantonese, these ghosts are often foreign and used to be mostly pale white when spotted in the past. Recently, black coloured ones have also appeared and have become so prevalent that you are more likely to bump into one of these than an actual Singaporean human! It is also pertinent to note that one must avoid them at all costs this seventh month as it is also Jay-See-I (pronounced J-C-I) haunting month. They may well be one of the auditors from Gwai Lo Land and it will be a straight road to hell if you kennah caught by them!

Count Docula

Spotted this article in Tomorrow. jkaiser donated his blood, all 100cc of it.

This really reminds me of the time when I was a lousy HO (lousy not because I was incompetent but because I felt lousy). It was 3 pm on a Sunday afternoon and I was post call. My last job of the day was to take blood for 6 old man in this particular cubicle . And anyone who has any experience with RPG can tell you that your dexterity is ZERO on a Sunday afternoon when you are post call. So, I was missing all the veins and everyone of them I had to try again. No one shot one kill!

As I went around each bed, the ah peks assumed I don't speak dialect and broke into a conversation in Hokkien,

Ah Pek @ Bed 13: Wei, why you think they always take our blood?
Ah Pek @ Bed 12: Yah loh, everyday also take blood take blood.....
Ah Pek @ Bed 15: Mebbe they use it to do experiments lah, we guinea pigs here!
Ah Pek @ Bed 13: Wah lau....
Ah Pek @ Bed 16: I think they SELL our blood. See take so much each time.
Ah Pek @ Bed 12: Like that take, I not enough blood, sure die!!!

6 old ah peks don't make a Zhu Ge Liang...... Actually, Dr BL Og is a vampire who goes around feeding on old Ah Peks' blood with no fear of contracting HIV or Syphillis.

--------------------------------------------

Don't know why, but Asians thinks that their blood is so precious that it is worth more than gold of the same weight. You don't die from the 5-10cc of blood your doctors take. You can't even get anaemia from it! In hospital, we don't sell your blood and as far as I am concern, I have no interest to "do experiments" on your blood either!

So please, if you can, donate blood. The doctors don't need it. The patients do!

Houseman Survivor Guide: Why?

Houseman Survivor Guide (Monkey Edition)
I. Introduction
II. Hospital Hierarchy
III. A Typical Day
IV. Painkillers
V. Meet The F*ckers
VI. Kopi Politics
VII. Why?

On paper, housemanship or internship is suppose to be a time of learning. Technically, you still belong to the faculty of medicine rather than the hospital (clusters). In actual fact, housemanship is just an excuse to make new doctors do all the sai gang and still get paid peanuts (our national currency).

So it is no wonder that despite encouraging HOs to learn, asking too many questions is often frowned upon. After all the hospital is a very busy place and if you have so many "why this" "why that" who is going to do all the digital evacuations and take all the bloods?

Asking too many silly academic questions will also definitely not impress your seniors. You risk exposing their ignorance and in the process offending them!

HO: Hmmmm, why give medicine A in condition B and not medicine C+D?
MO: Emmmm, very cheem. I go find out, you finish all the changes yourself!

Of course the more lao jiao senior doctors have this strategy,

HO: Er, why give medicine A in condition B and not medicine C+D?
Consultant: What do you think?
HO: Er......
Consultant: You better go home and read up. Tell me the answer tomorrow!

They throw the question back in your face and quickly walk off, wiping the sweat off their forehead.

But yet, we often hear senior doctors telling us that "you can only learn by asking questions!" Alamak, ambivalence. So how? To ask or not to ask?

Dr Og gives you the simple Og's golden rules of asking questions during ward rounds.

1) If you have any clinical questions or doubts pertaining to patients and their treatment. Always ask. Look stupid also must ask.

2) If you have any academic questions or doubts, go read up yourself lah! Don't be lazy! Don't ask stupid questions and make yourself look stupid can?

3) Only ask academic questions if you already know the answers,
HO: I always wondered why medicine A is preferred over medicine B.
Prof: What do you think?
HO: I reckoned it is due to the fact that A has effect C?
Prof: Excellent!!! You are spot on!
(Brownie point ++++)

4) Of course there are those insightless HO who will always ask the most inappropriate question at the most inappropriate time. In front of the whole team,
HO: Prof that night I saw you swimming with the female HO from internal med. She is your daughter ar?
This type of HO I suggest go and specialise in pathology.

My First Kill

Ok, this is a meme (whatever the hell that means) from the angry one (link is at sidebar). I suppose I should be talking about my first kill experience as a doctor?? I mean when I was 2 years old, I killed plenty of ants. That would technically be my very first kill, though which ant, I really cannot remember. Nevermind lah, they all look the same anyway.

As a doctor, hmmmm.... That IS an interesting story......

One night as a Houseman on call, Dr Og was given the mission to go buy dinner. I was a surgical HO and was too lazy to change out of the hospital baju (scrubs). So I wore that and went to the same place a few post back where I was digging in the dustbin. That place is always so crowded and everyone was of course staring at this weird person in hospital attire spreading germs around.

