Chest tubes

Accident cases are happening all the time, and serious cases like pneumothorax are not uncommon recently. 

I had just inserted a chest tube last week, and this week another patient came with pneumothorax which requires chest tube insertion.

This patient is referred from a district hospital, sustained multiple jaw-dropping injury like extra-dural hemorrhage, shaft of femur fracture, and bilateral pneumothorax.

The initial Chest X-ray only noted left sided pneumothorax with lung collapsed, chest tube was inserted in the district. 

However, repeated Chest X-ray noted there is expansion of pneumothorax over the right side too, albeit not obvious to the naked eye.

We managed to pick up the findings when we perform eFAST on the patient. The presence of 'lung point' on the right side prompt us to have a closer look on the 2nd Chest X-ray, which if observed closely, a rim of >2cm is present. 

Thus, I inserted the chest tube with Oscar who is the surgical MO oncall. It was quite a good learning process as both of us are still learning and are juniors in procedures like these. 

Take home message: eFAST scan saves life! 

A terrific day

It was the smell of disaster and accidents when the conditional MCO (movement control order) is relaxed, allowing people to travel inter-state. Some may argue that relaxing it may cause a sharp rise in travelling rate and hence, accident rate. However, just like the human body who will undergo illness and injury, people too, may not have good luck all the time.

Lue and I were the only MO (medical officer) working in red zone yesterday. I decided to pen it down as the injury is so devastating and the loss is beyond words. 

Being the junior MO, I was carefully guided by Lue. Thankfully we have a group of diligent team in the zone. We received an ambulance call for an intra-abdominal injury, were being told that few others had died on the scene and they manage to extract only this patient. 

Initial assessment had been done, we thought that there is only injury on the abdomen since it's tender and guarded. However, the Chest X-ray decided to add horror to our day. It was pneumonediastinum (thanks to Lue who is able to spot it) and pneumothorax! 

Chest tube were inserted immediately, albeit we encounter slight difficulty initially, but thankfully Janice came and helped. Ventilator setting has to be low in view of the pneumomediastinum which may be caused by tracheobronchial injury. 

Surgical team came and assess the patient. They requested for CT Abdomen and Pelvis. However, our radiology team noted the extensive subcutaneous emphysema and decided to do a CT Thorax too. True enough, all the other injury you could possible think of is present.

This is just one of the patient for my shift. Not mentioning the other accident patient we attended with Le Fort II fracture (involving inferior orbital wall and maxilla); the one DKA (diabetic ketoacidosis) patient whom we can't find the source of infection; the anterior chest wound patient at the beginning of our shift which pushed to OT straight; the stranded patient in our zone who developed hypotension; the vagabond whom we don't know the cause of his altered mental status; the elderly patient from Hospital Bahagia who had persistent hypoglycemia; and many others.

As a junior MO, I feel the patient does not wait for you. You just have to progress, and improve. Patient will come with the worst possible injury without asking who is the most senior in the Emergency Department. 

In order to strive, sometimes we have to make tough choices although easier ones are available. 

Home Quarantine Day 4-6

Day 4

By the end of Day 3, I got my first swab result, and of course, its negative.

Another day of studying goes.

I tried to relax my mind by watching some movies that I've missed for the past years.

Secret Life of Pets 2.

Greatest Showman (rewatch for the 6th time).

A call to Spy.

I think by the end of Day 4, I already got past my denial stage.

Day 5

We were once again to ask for 2nd swab today.

As I walked past the road of my hospital, I actually never realize that the building is so mesmerizing.

Simple, stable yet provide care for the folks of Ipoh for so many years.

Swab taken at 7.30am by my lovely MO, Dr Chen. 

I like how he can always joke on everything eventhough the situation is like fire burning on yr feet haha.

This time, shit just got real.

We were required to wear the legendary pink wristband, the prisoner band, that forbids us from moving a single inch out from our house.

One of the staff nurse I met that day, told me that his husband is working in the police force, and one of their job is to conduct regular spot checks on us.

True enough, police came knocking on my door in the evening.

I was instructed to lift up my hand to show the pink wristband for them to snap a photo to proof that I am at home.

