王盈方醫師瘋狂之旅 Dr Yvonne Wang's Blabberings

Week 3: the hell week

This was the week where I did my first weekend shift in Dubbo. They have a rather peculiar way of rostering our overtimes where everyone will eventually go through the exact same cycles (probably a lazy way of doing things): on my 1^st week I was rostered on a Tuesday, 2^nd week on Monday, this week I’m on Friday & Sunday, and next week I’m on Saturday etc… 2 weekends 1 week after another!

The interns/RMOs who did weekends before said it was very bad. I was not looking forward to it at all…. And even before the weekend shift, we’ve already experienced some bad things w/ some of our patients, as if foreshadowing the horrible weekend coming up!

Firstly, there was a consult from the ortho team who was a middle aged lady admitted for elbow wound infection post ORIF, w/ multiple co-morbidities like diabetes, renal impairment, IHD. The patient was in APO & NSTEMI by the time ortho decided to consult us. Echo showed regional akinesis and sestamibi showed +ve changes of ischemia/infarct. We were going to send the lady to Sydney for angio but found that the patient became neutropenic, and therefore delayed the transfer. Anyway, this week, the patient had a cardiac arrest, and it was dramatic! The small ICU room was flooded with doctors – the medical registrars and the junior medical officers! There were cameramen roaming outside the patient’s room, although I wasn’t sure if they were filming (or even allowed to film). The classical resuscitation happened.

Secondly, a patient of ours kept getting issues w/ venous access. With her condition, she must have antibiotics and intravenous fluids. However, we could not get IV access, and her central venous line blocked up the day it was inserted. Then we asked for a PICC line to be put in and had a problem with consent where both the med registrar & anesthetist refused to do the consent, and the anesthetist kindly did the consent in the end. Then her PICC line blocked up again, and we had to ask for another PICC line to be put in. My med reg gone off to Sydney so the anesthetist I spoke to kindly agreed to do the consent. However, when theatre called for the patient during my Friday overtime shift, the anesthetist on had already changed over and the new anesthetist refused to do the consent. The med reg on said I could do the consent provided I explained the risk of infection, clots and hemorrhage…. But then the family was not with the patient, and the patient wasn’t competent to do the consent at that stage!

Thirdly another patient developed pulmonary edema and we couldn’t establish IV access. Fortunately the anesthetist kindly put a cannula in.

Then came Sunday, the 14 hour weekend shift! It was a totally different experience from the RPA overtime shifts. Apart from being very busy with stupid things like fluids, IVCs & bloods, I was also asked to do some very strange things which I was never asked to do at RPA, eg. Disimpact stool from an elderly lady! And believe me, digging shit was not an enjoyable experience at all. What’s worse, the registrars on were not too friendly either – they get very overworked on the weekend and the hospital environment as a whole was just not very supportive.

There was a patient who I just couldn’t categorize clearly in one category, as I could not really work out what was wrong with him, and therefore was not sure about which registrar I should consult. He was admitted because there was suspicion that he might have septic arthritis. Knee aspirate was taken and gram stain was negative. The orthopedic reg did not seem worried and crossed out the IV antibiotic which the night resident had charted. I was asked to see the patient because he vomited feculent looking material. Abdo xray was done which showed dilated ileum and multiple air fluid levels. There were only occasional bowel sounds on examination. However, I also noticed that his O2 was 84% on room air and his electrolytes were abnormal – with a hyponatremia of 129, slightly raised urea & creatinine. He even had neutropenia on the bloods taken four days prior! His vital signs were otherwise stable. The patient was confused when he first came into the hospital, and the family said that the patient had been alert w/ independent ADLs prior to admission and is a nonsmoker who never had lung problems! The patient did not have any recent bowel surgery or hernias either! It was all very strange. When I called the med reg, he thought the patient was surgical. When I called the ortho reg, he said to consult general surgery for the possible bowel obstruction. When I called the general surgeon, I wasn’t able to give a very convincing story as I couldn’t work out the patient myself, but the surgeon said he would review the patient. Anyway, the day passed and the patient had two more vomits. The nurses and I tried to put in the nasogastric tube but couldn’t – the nurse was a very experienced nurse who claimed she had a 100% success rate track record in nasogastric tubes! Anyway, the patient became very unwell 10 minutes before my shift was supposed to finish! His vomited again, was clammy, wheezing loudly, with an O2 sat of 84% on room air! I wasn’t sure if it was pulmonary oedema or chest infection. So I called the med reg who thinks I didn’t know what I was talking about – well I really didn’t know what was happening to the patient! Anyway, ECG, ABG, bloods & CXR were done. The registrar thinks the patient might have aspirated and said we needed to wait for the CXR results for an answer… so I handed the patient over to the night resident and finished work half an hour late><

There was also a patient with what appeared like compartment syndrome of the lower limb post tibial fracture ORIF – what he described just seemed very similar to the compartment syndrome described in the textbook! However, the orthopaedic registrar only reviewed the patient 15 minutes before me and did not think it was compartment syndrome. The family was getting very worried because the patient had a high threshold to pain. I called the ortho reg again with my opinion but he still did not think it was compartment syndrome. So I decided to consult the general surgical registrar on as well. The general surgeon said it is the orthopedic registrar’s responsibility to make sure the patient did not have compartment syndrome. Anyway, I didn’t have much experience with compartment syndrome so I charted a higher dose of morphine and left it at that.

By the end of this shift, I was certainly not looking forward to the upcoming Saturday weekend shift! What’s worse, I just realized I had eaten up most of the goodies my mom brought me the week before>< No more comfort eating!