I decided to by-the-way, get myself a nice cup of coffee. Everyone knows Dr Og loves his cup of chino. In the coffee place (will not name the place since they are not paying me advertising fees, but you can guess lah) was this really hot chick!

Our eyes met. (And I confirm she was not my patient. Woohoo! Wah lau, patient so chio I sure remember can?)

She must be intrigued by my OT (operating theatre) attire. You know, girls get attracted to such stuff! I walked up to her and striked up a conversation (one month from completing housemanship, lots of confidence). She was from Malaysia, an Eurasian (explains the shape features)and was doing an elective program at the university next to my hospital. I entertained her with some of Dr Og's all time classics.

Just as we were warming up to each other, my pager beeped. Damn, my fellow HO must be hungry liao (or he is overwhelmed with cases covering me hahaha). I asked her for her number and she said," I don't think my boyfriend will be too happy about it. He is over there waiting for me in his car"

She pointed to a Porsche with an Ang Moh inside. And to add salt to wound, she told me giggling, " Oh yeah, do you know that your hospital pants is really translucent. Can see your underwear beneath it." Damn those cheapo hospital attire!

And she walked off.

My first kill....... almost.

Houseman Survivor Guide: Kopi Politics

Houseman Survivor Guide (Monkey Edition)
I. Introduction
II. Hospital Hierarchy
III. A Typical Day
IV. Painkillers
V. Meet The F*ckers
VI. Kopi Politics

Do understand that drinking coffee for a HO is not a leisurely activity. It is often a life saving measure. How to survive the rest of the day without a nice cool cup of kopi peng after a horrendous night call with no rest??!! Remember, post call (time off after night call) is a priviledge, NOT A RIGHT.

Kopi peng is the way to go. I will seriously not recommend hot coffee to any HO unless you want to burnt your throat gobbling down your cup-of-chino. No you still won't sound like Darth Vader after that, you idiot!

Notably, drinking coffee has become such an entrenched social activity amongst doctor that it has evolved into Politiks. This is akin to social smoking in other industries whereby if you don't go for smoking breaks with the Boss, you will be excluded from the boy's club. As most doctors do not smoke, or pretend not too, drinking kopi is our own version of social smoking. YEAH!

So dear HOs, please don't reject your senior's kind offer to go for a kopi break. In fact in some disciplines, it is mandatory to lim kopi after the morning rounds. These are times when your seniors actually have time to talk about your performance and as Asians generally do not criticise people in their face, the more you go for kopi, the less likely people will talk bad about you!

It is also tradition that the most senior doctors pay for the kopi while the most junior go pang kopi (carry the coffee). It is important that you know the different combi:

1. Kopi orh kosong: no sugar no milk (for fat doctors on diet)
2. Kopi: with milk with sugar (for fat doctors, how did you think they became fat in the first place?)
3. Kopi Si: with evaporated milk (for fat doctors with no idea what they want)
4. Kopi Peng: with ice (for fat doctors who otherwise will be perspiring away)

(NB: If you purchase a full copy of the HO survivor guide, Dr Og not only teach you how to carry coffee, I will also teach you how to carry ass! Order one today!)

Sometimes, our poor HOs don't even have time to get a decent cup of coffee. I once saw this poor chap (yes Rambo, I'm talking about you!) pouring a packet of 3 in 1 into his mouth after a busy night call!!! So sad hor..... like that waste coffee!

"HO! Please glove up!"

One day, during my surgical rotation, I was paged by my HO to see a case of bleeding piles. When I got to the ward, I saw my registrar coming out of the cubicle which was curtained up. She must have been examining the patient with my HO.

"BL, haven't examine the patient yet, you take over, buay tahan!" She said and left in a huff. Hmmm, maybe the newbie HO did something wrong again.

I was proven to be wrong when the HO came from behind the curtain sniggering away. Strange..... I asked her what happened.

"You see yourself loh, but don't laugh ah!" She said.

Puzzled, I pushed the curtains aside and stepped in with the HO. There laying on the bed
was a young man in his early twenties. He was hugging a teddy bear. Chey, the HO like that also find funny meh? I myself was a great fan of teddy bears just that in our society if a guy collected this kind of thing, sure kenna ridicued!

I then politely asked the young man to take off his pants while I put on my gloves and squeezed some KY jelly (lubricant) onto my (gloved) fingers. The KY jelly in the hospital always look so yellowish, maybe keep too long. All ready, I turned to look at the guy's perineal area (the ass lah) and had the shock of my life!!

He was actually wearing a sanitary pad! What the @#$#%~!

I took a look at my HO who on seeing my reaction was obviously trying not to laugh. The gay guy sheepishly told me "I was bleeding so I thought better wear a pad (giggles)"

Being the professional doctor that I was, I removed his pad (with wings) despite feeling extremely nauseated. There were some blood stains on the pad but at a lower position that it usually would be. Closer examination did not reveal any prolapsed piles and I will need to insert my fingers.

