Tuesday, January 24, 2012

The job of the emergency resident...

So we see a lot of young (and not-so-young) doctors leaving A&E for another job. Is it that bad a job? I don't think so. Somebody (@Attachment Vesco) mentioned that there are not so much to learn and perhaps it is all too tempting to use the easy way out (admission, that is...) for the emergency resident/officer...

There is perhaps some truth in that it is very difficult to become a good emergency resident. You need to deal with both medical and social aspect of the patient, and patient do not come in really sorted by their severity. Triage helps sometimes, but quality of triage is REALLY operator-dependent (more so than ultrasound, may I say?).

I have only worked in this emergency department for two and somehow more than a half year, but in the last month I have already seen a few patients categorized as category IV becoming rather critical in my eyes. One of them (an adult) had epiglottitis, and another had AMI complicating GI bleeding (who complained of mild epigastric pain, but was noted to have brief episode of seizure-like activity which lasted only seconds – which turned out to be short runs of ventricular fibrillation). Both of them of course are identified and treated in the resuscitation room and was discharged home.

These are not mistakes of the triage nurse – these are stuff that are not well-covered in triage guidelines – those who complain on the nurse not listening to the stridor are invited to listen for it in our busy emergency department (the truth is that even on assessment in the relatively silent resuscitation room there were no stridor for that particular patient)

What these cases highlight is that emergency medicine is a risky, difficult business and is not in any way easy. It is the clinical sense that developed in these two and a half year, guided by seniors in my department, that enables me to manage these two patients appropriately.

And then we (sometimes appropriately) receives feedback (often not personally, though) that our admission quality is not good enough. The simple test though, is, “Can I send the patient home today in few hours' time?”, and, “Out of 100 patient I sent home this way, would one of them eventually had some problem that surfaces soon after discharge?”.

When we talk about tests, we talk about the receiver operating characteristic curves. Whether the patient requires admission is a test. How much sensitivity do you require an emergency resident to have in terms of e.g. mortality?, significant morbidity (e.g. undetected sepsis which resulted in shock in later presentations)? I really do not know the AUC of a typical emergency resident, but I'd assume that the sensitivity of mortality (e.g. in 7-days' time) got to be much less than 99% or else we would be seeing some 3 deaths in recent discharged case in the A&E I am working in, for example, daily. (Now that's quite gross isn't it). I guess then it is not unexpected that the specificity would be quite poor in a high sensitivity requirement.

But then life in the emergency department is a really happy job for those who are always in a hurry, those who longed for an answer for every patients. The availability of various rapid diagnostic tests (particularly imaging via ultrasound) makes managing patients (in both diagnostic and therapeutic manner) much easier and quicker.

Of course there are other problems (e.g. social problems that annoys me very much) but these really depends on the center one is working in and the interest of the doctor.

And finally, you get to see different group of patients, the rich and the poor, the newborn and the centenarian, and of course people from different ethnic groups. It is only in the emergency department that one can learn how to take care of all these people (and your very own family).

Thursday, January 12, 2012

Two and a half years into A&E...


 It's time for a brief looking back. In this job I got to see people from different walks of life, maybe more of the poorer ones than the richer ones, but then you got to see them too. It is perhaps difficult not to make stereotypes of people and this is also perhaps detrimental to clinical care... But that still happens in the subconsciousness even if it is well suppressed.

The greatest impression to me is perhaps that Hong Kong is really a difficult place to live in, and people here in the shumshuipo district are full of stories.

Years ago when we listen to the news that there are increasingly more aged people in Hong Kong going back to mainland and get a pretty-looking bride, and now we see the problem: Now that the husband is bed bound, non-communicable, ADL-dependent, the wife really doesn't want to take care of him, and yet, they are not yet ready to dump their husband yet because she is still not yet eligible for CSSA, and she is dependent on his portion of CSSA for the living of two person. And then you see her going into a dilemma. She doesn't want him to stay in hospital too long (because that cut short of his CSSA pay), she doesn't want him to live too short as well (for the same reason). And thus we see them reattending a lot for a medical problem that can be treated rather easily in an inpatient setting. Whether that is an indicator of poor development of outpatient care or a case of elderly abuse, is up to the judgement of the society.

And then we also see quite a number of paediatric patients who are really... ill. To me, they really don't have such a thing as free will, or to make it more humane (or inhumane), they really don't have a way to act according to their free will (if any). They are bed-bound, 'oft obese (well, I am), and had all sorts of anti-epileptic medication thrown on them. They may have been worked up extensively for a genetic cause of their disease, and hundreds of thousands of dollars poured onto them to give them education, and to extend their life for perhaps ten more years... Is this still humane? If I were the patient would I want to stay alive just to be admitted few times a month because of sputum retention and faced with a medical crew that is really trying hard to find superficial veins on my forearm that is without any? What about the frequent suction that is not exactly a happy experience? and to develop pressure sores on my sacrum before the age of 80? But I guess they don't even have a choice of euthanasia...

Afterwards it comes back to the problem with pregnant ladies who are not Hong Kong citizens (and this is the reason why I took the time to write this post, it's your post - Sidney Hok Nang Fong). It is an unfair business. It's unfair to the taxpayers who need to take care of those who didn't really contribute to the society of Hong Kong, it is unfair to those who really deserve the care of the obstetrician on-call who need to divert their attention to those NEPs, and it is unfair to the medical and nursing staff who need to work with these patients who are not even worked up for transmissable diseases such as HIV. It is really not the amount of money that matters- it is the underlying mind-set, and the gradual acceptance (to both local and non-local people) that Hong Kong is a place that allows other people to take advantage of her social security.

And did I mention, refugees? These are people without an identity card, having a often laminated form that proves their eligibility to stay in Hong Kong, and are sometimes rude and violent towards our staff. And then you can't send them back to their home country because they apparently will face some sort of torture or political persecution if they are sent back. And they are giving our medical and nursing staff physical and verbal violence every day. And they are coming from a country with high HIV prevalence. Dare you restrain them chemically? Can you restrain them only physically? And what about the diverted attention which should be given to those sick and ill, who served the society for many years? We are keeping them for "humanitarian reasons" and yet they are not even treating us humanely. What the?

I guess these people are some of the stressors that surround our medical and nursing staff and the reason behind some of us moving away from the emergency department.




你還會看見不少兒科病人,他們真的病得很...重。對我來說,他們真的沒有所謂自由意志,或者換個較人道(或較不人道)的說法,他們真的沒有機會執行自己的自由意志(如果存在。) 他們卧床不起,往往癡肥(嗯,我也是),各種各樣的抗癲癇藥拋至頭上。為了找到基因中的病灶,他們或許已經過種種測試,大把鈔票灌注至他們身上以讓他們受教育,或許再讓他們多活十年...這還算人道嗎?如果我是那位病人,我會希望繼續活下去,就為了一個月因氣管堵痰住好幾次院,讓醫療團隊拼命在我前臂上搜索表層靜脈--其實根本沒有--嗎?還有成為日常的抽痰--實在不算愉快--呢? 還有八十歲以前就在我的骶骨上擁有褥瘡?可我猜他們甚至沒有安樂死這個選項。