A Whole New Experience In UK Hospital

I'm privileged to have the opportunity to be a clinical observer in one of the local hospitals prior to my exam.

I must say it was an eye-opener as one could really appreciate things differently.

People here tend to express themselves more openly. I must say I like that very much in fact ;)

Will share more experience upon touching ground back in my 'waterland'.

Cheers mate ;P

Encore! Another Round?

Of late, I had an interesting conversation with one of my senior colleagues in another department.

We were discussing about the number of ward rounds per day that should be fulfilled. In my department, we only had 1 official round per day. Altogether bosses, SHO's and HO's would do round together and settle clinical issues as they arise. Of course, unstable patients will be kept in mind for more reviews in the late morning or afternoon, keeping in view of passing over to the on-call team for review after office hours.

My senior colleague had proudly told me that in his department, there is no such thing as daily round. Ward rounds are carried out in a tds (3 times a day) or at least bd (2 times a day) basis, and that is compulsory!

He suggested to me that maybe my department should follow their 'noble' path as well.

;)

Ward rounds are designed to pick up clinical problems, so that appropriate clinical action can be taken. Imho, ward rounds should NOT be routine or compulsory, as there are no such thing as 'routine' clinical problems in all patients. Unstable patients should be given more attention and hence more reviews (I won't even call it a ward round!). On the other hand, doing a routine round on a stable patient would be mean a wastage of manpower and resources, which could be channeled elsewhere more needful.

I end my blog by giving you my own experience when I was a paediatric HO.

In the morning, I was following the ward round.
HO:'Day 3 of life, admitted for NNJ, now on single phototherapy...'
While examining the child, the specialist murmured:'Active, not tachypnoiec, jaundiced. CVS no murmur. Lungs clear. Per abdomen, soft non-tender, liver palpable 1cm. Moro's complete. OK, continue the single photo.'

At noon, the same baby was reviewed.
HO:'Day 3 of life, admitted for NNJ, on single phototherapy...'
The same specialist:'Active, not tachypnoiec, jaundiced. CVS no murmur. Lungs clear. Per abdomen, soft non-tender, liver palpable 2cm. OK, continue the single photo.'

Right before going home late in the evening, another round.
HO:'Day 3 of life, admitted for NNJ, on single phototherapy...'
Again, the same specialist:'Active, not tachypnoiec, jaundiced. CVS no murmur. Lungs clear. Per abdomen, soft non-tender, liver palpable 1cm.'

As you can see, the only changes were that of the liver size, which grew to 2cm and shrunk back to 1cm in the same day!

Switched Folders, I Have

Shortly following my blog on the public health equation, I am privileged to have picked up yet another interesting gesture by some patients.

My patients just hate waiting. Well I guess most human being dislike waiting, in particular, waiting for no reason. Nonetheless, I think waiting in a queue to be seen by a non-stop performing doctor is a justified act... suffice to say.

It was a fine morning clinic session. I was seeing a long queue of patients. Some were stable enough to be seen quite fast. Some would need more meticulous consultation and hence more time spent. There was this 68-year-old uncle, who was an ex-teacher, came for follow-up for his chronic stable angina.

I had just finished seeing the 32th patient. Owing to the lack of manpower, the folders were arranged in a row near the entrance to my room, and I'd have to walk in front to pick up the next folder and call the corresponding patient by myself. I had noticed some peculiar stigmata when I saw that this 68-year-old uncle had switched his 36th folder to the top, covering the 33rd.

Honestly, I wasn't happy at all. I then told him:" I'm sorry uncle, it's not your turn yet".

He quickly retorted me:" You know how long have I been waiting? I'm an old man. I can't stand waiting for too long!"

I said:" I understand that you've been waiting. But the queue is moving. I'm afraid you'd just need to wait for your turn." I added:"Most of my patients here with heart illness are elderlies anyway!"

He retorted further:" You don't talk to me like this young man. I was a faithful government servant that served this country before you were even born! I deserve to be treated nicely! You are very rude you know young man"

Somehow my conscience told me that any further arguments would not be fruitful anyway. To me, we were seeing things in 2 extreme perspectives.

I quickly glanced through the 33rd patient's folder who I should be seeing in queue. I was instantly struck by an inspiration...;)

I called the 33rd patient by name and summoned her into my room.

She was a 82-year-old lady with history of multiple embolic stroke being followed up for chronic persistent AF with anticoagulation. Her daughter was wheeling her in on a wheelchair!