My nausea became worse at this point as thoughts raced through my head. What if he actually enjoyed my fingers the examination? Yeeooooow!!!

Since shit always gravitate downwards, I said,

"HO! Please glove up!"

Houseman Survivor Guide -Meet The F*ckers

Houseman Survivor Guide (Monkey Edition)
I. Introduction
II. Hospital Hierarchy
III. A Typical Day
IV. Painkillers
V. Meet The F*ckers



This chapter will be about meeting family members of the patient. Communication with family members is a tricky business especially in these modern times. Do not expect them to come with chickens and eggs like in those period dramas to thank you. Be prepared for an onslaught as these days, the public view doctors with much animosity.

Be Prepared
Remember that you are the host here and there are many things you can do to put yourself at an advantage. For eg, prepare the interview room by turning the air-con to the max. In our hot weather, it is unlikely that they will come in sweaters. But of course you have one ready in the locker. No one will ask too many questions when they are freezing.

Do Not Be Intimidated
The most common mistake a newbie can make is to speak to a whole kumpung of relatives. With each one shooting a question at you like machine gun, no wonder you feel intimidated!! Identify the Indian Chief, make him the representative and turn the tables on him. Have you not notice why the senior consultant always has to have the HO and MO around when he speaks to family? It is not so that the HO can record minutes of what conspired in the meeting but to intimidate the representative with numbers!

Beware Of Handphones
These days, the mobile phones can be easily used as a voice recorder. On many occasions, family members had recorded conversations with Drs and they usually do so on the sly. Any evidence is usually beneficial to Drs since we have nothing to hide. But because this is such a rude act, it is mandatory for us to foil their evil plans, just for the kick of it.
Unless you have thousands of dollars to spare for an anti-spy device, my advice will be to speak in a soft and low tone. The recording will just turn out muffled! hahahaha!

Beware Who You Speak To
Never never speak to family members over the phone unless you already know them well. You can never positively identify the person on the other side of the line. It can be the company checking on the employee pretending to be family, it can be insurance agents investigating the patient's claims and sometimes it is just some kaypoh friends. Whatever the reason, the above mentioned have no rights whatsoever to access patient's info without his/her consent.

Be careful even when the relative is there in person! This really happened:

Relative: Lokun ar, how is Bed 10 ar?
Doc: Sorry m'aam, how are you related?
Relative: I'm the sister la.
Kiasu and Kiasi Doc: ok, can I just see your I/C to make a record..... hmmmm how come you have a different surname huh?
Relative: errrr, I'm the god sister lah!
Doc: In that case I think you better go ask her personally, I have told her about her condition.
Relative: Ya Lah! I ask her already, she don't want to say, thats why I ask you mah!

Sometimes we Singaporeans just don't know how to respect other people's privacy......

Houseman Survivor Guide - Introduction

Houseman Survivor Guide (Monkey Edition)
I. Introduction
II. Hospital Hierarchy
III. A Typical Day
IV. Painkillers
V. Meet The F*ckers

As the most junior of doctors in the hospital, life can be rather depressing. Do not expect any respect from the nurses, clerks or even cleaners. Do not expect any sympathy from your fellow more-senior doctors as we believe this to be a test of strength and the best time to prove yourself. If it doesn't kill you, it will make you a better man. To help you survive this trial by fire, I present to you a many parts mini series - The Definitive Housemanship Survivor Guide.

I have previously dropped some tips along the way like what a typical day entails and why panadol is so damn important. Today I kick off this series by having a detailed analysis of the types of housemen there are. Correctly knowing yourself is crucial for HOs or HOs to be improve! (no lah i just want to flame HOs after flaming MOs and nurses, hahaha)

1. The Sotong HO

Everywhere we go, we have sotongs. Those blur pricks who just can't seem to get their acts together. The Sotong always look busy but never seem to be getting anything done. During the rounds, he will get lost and cannot find the team.

MO calls the HO: Sotong! Where are you!!!
HO: huh?? I'm with the Consultant. The one who wears a crocodile belt.....
MO: Wah lau, that is the gynae team, you are in Internal Med, you BODOH!

The saving grace for a Sotong is that sometimes the blur-ness is just a transient reaction to adjustment disorder and he is actually trying his best.

2. The Zombie HO
Permanently dissociated, the hospital is to these HOs what full moon is to werewolves. These HOs do not smile and they do not cry. They do not take initiatives but when asked to perform tasks, they will do so.... like a Zombie. They recover when it is time to go home (see them take their bags and run out of hospital) and are permanently cured when they get promoted to MOs.

3. The Slow Coach HO
In medicine, the tortoise will never win the race. The slow coach HO is not just slow because he is new. He is inherently just......slow. He will take one whole night to see one new patient while his MO has to clear the rest of the 20 cases. He takes the whole morning to take a few bloods leaving his team members to pull out their hair (or what remains of a balding head) in frustration.