So this is how it feels when freedom is being taken away....

and yeah, my 2nd swab is negative, of course!

Day 6

I woke up to the voice of my mom urging me to go downstairs, as our dear police officers are here again 'to make sure I'm alright'

Urghhhhhh

I am okay with the way they conduct spot checks but to take photos, its so frustrating.

Maybe its their SOP for doing so.

But its so uncomfortable, especially when some of your neighbours are peeking through the cement wall only to have more question marks on their head as of why police officers will come to my house everyday.

I am so bored.

I was suppose to go for BBQ session in my friend, Fadhirah's house.

It was suppose to be a last gathering among me and my colleagues, but yeah, sometimes life just cheat on you when you are most vulnerable.

It's so thoughtful of them to give me a call. They knew I wouldn't miss this kind of fun gathering especially with colleagues cum friends whom I have been working with for the past 2 years.

I even tried out the trending game, Among Us with my friends.

That is definitely a stress-relieving game indeed.

Home Quarantine Day 1-3

Day 1

So apparently I've come into contact with one of the COVID PCR positive patient while I was working in trauma clinic in Emergency Department.

This comes as a surprise as the patient was not complaining of any respiratory symptoms, but just trauma related complaints. 

I've seen the case with one of my colleague.

On the day when the result is out, I was shocked when my colleague is the first person to notify me.

Subseuently, 2 of my emergency physician contacted me.

I was working in yellow zones that day, having seen total of 6 patients from 3.00-5.00pm, and able to discharged 4 of them.

Yellow zone was busy as usual, but I'm glad we have great souls like Dr Shankar and Dr Iman to tank the zones.

I was asked to immediately go back home.

I clocked out at 5.30pm.

Sat in my car.

No idea what to do.

Later I received a call from occupational health and safety unit. Briefed me about what to do, the need for isolation.

I was so frustrated, angry and sad at the same time.

This means that I am not able to work, my service is abruptly stopped, albeit temporary.

I reached home late at 8.30pm, breaking the news to my mom, who just recovered from the trauma of my dad being hospitalized for secondary dengue infection.

Day 2 

I woke up feeling aimless. 

Although I've longed for a holiday before I'm being sent out to other hospitals, but I've never expected it to be in this way.

Most of my friends were able to see the part of me being granted free MCs..

But the psychological stress is real. This is same like the needle stick injury I got during my first posting as a houseman. You know the result is likely 99% negative but the 1% scares the shit out of you.

I tried to minimize contact with my mom, and advised her not to go out too.

I concentrated on my studies, watching one movie to divert my mind, only to step back to reality after the credits rolled.

Later that night I was again informed to take a COVID swab coming morning.

Day 3

I reached at 7.30am to the COVID container. This is a full container where healthcare workers are able to take swab for patients requiring pre-op assessment and for PUI (persons under investigations).

Usually I am the one who is taking the swab for others.

But today, the feeling is different. I was taken swab by Dr Hariz (my senior MO). 

The feeling of me not being able to serve, but for others to serve me, is devastating, especially when I'm asymptomatic!

I'm also required to fill in a google doc to assess my daily symptoms and temperature.

At noon, I was again received call from psychological unit, to assess my mental wellbeing.

All this has come too sudden.

I still need time to process.

Hopefully during quarantine, I am still able to utilize this time to benefit myself and to serve more in the future.

Do we have control over our lives?

 Do we have control over our lives?

Since we were born, we were guided by streams of culture, sets of rules and social upbringing. The path is clear, we just have to walk on it.

Slight deviation from the path is risky, as we were told to have a path that is clearly defined, but not necessarily refined.

People who deviate from the path can be huge successful, or they may go downstream, unnoticed by the world.

Great things and discoveries can only be done by people who dare to take the first step; as the journey of a thousand miles begin with the first step - Lao Zhi

So ask yourself, what do you really want?

Time?

Money?

Happiness?

or all of them? which we knew its utter impossible.

Or we can have a balance, and only you can determine your own balance.

Thankful

How often do we complaint?

When someone is not doing their job right, or they are slacking, being irresponsible, and the long list goes on.