I told her that this 68-year-old senior gentleman was trying to jump into her queue, because he couldn't stand waiting anymore.

She became agitated and almost cried:" I was waiting for a long time also. Doctor, can you please see me first?"

That 36th uncle, red-faced, walked away. He didn't say a word, not even a word of apology.

Our Public Health Equation

Q=Quality/speed of service
MD=Staffs available, in this context, MD
t=Time available
P=Patient load

Well, let's do some maths then.

I was recently approached by a patient who relentlessly complained to me about his unacceptably lengthy waiting time. Our follow-up clinic has always been fully booked and occupied, partly owing to the fact that we are the only cardiac referral centre in the whole region.

Mr F's waiting time was, effectively, 48mins, running a bit short of an hour.

He was the 69th patient in the queue. The total number of patient for the day was 127, and the total number of doctors in the clinic was 8. Let's say one patient takes 15mins, it'd require approximately 2 hours to reach Mr F by right.

I'd said: "Guess we're seeing you too soon."

Our clients (the public) usually cannot appreciate this simple equation of relationship between capability of the system and demand on the system.

You'd need an upgrade on your processor and peripherals (of manpower and resources) if you don't want to wait for your Windows to load a program for too long.

Well, another option is to overclock the system. Be wary though, your motherboard would probably die faster and your processor would suffer premature failure and finally refuse to work if you push it too hard!

Happy Birthday To eMRCPian!

I devote this special blog to my dear friend emrcpian. Happy birthday!

Now you're older by a year ;P

Something About Referrals

In my recent calls, I received numerous referrals from my colleagues, of which some were pretty much out of expectation. Of most interest was a referral by my former senior cardiology colleague.

He asked me to review a middle-aged lady who had multiple myeloma and complained of atypical chest pain which was pricking in nature. Her ECG had shown 0.5mm T inversions from V1 to V4. He told me that he was sure that it was nothing of cardiac in origin. Nonetheless he still would want me to see. Just to cover his track as he said.

I saw instantly and repeated an ECG which showed T inversions from V1 to V3 of the same morphology. I proceeded to demonstrate to the ward nurses the way to 'reproduce' the inverted T in V4. I placed the V4 lead closer to the sternal border and wahlah! ..T wave was inverted again in V4. I wrote down my assessment and offered my opinion that it was non-cardiac atypical chest pain.

Well, don't get me wrong. I'm in no way against any referrals from my colleagues. It's the professional codes that dictate every doctor to see referrals and to offer assistance to the very best interests of patients. Nevertheless, referrals must be indicated, and if possible, be optimised, so that limited resources and manpower could be channelled to the necessary individuals and patients. We live in a world with scarce and limited resources. This, unfortunately, we can't change.

If my former senior cardiology colleague was sure about the diagnosis, why refer? This is something for everyone of us to ponder about.

What'd be your say?

Back In Action After A Long Break!

Aha.. I'm back in blogging business after a break for my peri-exam period. On the whole, I can only say that the exam was surely tough. In fact, it's tougher than anyone (who hasn't gone through it yet) can imagine!

Thought of starting another blog on my social life but so far need to gather up some extra time for that :)

I'd already done 4 calls after coming back from my exam. Interesting things ahead to share with all! Stay tuned :D

Chorus That I Need To Sing;P

MRCP- It teaches more than it tests

This is the quote that I find most inspiring and it really holds true as you venture along the path of being a 'mrcpian'.

Singing the 'songs' after the end of each examination would better be termed singing the 'choruses', as each of these would invariably be repeated for tonnes of times before one would sit for the exam:)

I would like to complete my examination by...



1) CVS: AR
BP for wide pulse pressure
Peripheral signs for AR
Signs of IE if suspected

2) CVS: AS
BP for low systolic/narrow pulse pressure
Signs of IE if suspected

3) CVS: TR (functional or structural)
(Of course, you'd have found a PSM at lower LSE best heard at inspiration along with a promivent v wave to say this:)
Examine the abd, in particular, to look for a pulsatile liver

4) CVS: Severe MS +/- pulm HT
BP
Signs of IE if suspected
Examine the lungs to look for bronchial breathing at left middle zone (collapsed consolidation of left middle lobe d/t enlarged left atrium compressing on the left brochus)
Talk to patient to look for Ortner's syndrome (hoarseness of voice secondary to left recurrent laryngeal nerve palsy from left atrium enlargement)

5) CVS: prosthetic valve(s)
Midline sternotomy scar is present...there is a metallic click which coincides with the 1st HS best heard over the mitral area...and there is no evidence to suggest leakage of valve...and clinically there is no evidence to suggest overwarfarinisation.