4. The Tai Tai HO
You recognise them with the LV or Gucci bags they are carrying. These girls come to ward rounds in high heels and have a tendency to fall on consultants. Male consultants with lots of mojo might give them some luviing but most of the time they just get a good scolding. These HOs are disinterested in their HO work and try their best to become gynaecologist.

5. The I'm-so-Angy HO

Forever BCC (臉臭臭), these HOs walk around with the you-owe-me-money look. The senior doctors want to ask them to do things also scared. Don't say the nurses.

MO: Hi, are you alright, how come you look so sad today.(trying to cheer her up)
HO: On call, what do you expect!!(walks away)

6. The HO from Hell
Every now and then, you get a HO that you say to yourself "SHIT!". These HOs come in many shapes and sizes, and different sex as well. But one thing is for sure, no one wants them in their teams.
Simply put it, these HOs quarrel with nurses, argues with Consultants, scolds patients and do not get their work done. They leave for post call right on the dot, disregarding the fact that 8am post call is just an admin ploy to make things look good on paper. They simply boh chap and leave leftovers for other HOs to clear.

They make mistakes but think that others are against them.

MO: er, I think you labelled the bloods wrongly....
HO from Hell: No i din!
MO: never mind just re-label it.

ten minutes later:
MO: you labelled it wrongly again!!!
HO from Hell: you all are against me!!!!! Boo hoo hoo (runs away crying)

If you happen to be a ger HO, crying might get you out of the fix. Male HO please don't try hor, you might just be mistaken as a gay and get a bashing in the toilet!

7. DAMN POWER HO (DPHO) Contributed by drrw

The one who is on the right ball. Unselfish, punctual, hardworking, mentally strong and doesn't crack under pressure easily, has good people skills to deal with difficult relatives, able to take blood and set plug perfectly 90% of the time, willing to learn and take constructive criticisms, independent, helpful, super efficient, medically competent, has good judgement when to call his seniors and has a good self awareness to know what he can handle himself, able to prepare for Grand ward round independently without embarassing MO and Registrars.

Hmmmm..... Sounds eerily like me. :P

The Curse

My first day at work, the rather grumpy clerk ("No! I'm not a clerk! I'm an admin executive!") passed me my pager. I last used a pager when I was an army boy. At that time, handphones were as big as water bottles and were often the favourite murder weapons in Chinese drama serials.

I did not know what to expect with the ancient gadget in my hand. Like a hooker, I waited for my "customers" to page for me. It did not take long. Before the day ended, I had 40 odd pages. That made it an average of 4.4444444 pages per hour. Die die die die die die, it cried out at me.

The usual culprits are the nurses who can page you incessantly for the most ridiculous of things. You would think they would at least wait by the phone for you to answer. But there exist a particular university hospital where the culture of the nurses are such that they will page you and just leave.

Doc: Hello, docto- on-call here, who paged?
Nurse(on the other end of the line) shouts: ANYBODY PAGE????!!!!
Nurse: You wait ar!
And so you wait, and wait, and wait. All this while, your pager goes off a couple more times and your patients are waiting for you to digitally evac their impacted faeces!
Hello! If you want to page people, at least wait by the phone for 5 minutes, can????

Many doctors have this same experience. You are on call, it is the wee hours of the morning, you are cold, tired, hungry and sticky. The pager keeps beeping...... You ask yourself what the f**k you are doing here, you just wanna throw the god damn thing out of the window, walk out of the hospital and take a taxi back home where your comfy bed is. Don't worry, we all have the same experience. One foreign talent did just that, she walked out of the hospital on the first call and took the next flight home. But at least she left her pager behind. Beep!

All said and done, a junior doctor is expected to have good pager habits. That is to answer all pages and to answer them ASAP. The pager is like an invisible leash on the doctors. It is a curse. It is a curse that we carry.

Technorati Tag: singapore doctor medicine blog

Hospital Hierarchy

Houseman Survivor Guide
I. Introduction
II. Hospital Hierarchy
III. A Typical Day
IV. Painkillers
V. Meet The F*ckers

I have been asked to explain the hierarchy in the hospital. I guess that is pretty reasonable though I am quite disappointed....... haven't you all been taking careful notes of my posts!!!??? And by now shouldn't you already know the answers??!!!

I guess not and here goes (from the lowest rank to the highest):

1) The houseman a.k.a house officer, a.k.a HO also known as intern in America
Experience points needed: 0, just need to pass MBBS (Monkey REpublic)

The lowest life form in the hospital. Looked down by everyone and despised even by the amahs. Despite the fact that they do the bulk of the dirty work, do not even think of appreciation. A HO's duties include getting to work before his bosses and preparing for the ward round before the team comes. He is in charge of all the ward duties and orders given by the team (we call them changes). He has to take blood, do discharge summaries, speak to full of nonsense relatives that no other team members wish to entertain, take some more blood and occasionally suck his bosses' asses. Do not despair coz each sucky low down brainless job gives you 1 experience point and in no time (actually in one year) you will gain enough EP to raise level.
A successful HO is best described as a prositute, providing the best service to everyone including the MOs, Registrars, Consultants........

