Sorry, 'Cinderella Effect' Not Available Here

As I have repeatedly alluded to my house officers before, becoming a competent and reasonably knowledgeable doctor is a tough ticket to get, at least not without going through a rather eventful learning curve. There's definitely no such thing as 'Cinderella effect', whereby one can become a super consultant overnight by wearing a pair of magic glass slippers!

Of late, I had a disagreement with my ward nurses over the issue of 'informing house officers first' versus 'bypassing the house officers and informing SHO straightaway'.

Basically I have no objection on the notion of informing SHOs in the first place if the urgency of decision on management is going to alter the course of clinical outcome. One good example would be a collapsed patient needing acute medical attention. Any doctors at hands should rush to the scene to resuscitate the patient. The SHO, being more experienced than his junior counterpart, would be of role in carrying out important decision making. Making him available would thus be a wise choice.

On the other hand, house officers should not be deprived of any chance in attaining clinical experience just because they are less experienced!

As recalled from my conversation with my ward nurses, one of them had shamelessly said so:" Aiyo doctor, housemen cannot make decision one. So why not call you straightaway. Later call the houseman, he also need to call you..." I said:"OK, I'm here now, please call the house officer along." She answered:"You're here already, no need to call him. Let him rest."

I couldn't have disagreed (and been disgusted) more.

Luckily, only one particular ward nurses behaved in such a way, other wards are still manageable. Well, I did think it over and try to put myself in their shoes. I think it's really tempting to 'settle' things as soon as possible. After all, they'll probably need to pick up the phone the second time (to call me) if the house officer can't come up to a solution. Extra work always means 'no good' to them :(

Nonetheless, on the whole, I think it's critically unfair to the house officers if they are ousted just because they are less experienced, and hence denied of any potential opportunity of decision-making.

To 'Trop-T' With Love

Sometimes the realm of 'situational wisdom' is rather difficult to apprehend. Apprehension is one aspect... then again, failure to realise the mishandling of one even after being prompted and told otherwise is indeed a gross mistake that is totally unacceptable..

As I was browsing through my blogs at 0330H on my on-call day 2 days ago, I was approached by my house officer for an ECG that was totally hazardous! It was a complete LBBB with wide QRS, almost mimicking a VT. I attended to the patient immediately.

Mr. S had presented himself with symptoms of heart failure of acute onset, however he denied having any chest pain, and he had no ECG done before for comparison at this admission. Having reviewed the ED notes, I was rather displeased by the fact that no ECG was done at ED. Well, I could accept this, owing to the fact that I had worked in ED before and hence I know the plight of my ED colleagues quite well - short-handed and overwhelmed, being yelled at frequently by patients and relatives, both with solicited and unsolicited reasons. My patience was further 'tested', as I later found out that iv furosemide was not on board, given that my ED colleague diagnosis was congestive cardiac failure and that patient was panting away profusely!

I reckoned that probably Trop-T would be a helpful tool in deciding the significance of complete LBBB. Hence I called up the same ED colleague who had managed the patient initially, and courteously asked for a lift of helping hand on supplying me a Trop-T test kit. (Trop-T test kit is only available in ED in my hospital)

Then, I was rather irritated when she kept on insisting that in order to use Trop-T by other departments, the head of emergency department must be informed and give consent first. My god, it was 4 in the morning! And the best part was that this case was obviously mishandled by the ED colleague, who's supposed to be able to prescribe Trop-T anyway!

I told her that if she would have managed this case properly (did an ECG), she would have called me to ED to review and hence I would have ordered a Trop-T anyway (which in that case, she'd be obliged to comply!). I could easily swallow the mistake of not doing an ECG initially...and probably also the failure of prescribing furosemide. But why not lift me a helping hand and spare me a Trop-T test kit for rapid diagnosis and hence I could carry on to my appropriate treatment?

This is what I call 'situational wisdom' - To be sticky to the bureaucratic formality as far as possible, but at the same time, to use our wisdom to do away the sometimes unnecessary red-tape that could hinder optimal performance.

Verdict:
Mr S was later intubated and ventilated for acute pulmonary oedema secondary to an acute coronary event. The LBBB was most probably new onset and represent an acute ischaemic event.