6) Abd: CLD
Scrotum for testicular atrophy
PR to look for malaenic stool (if pallor present)
...there are signs to suggest CLD as evidenced by the presence of... Therefore, I think this pt has CLD, but there is no sign to suggest that he is in hepatic encephalopathy. The possible etiologies I'd like to consider are...

7) Abd: APKD
Examine the BP to look for hypertension.
Dipstick the urine to look for proteinuria & haematuria
Examine the CVS in particular to look for MVP.
...previous peritoneal dialysis scar noted at the infraumbilical region... I think this patient has adult polycystic kidney disease in ESRF requiring haemodialysis. No signs of fluid overload. No signs to suggest that this patient is in uraemic encephalopathy.

8) Abd: Hepatosplenomegaly d/t myeloproliferative disease
Examine all the lymph nodes to look for generalised lymphodenopathy

9) Respiratory: Pleural effusion
Examine the sputum macroscopically, in particular, looking for haemoptysis
Dipstick the urine for evidence of gross proteinuria
....the etiologies I would like to consider are mitotic lesion of the lungs as evidenced by finger clubbing, cachexia and heavy nicotine stains; mycobacterium infection of the lungs and the remote possibility of a parapneumonic effusion of the lungs.

10) Respiratory: AECOAD
Examine the sputum mug to look at the sputum macroscopically, and to do a bedside PEFR for the pt.

11) Respiratory: Bronchiectasis
Examine the sputum mug to look for foul smelly copious sputum and haemoptysis
CVS- dextrocardia (if suspected Kartegener synd); loud P2 with left parasternal heave to suggest pulm HT

12) Respiratory: Dullness/consolidation apex
Examine for wasting of the 1st dorsal interossei of the ipsilateral hand, and to look hard for ipsilateral Horner's synd.

13) Neuro: Parkinson disease
Examine the standing and lying BP, examine for coordination to look for cerebellar signs and to check patient's upward gaze. I also would like to look for any evidence of long tract signs by carrying out a full upper limbs and lower limbs neurological examination.

14) Neuro: Unilateral facial nerve palsy
Examine for cerebellar signs, checking patient's ant 2/3 of the tongue for taste & sensation. Further examine the 8th CN by doing Rinne & Weber's test and to do a full otoscopic examination.

15) Fundus: DR with maculopathy
Examine pt's visual acuity (& to plan for an urgent ophthalmology referral; esp when there is significant VA impairment)

MRCP; Membership of Royal College of Physician- They only give that to the crowned heads of the world:)

Homage To Traube;)

My dear friend emrcpian had recently posted a blog on abdominal examination and had mentioned about the use of 'traube's space'.

It remains as elusive as it was back in my student years whereby conflicting opinions prevail till these days.

I had done some 'click and research' via the net. Would like to share :)

About Ludwig Traube, the original guru who described the Traube's space:
"Great merits and fame earned Ludwig Traube by establishing of the experimental pathophysiological research in Germany (e.g. he did animal experiments in the 1840th in his Berlin flat in the Oranienburger Str.) He improved the physical-medical methods like auscultation and percussion and was a taxonomist of the medical documentation. (e.g. inaugural of the temperature-pulse-frequenz of respiration-curve into clinical praxis). He investigated the pathophysiology of the respiration and the regulation of the body temperature, and gave a scientific basis to the digitalis therapy. The narrow coherencies between heart and kidney diseases have been well demonstrated. He worked together with Rudolf Virchow (1821-1902), they substantiated the „Beiträge zur experimentellen Pathologie“."

Wikipedia:
"Traube's (semilunar) space is an anatomic region of some clinical importance. It's a crescent-shaped space, encompassed by the lower edge of the left lung, the anterior border of the spleen, the left costal margin and the inferior margin of the left lobe of the liver. Thus, its surface markings are respectively the left sixth rib, the left anterior axillary line, and the left costal margin. Underneath lies the stomach, which produces a tympanic sound on percussion (medicine). If percussion over Traube's space produces a dull tone, this indicates splenomegaly. Assessing this may be more difficult in obese patients. The normal human spleen measures about 125mm in length, and splenomegaly is an important clinical sign. There are 2 possibilities to evaluate splenomegaly in the clinical examination: percussion and palpation. Percussion can be done in Traube's space, as described by his pupil in 1868. Another method was described by Donald O. Castell in 1967 (Castell's sign)."

