Jonah Neurosurgery call Part 2

Neurology has been 1 of my sore spots in medicine, but my 3-month neurosurgical rotation in Australia has been fun. Somehow, 2 calls in neurosurgery has completely ruined my impression of it :p lolz
After finishing work at 6.50pm during a long surgical day, was just about to grab some dinner and have a rest, when neurosurgical male ward called at 7pm. They needed somebody to call Kluang hospital's MO to accept a patient due to be transferred. It's funny how the person who wrote the referral letter earlier did not call them up as well.

Going through the case files, before I could figure out what to do or say, rushed to the Neuro HDU - 1 patient has asystole. Upon arrival and jumping onto the bed to commence CPR, the heart monitor reveals the rhythm to be ventricular fibrillation (this would be a very good time to try and remember what was practised during SIM centre).. The MO allowed me to play with the defibrillator (different from the one we used in Monash / Australia), so I delivered 3 shocks to the patient. Adrenaline and atropine given. No response. The MO told me to go do rounds since nothing much could be done.

Going back up, managed to call up Kluang hospital and push through the referral, only to be told that the Kluang ambulance people could not wait and had already left. So the patient is staying with us, whether we like it or not. Returning to the HDU, had the unenviable task of filling up the death certification and documentation, as well as informing the friends who arrived and family over the phone. So unprepared.. I think I did fine, but if 1 thing bothers me, CPR attempt was documented as 30 minutes in duration, when in actual fact I don't remember anybody bothering to go on even more than 10 minutes..

Was in the process of taking ABGs when the OT called to run for blood at the blood bank. An 8-year old boy whom we saw earlier when he came to HDU was undergoing craniotomy, but upon arrival at the blood bank with the patient's info, they denied receiving any forms for blood request. It turned out that of all the bloods taken, the nurse forgot the GXM cross-match, and knowing how difficult it is to take blood from kids in the middle of surgery, the anaesthetist literally blew up in the OT..

It's already midnight, and I have been running up and down, and up again to the paediatric surgery ward. New case for admission, as the poor little girl fell forward off her bicycle and hit her head on the handle bar. You know what was the best part of clerking her? Dozing off in front of her mum.. and to add another moment of laughter, when I drew the diagram of the haematoma, I was actually extremely tired and sleepy, so for some unknown reason I labeled the wound 'For bowel prep'. By the time I was done, started TDS rounds at some weird time in the morning - 2am at male ward, and 3.30am at female ward.

At the female ward, I was greeted to the sight of a patient who appeared tachypnoeic, which was being ignored by the staff nurse to my annoyance. Suddenly, she began hyperventilating / gasping, and you could hear wheezes from her tracheostomy. ABG: respiratory alkalosis. Gave her some nebuliser and trachymask oxygen. Sent down to neuroHDU.

My colleague, who came into NeuroHDU as I left, was greeted to a sight of 10 patients, and turned towards me and griped, "Why in the world did you fill up my ward??!"

Call ended around 6.45am. No time to shower / eat / sleep also.. start surgical rounds.

30

The following 30-hour marathon takes place between 5.30am (14 February) and 12.30pm (15 February).