We always complaint.

Don't get me wrong, complaining is not a bad thing, we all tend to repair our wrongdoings and improve, and we hope people learn too.

But do we thank them when someone is doing a good job?

Think about it.

I think we should all be thankful. To the people around us. Towards what we have.

The above photo is an example of a typical Malaysian 'hospital meal'.

Most of my colleagues will complaint that the taste is awful, or its cold, or its meant only for patient.

THEY ARE ABSOLUTELY RIGHT!

There is no perfect meal in this world, even if there is, it's just for our temporary happiness.

I started to be thankful towards the meal that I have everyday. As I know happiness comes from within, not from external sources.

For it is not the happy people who are thankful.

But the thankful people who are happy.

FRCEM Primary!

It's set!

The pathway to becoming an emergency physician!

To cure, sometimes

To treat, often

To comfort, always

Ivan Tan

22/7/2020

Don't stop

Hey friend, I didn't know so many things happened to you until you told me just now.

It must have been a rough journey for you. If it was me, I don't know if I have the strength to endure it all by myself, alone. But I'm glad you still manage to storm thru all these.

I think the hardest part now is how to continue this windy road ahead.

Well, its really not easy in my opinion. I remembered when I was a first poster, inserted a branula was the most challenging thing for me, especially when the pregnant ladies' vein are large, and I still managed to bunk it.

But I feel the most difficult part is not bunking the vein, its the moment I decided to pick up the branula and poked it into the patient's skin.. that's step 1 for me, and I feel step 1 is always the hardest, no matter what procedures I'm doing.

Of course there are times where I will avoid doing it, as the fear of me bunking it again is so intense. But then I realized, the more I repeat step 1, the more I can progress, physically with skill, or mentally with courage.

Often I have to repeat step 1 for upto three/four times to be able to proceed to step 2, and I tell myself that's ok, because patients come and go, but my skill will build overtime.

Sometimes in ED, we have to use the ultrasound machine to guide us when we encounter difficult branula insertion, and we succeed. But come to think of it, we can succeed is not due to the ultrasound probe, but it's because we ourselves pick up the branula and insert it.

You may have stucked in step 1 now, and have tried few times, but still felt helpless. I'm sure deep inside you, you wanted to do step 1, and many of us are willing to help you to pick up the branula again, but you must insert the branula yourself.

Give yourself time, but not too long.

I'm always available.

A holistic approach

While dealing with specialist, one would usually learn more from the experienced ones.

While there are things that we often miss while dealing with patients, there are also things that is obvious but deliberately missed by us, the healthcare 'professionals'.

In the emergency department, we often tend to give treatment to patients, without explaining much to them, or to their next of kin.

The lesson I have learnt from Dr Chan Pei Fong was a valuable one.

Most of the patients need to pass urine, pass motion and some will feel hungry after more than 6 hours in the ED.

However, we often ignore them while dealing with more vital stuff, forgetting that those are the basic human needs as well.

'Patient will remember you if you take care of those 3 things, and not by how much medication you have administered to them', said Dr Chan.

This is undeniably crucial.

Those are basic human needs.

Also family members are worried too, it is our responsibility to explain to the family members and reassure them!

So yesterday I did the exact same thing, I guided a 80 years old patient to the loo, step by step, slowly.

I looked out for patients without blanket, and asked if they would like to have one, and nicely covered it on their shivering body.

I guess after 2 years of working, there is a need to revive the compassion in me.

There is no excuse to just focus on the 'important' stuff, while ignoring the 'basic' stuff.

It's time to improve!

How is my night?

Last night I was dealing with 2 deaths in red zone ED itself.

As contrary to what others believe that doctors are acclimatized to death, what I can say is, I have seen death in the past 2 years more than most people in their lives, but the scene of family members weeping in front of the cold body lying lifelessly is still not a good sight to me.

There is an old aunty who was involved in a road traffic accident, and sustained multiple extensive intracranial hemorrhage.

Her conscious level started to drop after few hours, and by evening she is already not responding to call.

'Ma, I am back to see you', uttered her son who rushed back from JB to see her one last time.