2) The medical officer a.k.a MO
Experience points needed: 10,000

After swimming around the wards as an amoebic creature, a HO after one year develops into a more decent life-form (like tamagochi like tat lah) : the MO. A 1st year MO is known as a baby MO. The MO's job is quite different from his amoebic past. For one, he can acutally argue back with the nurses. If things really get out of hand, he can also complain to the nursing officer ("MO also o-hui-cer, NO also o-hui-cer, who scared who). But bare in mind that the nurses always win (unless you no scared make girls cry).

A baby MO with new found power (and dignity) often acts irrationally and rashly. He will not hesitate to show off his knowledge or correct the senior doctors especially if he not been properly baptised into medical practice during the HO year (not tekan-ed enuff).

He will learn that you don't do stupid things like quarrel with nurses and argue with your bosses when he gets a "C" grading for his posting and consequently gets only paltry pay increment and bonuses.

When the MO manages to pass an interview and is successfully accepted into speciality traineeship, he becomes a trainee or MOT. It is something like a promotion in that you are now accorded slightly higher status and more responsibilities are expected of you..... No! You don't get a pay raise, instead you have to PAY for the traineeship!!!! Yes you pay to do more..... its like SM, come on give it to the MOT!

There is another MO entity..... Lurking in some corner of the hospital is the chronic MO. These are doctors who fell off the system but somehow never made it to GP pratice. They are chronic as they do not specialise and they will forever remain MOs. You can easily recognise them from their BCC (臉臭臭) facies and their preoccupation with some other side lines. Chronic MOs are the nautral nemesis of nurses as these are people who can be of equal seniority to the ancient matrons and like them still have not moved on.

Specialist and the Senior ranks
HOs and MOs are not specialist. A MO can transiently become a MO-specialist (MOS) if he passes all the exams but there is not specialist slot for him.

Registrar a.k.a Reg a.k.a 'R'
Experience points: 100,000

Usually when a MO gains enough EP from performing countless procedures, therapies and politics over coffee, he is ready to attain Advanced Specialty Training and raise level to a Reg. The Reg now can independantly make decisions and lead the team. He is a specialist but still need approval and guidance from the Consultant for difficult cases. Otherwise he can afford to come later than the MO for the ward round.

Associate Consultant a.k.a AC
Experience points: 200,000

Having served his time as a Reg, he gains level quickly to become an AC after completing his exit exam. This is the same as the previous Senior Registrar rank. They just change the name to make some hanta kaki senior reg happy. This is usually a transient rank as the AC will soon depart for foreign land to learn this ancient art from a different race.

Consultant
Experience points: 500,000

A consultant is a full fledged specialist. He is now the boss of his own team. Everyone in the team kow tow to him. Other than clinical responsibilities, he has to wrestle with administrative irritations. He has to approve the bloody leave of that stupid MO who decided to get married when the rest are busy preparing for exams.

Senior Consultant
Experience points: 1,000,000

Having grown roots in the department, the senior consultant is a god-like figure. He appears to save the day when less experienced doctors botch the job. He makes the final enlightening comment during the grand ward rounds and he will soon be forced by admin to either semi-retire or go private as he is too expensive to keep around despite the gem that he is.


The Private Doctor
Experience points: 0 or 1,000,000,000,000

Sometimes, doctors fed up with public hospital and will go private! Most times this is an upgrade and the experience points goes up! But at times, some lokun experience points become zero after going private.

The Worst Day of My Life

Houseman Survivor Guide (Monkey Edition)
I. Introduction
II. Hospital Hierarchy
III. A Typical Day
IV. Painkillers
V. Meet The F*ckers

This is going to be a long post. But I hope that for those who start reading it, please finish it.

0700Hr: I was driving along ECP, listening to the radio. Trying to catch my horoscope. Don't usually believe in those things. But today I'm on call. Boy the last one was bad. Thinking about my last call, I started having palpitations. The odds are you don't have two bad calls in a row. I consoled myself.

0730Hr: Reached my ward, it is a respiratory ward. One of the worst, one of the busiest. Most of the patients end up here after one too many sticks of cigarettes. Its too late for them, their lungs are gone. They probably know, coz none of them ever stop smoking. I was busy getting everything ready for the morning round. Putting all the case files to the correct bed and entering all the new results in the case notes for easy reference. I looked at the team list which is basically a list consisting of all the patients we must see. 35....

0800Hr: As usual, my Medical Officer came first. He is this 30ish guy who look years beyond his age. He always seemed so tired, hardly smiles. Sulking all the time. "Had your breakfast?" he asked me. I don't take breakfast, never had. "You really should you know, you never know when is the next time you can eat....." We started the round.

00845Hr: The Registrar arrived. She is a petite lady but you don't wanna mess with her. We restarted the round.

0930Hr: We were almost finished with the ward when the Consultant came. He is the head of the department. I tried to hide behind my MO and remain inconspicuous. Don't wanna get shouted at early in the morning. That would be a bad start to an on call day. We restarted the round again.