6.00am - Leave for work.
6.30am - Start clerking patients.
7.15am - Patient came in for epigastric pain TRO acute cholecystitis. Amylase 2478. Acute pancreatitis! Quickly scramble with MO to work out our management plan.
7.45am - Another surgeon replacing my consultant comes to review patients. Changed the Ranson criteria to modified Glasgow criteria. When everybody (even the MO) did not know what is the Glasgow criteria and its significance, he called all of us @$$h****, and asked how in the world did I pass med school.
9.15am - For some reason, today there are only 3 of the usual 5 people in our team. So with 1 patient who needs to rush to the scope room accompanied by a houseman, 3 patients who need to be discharged, nurses bugging you for bunged IV drips and bloods to be taken, the pancreatitis patient who needed an ultrasound etc, the surgeon asks 2 of the 3 to go down to clinic immediately coz it's overfilling with patients and the 5 housemen rostered for clinic are missing,(obviously not possible, ward work needs to be done 1st).
10.10am - The usual routine of being yelled at by the radiologist.
10.25am - Cancer patient A needs to postpone chemotherapy due to electrolyte imbalance. Palliative care unit not picking up the phone.
10.26am - Cancer patient B needs an oncology opinion regarding her chemotherapy due to neutropenic sepsis. HSI not picking up the phone.
12.15pm - A patient previously discharged after a Hartmann's procedure got readmitted for wound breakdown. The ward is filling up.
12.55pm - Just when you thought you have finished the work and are about to grab a quick lunch, the paediatric ward upstairs called. As the neurosurgical HO on call, need to review a young kid who suffered a temporo-parietal haematoma after a fall from 1 metre supine onto the concrete pavement while at the playground.
1.45pm - Rush back to the ward to review patients for afternoon rounds.
2.35pm - Afternoon rounds start.
3.15pm - Our consultant surgeon came. Learnt a lot from him, though got grilled a lot also. Asked me to be more confident.
4.15pm - Apologised to head of department who happened to be in the ward, for failing to trace his patient's histopathological report. Simply did not have the time.
4.40pm - Just realised that the next day's on call roster has not been drawn up.
4.45pm - Patient suspected anastomotic leak post-reversal of Hartmann's, planned for CT gastrograffin. Rushed to take consent and fill up forms.
5.15pm - Patient who came in earlier for wound breakdown had seropurulent discharge when sutures removed. Surgeon was initially worried about faeculent material resulting from fistula.
5.45pm - Family of a patient who has recovered from an upper GI bleed due to a gastric ulcer demands that you allow her to be discharged as she has been feeling anxious and uneasy with her hospital stay, though you wonder how to break the news to them that you were actually awaiting medical opinion regarding beta blockers for her sinus tachycardia, and psychiatry review for her apparent symptoms of low mood, poor eye contact, symptoms of persecutory delusions (bed has electric shock) and hearing voices of children playing nearby. Eventually no psychiatry condition elicited, allowed AOR discharge.
6.30pm - After the tests were planned, confirmed, and everybody has gone home, patient who was planned for CT gastrograffin mentioned that she had the abdominal pain because the nurse clamped her CBD. She felt better after its release. Endured a scolding from a pissed off MO to just do what the boss ordered when asked opinion to cancel the CT.
7.00pm - Ward work done. No time for dinner. Grabbed a bun and start Neurosurgical HDU night rounds.
8.15pm - Wondering what are all the PEEP/SIMV/CPAP measurements which the consultants and lecturers all dismissed as not important for our level during medical school..
8.30pm - 8 ABGs to be taken, 4 turned out to be VBGs.. *swt* have to re-do..
10.30pm - Night rounds at male and female ward upstairs..
3.30am - Finished night rounds. Felt like sleeping in one of the ward beds. Blurring of vision sets in (hungry and running on 2 cans of coffee) :p
4.30am - Patient from Segamat suspected intracranial bleed. Inserted CBD. Patient decided to urinate before CBD could be secured with balloon. CBD was shot right back out of his urethra, followed by a fountain spray of urine. What a mess..
5.55am - Half an hour more before my presumed end of neurosurgical call (and freedom) when the HDU phone rang. Please come upstairs to neurosurgical ward female, a patient chose this moment to go into asystole. CPR for over half an hour and had to accompany patient back to HDU..
7.30am - Start morning rounds (despite it being public holiday)
12.30pm - Finally able to go home.

Week 2 in General Surgery - Things that keep you going

Currently listening: Hillsong - Love like fire

Surgeon: So Gary, do you like surgery enough to become a surgeon?"
Me: Err.. actually not that keen on things which require quite a fair bit of hand dexterity.
Surgeon: I see, so what do you prefer? Something which requires more of foot dexterity?
Me: *swt*

2 weeks already. Finished tagging and already went through 1 episode of Operating theatre on-call. Imagine the sight of laparotomies and colostomies at 2am in the morning. 2 hours of sleep before starting next day of work, making it 36 hours straight on the job. Nevertheless, I think I can say things have been good so far.

Fell sick while working during Chinese New Year, but no choice lar, since I am saving my leave for convocation in Sunway. Being a 1st poster in the ward, among mostly more senior and experienced housemen can be intimidating, but should be fine as time passes. My philosophy has always been 'I may not be the smartest, but I try to compensate for it through hard work'. Yes, did get scolded by surgeons for things which are not really your fault, MOs who are hard on you coz I was quite blur having forgotten a lot of things since leaving med school, nurses with attitude problems, and colleagues who disappear and dump their work on you.. Also have been thrown into the deep end by being called down to review patients in the clinic, despite being only 2 weeks on the job (due to staff shortage).

However, amidst all these, able to see the positive results of going the extra mile for your patients, some of whom actually walked up all the way to your ward workstation to shake your hand in gratitude, while 1 Chinese patient gave me an angpau and orange.

There was also a difficult moment with an elderly Malay patient. She was a known case of anaemia, had cholelithiasis and was due for a cholecystectomy. Initially she was allowed to eat, then fasted, and the cycle repeated for 3 days in a row as her surgery kept getting postponed. Her young daughter, whom had taken weeks of leave from her workplace in Simpang Renggam, broke down in front of me, at the sight of her mother having to endure such a fate. Duno what to do or say, could only offer reassurance and a packet of tissue. When the surgery was over, the T-tube dislodged, and they had to go back in to adjust it and correct the peritonitis. By the time they were done, she had severe metabolic acidosis and altered mental status. Despite her daughter's frantic cries at the bedside, she could neither recognise her, nor me. Honestly, I was trying very hard not to shed a tear.. but we did all we could.

To cut the long story short, she did come out of ICU a few days later, anxious to go home after bouts of physiotherapy. Today although I was not the one to write her discharge summary (as I'm not rostered for work), she doesn't need me now - her family is currently by her side, and the last sight as I walked out of the ward was that of her daughter's face brimming with a smile. Priceless :)