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).

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

(下有中文版，多謝穆琳小妹妹翻譯。)

 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.

也許是回顧一下這份工作的時刻了。從這份工作，我見識到來自五胡四海的人——大概窮人多於富人。或許不以有色眼鏡來評斷他人很難，也去這樣做對臨床的處理有害...但即使抑制得法，這種事情始終難免存在於潛意識下。

我最深刻的印象便是，原來香港，真是一個讓人生活艱難的地方；以及深水埗區的居民全都充滿故事。

多年以前，我們從新聞得知越來越多香港高齡男子造訪大陸好找個漂亮老婆，現在我們看見麻煩了：丈夫現已卧病在床，無法溝通，無法自理，妻子已經不想照顧他了，可是呢，她們還沒準備好拋下老公，因為她尚未獲資格領取綜緩（譯註：成文時移民必須住滿7年方有資格領取綜緩，目前的條件則為住滿1年），必須依靠老公那份綜緩支撐兩人生活。於是你目睹她陷入兩難：她既不想他住院太久（不然他的綜緩會被扣減），也不想他活得太短（原因同上）。故此我們會看見他們不斷造訪急診室，只為了一些原本在病房內可以被輕易處理的疾病。這究竟代表門診服務質素不佳，還是單純的虐待老人，就留待社會審判吧。

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。

好啦，我們回到非香港永久居民孕婦的問題上（這才是我寫這篇文的原因，這是因為你——六位能）。這不公平。這對被迫照顧從未貢獻香港社會者的納稅人不公平，這對明明值得當值產科醫生照料卻被非合資格人士佔用資源的香港人不公平，這也對需要照料這群或許還沒檢查過有否感染傳染病（例如愛滋病）者的醫生護士不公平。錢不是問題——其背後的心態，本地及外地人對於「香港是一個容許他人任意濫用她的社會福利的地方」的逐步接受，才是問題。

我提到難民了嗎？他們是沒有身份證的人，但他們卻持有那一張過了膠的行街紙，證明他們擁有留港資格。有時候，他們對我們的員工可真夠粗魯，甚至暴力。但你不可以遣返他們回祖國，否則很明顯地他們將面對某種酷刑或政治檢控。每天，他們都對我們的醫護人員施以言語及肢體暴力。他們來自愛滋盛行的國家。你敢用藥物限制他們行動嗎？你能僅用束帶就足以限制他們嗎？那些本該給予服務社會多年的老弱者的關注呢？我們為了「人道理由」讓他們留港，他們卻從不以人道對待我們。這世界是怎麼了？

我想這群人就是搞到我們醫護人員壓力山大的元凶之一，也是逼迫我們逃出急診室的其中一個誘因。