1100Hr: Finally reached the overflow wards. Things were not too bad today. Only got scolded twice for not knowing one patient well enough and not completing another's summary.

1130Hr: Ward round finally over! The sense of relief translated into a new euphoria and confidence. I had another hour left before the Journal Club starts. What should I do first??? Arrange for urgent CT scans? Call the specialist from other disciplines for the blue letter referral? Take blood? Set plugs? Do discharges? Talk to relatives? Only one hour.....

1230Hr: Journal (research papers)club started. Attendance is compulsory. Didn't get much done in that hour. Urgent stuff came first, arranged the scans. But not before getting humiliated by the radiologist downstairs. "Why do you need this to be urgent???!!" "Don't you know how to read Xray??!!!" "Who ordered the urgent scan?!!!" Wasn't me, I'm just a HO.
Couldn't really concentrate on the research paper presented. Kept getting paged by the nurses. "Dr, Bed 12 and Bed 15's family are here to see you. They gotta leave for lunch soon" "Dr, hypocount of Bed 13 is 12" "Dr, Bed 30 plug came out" "Have you done the disharge summaries? Bed 10 wants to go home now"

1340Hr: Journal club finally ended. Rushed back to the ward to speak to the family members. More pages from the nurses. They are changing shift soon and the morning shift nurses are trying to rush me to get the morning changes(orders) done.....

1600Hr: Finished most of my changes and discharges. 30 out of the 35 patients I am in charge of had bloods to be taken. 10 were discharged. Still have those god damn blood cultures.... Did I have lunch? Call starting in an hour, better go finish up and have dinner. Oh yeah, not done that summary, maybe later....

1700Hr on the dot: "HO 2 you have a new case in ward 44." Dammit, the ward HO must have left the case for me to clerk. "Saturation 85%, you better come now" No dinner.

12MN/0000Hr: Cases came one after another..... the old man with end stage renal failure, the fat man who was alcohol intoxicated, the psychotic woman brought by the police, the Samsui woman with no place to stay, the usual patients with chest pain, giddiness, dengue fever..... to name a few. I took 10 minutes to take a drink and change into hospital baju. Did I pass urine today at all? Can't remember......

0600Hr: Bad night, can't recall how many cases I saw. There were 2 collapses, both died. 4 more new cases to go...... Need to finish up and then go do my summary...... Hang in there.

0715Hr: Finished my 4 cases, no time to take blood for the last one. Need to take a shower and change into shirt and pants. Post call, no need for tie.

0800Hr: MO came. "Bad call?" Guess it showed in my face. He helped me trace the morning results already. Thank goodness.

1000Hr: Got a good scolding from the Consultant for not completing the summary. Scolded the MO as well, much to my embarrassment. "Summaries must be done by 24 hrs of patient's admission!!" "So how many in outer space today?" He meant the overflow patients.

1300Hr: Morning round ended at around 12. Again I had only an hour to do my morning changes before attending the Xray round. Attendance is compulsory. Nurses as usual pages me like mad even though they know where I am and what I'm doing. The patients or family give them shit, they give me shit.

1400Hr: Rushed down to the canteen. Ordered seafood soup. Damn. Too hot.... The pager kept going off. I should be post call and on my way home. (you get 1/2 day off the day after your call). But I haven't finish my changes. Can't wait for the soup to cool down. Ran back to the ward. No more hot soup from now on.

1630Hr: Did most of the work. Finished most of the bloods. I think.... Told one of my fellow HO to cover my ward..... "sorry man, can't take it liao". On my way to my car my MO paged me. "Where are you?" "Did you call the surgeon to come see Bed 15" "No? Why not?" I told him frankly, "I forgot." Asked if he wanted me to come back, still in the vincinity. "Never mind....."

1745Hr: Finally home..... bathed and went straight to bed. Told my mother I will not be waking up for dinner. Just too tired...... "But Ma, can you prepare some breakfast for me tomorrow?" You never know when will be the next time you can eat.....

WHAT CAN THE HOUSEMAN DO?

Saw this posted on one of the forums today... they were talking about a recent case of a patient who died from Stevens-Johnson. Then they diverted and started talking about other things...

"....I certainly hope doctors feel a greater sense of responsibility towards their patients. Cite a bad ex. My granpa had a major op. Fixed to glucose drips thru left hand. She complained of pain. the houseman that came. Face very very black. Only say nothing she can do. drip is there on order of doctor-in-charge. Few mins later nurse came in to chk on my granopa ask everything ok? We told her bout the drip. She say will inform doc. We say dun need coz we know it will be that houseman again. A while later, houseman came in say must give my grandpa anti-vomit drugs. Why? The nurse told her my grandpa vomitted. We are like .... duhhh... However she told us the drip can be removed as long as he takes enough fluid as she has just checked with the doc in charge. I dun know how to make out of the whole medical outfit in Monkey Republic nowadays. Gone are the days when the doctors are all patient oriented...."
So let's have a MCQ quiz: "WHAT CAN THE HOUSEMAN DO?"