Conclusion:
I think the percussion of Traube's space is both a non-sensitive and non-specific way of assessing for splenomegaly. As you can see, anatomically, it's bounded by the lower left lung, anterior border of the spleen and the left lobe of the liver. Hence theoretically, any enlargement/effusion of these structures could obliterate the space and hence would cause 'dullness' upon percussion.

As alluded earlier in Ludwig's biography, one of his main interests was in respiratory medicine. Hence it's not surprising that he had originally ascribed the dullness to pleural effusion instead :)

"Look out for the original papers decades back describing the eponymous syndromes or signs, and you'll be surprised how much they have evolved/changed through the years." -My neurology clinical mentor

A Little Untoward Event

An interesting event happened couple of days ago.

One colleague of mine paged me on my on call day, seeking for opinion on the management of a patient with unstable angina who had developed one episode of transient bleeding while he was on LMWH. From what I’d gathered over the phone it occurred to me that the patient was rather stable with minimal chest pain. I suggested him to switch to conventional unfractionated heparin instead, with careful monitoring, keeping in view of potential rebleeding. He thought the half-life of UFH was 6 hours. I corrected him by telling him that it was only 90mins (hence easier reversal and less prolonged bleeding should the patient bled again). Probably, this was what tickled him off ;P

I have always wanted to know (and get acquainted to) as many as possible of my medical colleagues elsewhere in the vicinity. Basically it’s for the sake of easier understanding among one another, as well as mutual sharing of clinical experience and knowledge.

As a friendly gesture, I had enquired him regarding the year of graduation and the university that he had graduated from, for I wanted to quote some names of my close friends of his batch. (We lead a rather small community in the medical line in our country, and eventually we tend to meet back one another rather soon!)

I was totally taken by aback when he accused me of being arrogant and that I had tried to insult him by asking his year of graduation. I eventually ended up half-apologising-half-pacifying him over the phone. Tough job indeed!

From this little untoward incidence, I could gather a few points of thoughts:

• Asking the year of graduation (and hence implies his seniority) would not be a good idea after a ‘skewed’ consultation. The other party would think that you’re trying to patronize him
• Over-the-phone consultation is both not specific and not sensitive (at least, the other party wouldn’t be able to pick up some visual cues that could have saved the misunderstanding)
• The referred party needs to be extremely cautious, as the referring party is easily sensitized by some unintentional audio cues, which is strongly influenced by the often imbalanced senior-junior relationship and is relentlessly driven by a hidden sense of inferiority complex among the juniors. Things could be quite different, if he were the senior :)
  

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.

Enigmatic CardioDetect(R)

I had my best call so far on the 12 March 2006, doing cardio posting on call.

Weekends were usually relatively quite (without much of the perioperative assessment referrals). And this was by far one of the most quite call I have ever had.

At 0435, my colleague in ED actually called me to review a case. A gentleman with history of end-stage renal failure on regular haemodialysis had presented with acute onset of dyspnoea but no chest pain. Coupled with the history of non-compliance to fluid restriction, and the antecedent history of inadequate dialysis, I was almost certain that it was a fluid overload case warranting urgent nephrology consultation.

I was called in for assistance as he was tested positive for CardioDetect(R) - a relatively new biomarker of myocardial injury with higher sensitivity but lower specificity compared to our good old Troponins. It was a falsely positive result as CardioDetect(R) - a human fatty-acid binding protein (h-FABP) can be elevated in renal failure and other muscular injuries as well. In other words, it is a good tool to rule out ACS, albeit an inadequate test to confirm one.

I printed out the article bearing the indications and limitations, together with the summary of the sensitivity and specificity of the test to my fellow colleagues in ED for their reference.

We learnt together by doing calls, seeing patients, albeit in a rather tiring way ;)

Back To Square One!?

I'll be posted back to cardio starting tomorrow. I gather that there will be plenty of learning opportunities for me, albeit it would be my 2nd round of doing cardio.

One of my colleagues had uttered: "You'd be better off doing something else rather than repeating the same posting. It's just like back to square one!”

I couldn't have disagreed more.

Cardio harbours the bulk of general internal medicine. Not knowing cardiology well, one would be a mediocre physician at best!

Though I must admit that most seniors in my department are relentlessly against the idea of doing cardio, the exact reason behind is way beyond my knowledge. And it has been sort of a taboo to bring the topic into discussion.

Instead of going back to square one, I foresee great opportunities ahead of me ;)