There was no response from his mother, not even a single sound, except for the constant beating sound of the cardiac monitor.

The woman died 3 hours after being sent to the ward for comfort care.

I wondered how many of us would be saying the exact same words when we are back to see our parents?

Saying it for a thousand times when they are gone does not make up the time loss when they are still around.

Another one was an Indian gentleman who has a wife and 2 children, suffered from heart attack.

We were starting chest compression from the moment he entered the ED door upto the zone itself, as he were already lost his consciousness before arrival.

He did not make it.

Heart rate and pulse oximetry not recordable.
Breath sound and heart sound could not be heard.
cardiac monitoring showed asystole (flat line)
blood pressure unrecordable.
pupils 5mm/5mm fixed and dilated.

As I penned down this routine words which is not something new to me, family members rushed in.

I did not talk to them. As I believe no words can replace a living man.

I was observing from afar, saddened by the harsh fact that we cannot save all lives, and eventually everyone will have to return to their creator.

I do not believe there is any doctors who are good in dealing with death, maybe not from my experience.

Life is temporary. Death is inevitable. 

'I am busy'

'I am busy'

Perhaps the most overused words for me, with such under rated meaning behind it.

When 'I am busy', I am spending 30 minutes taking blood from a difficult patient, with constantly cursing and screaming directly at my face.

When 'I am busy', I am tracing an important CT brain for a patient, as I am worried bout the outcome of the fall from 2 storey height that he had.

When 'I am busy', I am attending an unstable patient, whose blood pressure is constantly low despite giving high noradrenaline support.

Yet there are people who will say words like 'There is no such thing as too busy to reply a message, it just depends on your priority'

While some seem to be offended, it is actually quite true. Priority always comes first. And when you are dealing with humans who have excruciating pain, your priority is to win the deal between you and the grim reaper who wants to suck the life out from your patient.

Thus, the word 'busy' seems to not able to compensate the daily warfare happening in the hospital.

It should be replaced by:

- I was having a back-breaking call last night attending to the non-stop admissions to yellow zone

- I skipped my lunch as my 30 minutes early referral to ICU is more crucial than my rumbling stomach 

- I was late to home 2 hours as the patient decided to vomit blood and life out, right before I stepped out from the hallway

If you have been through what I have been, you will appreciate life and understanding more about suffering.

But fortunately, if you have also not been through what I have been, look around you, you should be grateful =) 

Who is your best friend?

Who is your best friend?

A question that is asked way too frequent.

The older you are, the wiser you become, and so they said, which is partially true.

As I continue to grow in the society, I realized that this question, which I can easily answered if you were to ask me 10 years or 15 years ago, is not an easy question afterall.

I have friend AAA, the friend who is aggresive in learning, believing in focusing on self, who constantly improves oneself. Whenever opportunity strikes, I am humbled to learn together alongside him. This makes him my best friend when I am learning while working.

I also have friend BBB, the friend who believes in work-life balance, the one who will not give extra effort once past her working time, which is not wrong afterall. This makes her my best friend, as she is the one who constantly reminded me of the life after work, that we do not dedicate our lives to just work, and life's too short not to enjoy with your love ones.

Not to mention friend CCC, my best friend when it comes to dealing with my hard times. He may not be physically with me all the time, but he assured me that he will be there whenever I needed advice or help. The one whom I will forget when I'm in my comfort zone, but will only remember when I'm down, and he doesn't mind!

Also friend DDD, the one who is way older than me, who constantly enjoy food all the time. I may not be a food lover, but I can't deny that sometimes a good meal with good companion is all I need after a long day work.

How bout friend EEE, the one whom I seldom meet, although we stayed not far from each other, the one who constantly shared the same beliefs and ideology, who believes in inspiring young people, our juniors, as life is not just about living with ourselves, but to interact with others.

And not forgetting friend FFF, GGG, HHH and so many more, who will only appear at certain times, a certain moment in my life, a certain place which is unpredictable, and at a certain stage of my life..

But one thing is always certain, we not only grow physically older, but our minds grow mentally wiser day by day.

Who is my best friend? This is a question way too easy but too complicated to answer.