1. “…My granpa had a major op. Fixed to glucose drips thru left hand. She complained of pain. the houseman that came. Face very very black. Only say nothing she can do….”

WHAT CAN THE HOUSEMAN DO?

1. Put on some make up before approaching the patient
2. Remove drip on left hand and set new drip to right hand
3. Order for drip to be taken off and get screwed by MO/Registrar/Consultant the next round
4. Kiss the grandpa’s hand and say that she hopes it’s better after the kiss
5. Go for plastic surgery like Michael Jackson

2. “…Few mins later nurse came in to chk on my granopa ask everything ok? We told her bout the drip. She say will inform doc. We say dun need coz we know it will be that houseman again….”

WHAT CAN THE HOUSEMAN DO?

1. Feel hurt “…Yes… it’s me again…”
2. Feel happy “…Whew… never call me again…”
3. Feel sad “…I wanted to set plug on right hand…”

3. “…A while later, houseman came in say must give my grandpa anti-vomit drugs. Why? The nurse told her my grandpa vomitted. We are like .... duhhh...”

WHAT CAN THE HOUSEMAN DO?

1. Scold the nurse, asking why she lied about the patient vomiting
2. Give the injection anyway
3. Give the injection to the nurse
4. Give the injection to the relative who was “…duhhh….” Because he might be choking on his own vomit or he was nauseous

----------

Well, the above is tongue-in-cheek, and meant no offence to anyone. Not to the houseman, not to the nurse, not to the relatives and certainly not to grandpa. Because we are patient-oriented.

Death: The High Cost of Living

I am an avid fan of Neil Gaiman and in his best work to date, Sandman, Death is the sister of Dream. She is protrayed as a perky goth girl.... how nice.

In reality, death is lurking around us all the time. Especially for those of us in the medical profession. Perharps so much so that sometimes we forget the tragic side of death and become numb to it.

There was a time when I was still young and nothing in life seemed impossible. I believed that we should spare no cost in saving every life. It was only after becoming a doctor that I realised my believe was just magical thinking of an immature child.

My first professional encounter with Death was with a lady in her fifties. She suffered diabetes and consequently her heart was failing. Her husband had admitted her for a severe infection of her right leg. The only way to save her life was to cut off the leg but there was no chance of her surviving such an operation given her heart condition.

I had seen her briefly during the morning round and she was pretty alert despite the high fever. As I made my way around the wards in the afternoon, I noticed her chatting with other patients, smiling to the nurses. I was paged in the night and the nurse in charge told me she had stopped breathing.

When I arrived at the scene, the MO was already there. I was panting from the 100 metre dash looking all flustered and unsure. The MO gave me a reassuring smile and told me that nothing needed to be done. Just to certify that the patient is dead.....

Pupils fixed and dilated
No heart beat
No breathing
No response to pain
No reflexes

This is Death. She is not a perky goth girl. She was cold and distant.

Night Calls II...

The last post was for the minor things that happen.

Major things happen just like in the movies. A patient might be found not breathing or without heart beat. Code Blue is announced over the PA system and the team doctors rush to resuscitate the patient.

All sorts of wires will be connected to the patient monitoring his heart rate, oxygen levels, ECG rhythms etc. CPR will be started with the most junior doctor jumping on top of the patient and pumping the chest. To give the uninitiated a better idea, CPR is actually more tiring than sex. The danger of the resuscitator collapsing himself is a real possiblity.

The second most junior doctor will see if there is a need to stick a tube down the patient's throat to help the patient breathe. By this time, the senior doctor would have arrived and will be looking through the patient's record to determine the cause. Although from the outside this whole senario looks like what army terms as operation cluster f**k, it is actually very well orchestrated and organised. There is hierarchy to be maintained. No one oversteps his boundaries. Sometimes we manage to get a heartbeat back. Often we don't. And when we don't, there isn't that dramatic "Let's call it. Time of death 0400hrs". (Duh! that's in the movies).

It is a quiet affair, certifying death......

Night Calls...

The bane of every junior doctors.

Each of us are scheduled to do a few every month. As the day of the call approaches, the morale of that doctor will sink to rock bottom. In movies, the doctors on-call can go about their lives, going pak tor until their pager beeps. In reality, the doctors have to stay in the hospital and wait for things to happen (by Murphy's law, shit always happens). This means that the night before a call, he/she has to sleep early (means cannot go cheong until 3am.) Will be stuck in the hospital the day itself and still cannot go cheong the next day! (usually no sleep on call day so the next day shack like hell). That's 3 days in a row cannot cheong!!!

What do we do when we are on call? We take care of all the patients under our department. Every little shit thing that happens, we handle.

Nurse: Doc, patient in bed 8 has a fever, patient in bed 19 has not passed urine since he slept, and patient in bed 20 complain of pain.
Doc: What's the temperature of patient in bed 8?
Nurse: 37.6 deg celsius
Doc goes see the temperature charts... Bed 8 has been having fever for the past 3 days. It is coming down. (Doh!)
Bed 19 has not passed urine since he slept. Obviously what.. who pees in his sleep??? So should I wake him up to pee??
Bed 20 has pain. But where? Head pain, stomach pain or backside pain? Can't the nurse get more information before alerting the doc? Like that, must as well, give all patients our pager number and get them to call us directly. At least like that we can get more information.

Worse still. At 3am in the morning, after a 20hr shift of running up and down the wards. We get called to see a patient.
Patient: Lohkun arh.. Pak tor tia. Sah jik bo pang sai liao arh (Doctor, stomachache. 3 days never pass motion already)
3 days never pass motion, dunno how to tell the day doctor. Must wait until 3am at night then tell doc. But then again, thinking back, these were usually old ladies who had difficulties sleeping and they justed wanted someone to talk to.

These are just the minor things that happen in the night. For the major things that happen at night, wait for the next issue... (To be continued)

MOdelling

Dr. K Lum always wondered why she was scheduled to be on call almost every day.





"...Modelling is the learning of behaviours and skills that can occur by observation without direct reinforcement...."

When we are junior doctors, fresh from medical school, many a times we learn from what we see. Usually, unless you are a damn chio babe (few are far in between. Refer to previous post for explanation), you will spend most of your time in the hospital with your medical officers. The damn chio babes will probably have more time with the more senior doctors. I believe that the MOs' behaviour and attitude do rub off on the junior doctors. You either learn to be like them, either for better or for worst. Or you try not to be like them. Usually for the better.

Here at State General, there are a few categories of MOs:

1. "Simply bo-chap" type
- These MOs just want to finish their bond and get out of hospital. They do their job sufficiently not to get into trouble. They grumble about hospital policies and how sian things are in hospitals.

2. "Sian cha bo" type
- These MOs will only spend time with you, teaching, guiding etc if you are a female. Sometimes, beggars cannot be choosers.

3. "Ninja" MOs
- After the morning round (where the senior doctors like the registrars and consultants are around), they will disappear. Sometimes, I think they were summoned by some feudal lords on some secret mission, because there's no way to contact them at all. They're not in clinic, not in the ward. And they only return pages hours later. Ninjas cannot carry handphones is it??
- They reappear during the evening round. Yes, when the senior doctors are around.

4. "Foreign Talent" MOs (NTS)
- I must qualify and say that some FTMOs are wonderful people, brilliant doctors. Not all of them are black sheeps, though most of them are black.
- Words that I have heard used to describe them include "lazy", "sly", "cunning", "useless", and the rest are not suitable for kids surfing this site.
- I have heard about this FTMO who made the House Officer(HO) deliver her breast milk (which she expressed during the day) to her husband waiting somewhere else in the hospital.

(during busy day in the ward)
FTMO: Can I be excused from the ward round?
Registrar: Erm... why is that necessary?
FTMO: I need to pump my breasts.

5. "Horse fart demon" type
- Rather similar to the Ninja, only appearing when certain people are around, but these MOs can be recognised by their pouty lips, developed after years of kissing ass.

The list goes on and on, but I suppose every organisation has these people.
Fortunately, the majority of seniors are really great people, wonderful, caring doctors.
They may be very strict towards the HOs but all things are done with good intentions, to help them learn.

There are:
- MOs who are willing to help do changes for the poor HOs, clerk new cases etc.
- MOs who stay back after office hours to help the junior doctor with the evening changes.
- MOs who never fail to impart their knowledge and skills to the new doctor.
- MOs who take up appropriate responsibilities when things go wrong, as they do sometimes (and not make the HO the scapegoat!).
- MOs who ensure that the HO is not bullied by the nurses.
- MOs who reply to their pages promptly and don't sound as though they wanna bite your head off for paging them.
- MOs who genuinely treat you as a colleague, a friend rather than a subordinate.

To all these MOs, we can say that we learn a lot, and we strived to be like them, if not better. And we sincerely give our thanks.

My Panadol

Houseman Survivor Guide (Monkey Edition)
I. Introduction
II. Hospital Hierarchy
III. A Typical Day
IV. Painkillers
V. Meet The F*ckers


Surviving in the medical faculty, be it as a medical student or a doctor, is not an easy task. This is especially so when you are just a junior member of the team (ie a House Officer or a Medical Officer) because shit tends to gravitate downwards. Nevertheless, being the altruistic and impressionable young lokuns that we all were, we took the shit in the face (literally).
Tips to surviving medical housemanship/ internship will be dealt with in due course but two things shine in their contribution in making good doctors.

If you ask me what is the greatest drug ever made, I will without a doubt tell you its Panadol (paracetamol). A doctor can survive a drilling 24 hrs call without sleep but he might not be able to endure the next 8 hrs of work with his head throbbing and about to explode! Headaches are not only caused by energy sapping night calls but also by nurses running around like headless chickens when someone in the ward (usually an angry relative) collapses. The consequences are not only related to work as the good Dr also has to fulfil his/her partner's sexual needs!

The other is of course my daily dose of caffeine.