Aug 3, 2019

Part 2: Reporting In

After a scrambling long drive from JKN, I finally arrived at the district PKD around lunch time. Two colleagues of mine, Y and N, were also stationed at the same district as I and we agreed to meet at the PKD office after 2 pm. When I arrived, they weren't there yet and I hadn't had my lunch so I wanted to go somewhere first to eat. Luckily, beside the PKD there is a Mydin mall building. I never saw a Mydin mall this big anywhere in the Klang valley - I know there's a huuuuuge one in Kuala Terengganu but this one was maybe 4 or 5-storey tall.

Anyway, I searched over the Google Maps and found out that this Mydin mall is the only mall-like structure in the town. Upon entering, I quickly realised that the only thing worth to be excited about this mall is the Mydin itself. The rest of the shops inside this "mall" are so.. disappointing. The town itself is quite a medium size one, actually, with blocks of shop lots that kind of have everything that you need. I counted a number of banks, restaurants, hardware shops, furniture shops, etc. But no malls. I saw one KFC franchise, no McDonalds, no Starbucks, no TGV or GSC cinemas (not even an MBO). But this town is the closest to Penang (is this a clue enough to guess where I am now?), which by my standard is similar to KL thus should offer me more of a city life that I am forever addicted to have.

Me hyping myself helplessly while my inner me just groan at this town

At around 3 pm, the three of us went to meet the boss of the PKD, Dr Z who is also a PKD. Not to confuse anyone here, but his title is the Pegawai Kesihatan Daerah of the Pejabat Kesihatan Darah here. He's so friendly and enthusiastic about us reporting in here. We were midway of listening to the introduction of PKD organization and filling out forms when more MOs came to report in as well. He was jubilant. In total, there's seven of us newly transferred here and they (the PKD people) were very happy in assigning us to the various KKs that are under this district's PKD.

There is a total of 10 KKs under this PKD and they are divided geographically into two and named as KK Laut and KK Darat respectively. I was assigned to this particular KK Laut (literally, my KK is very near the beach) because they needed a male doctor to balance out the doctors there. I did not have a say in this matter, unfortunately, unlike the rest of my colleagues. My face cracked a little and I felt myself showing a disgruntled face to my new boss - I told you I had this terrible poker face that is very much loathed by so many people. But I couldn't help it. This KK is so far to the west that it took me a solid 45-minute drive from my rented house (more on this in next blog post!).

You will be directed to a Pegawai Tadbir (PT) who usually is assigned to handle all MO-related matters. That person is the most important person that you need to remember when handling with matters related to the PKD, apart from your bosses. They will handle a number of things that need to be cleared out when first reporting in to a new place. In no order of importance, it include:
  • delivering the letter from state JKN that says you are to serve at that particular district
  • HRMIS update
  • CPD points of the next year
  • transfer claim
  • new KKM ID (passport photograph required)
Of those, the most exciting part but equally exhausting to complete is the transfer claim. The PT will ask you for a screenshot of the kilometres travelled from your home to the state JKN, from JKN to your district PKD, and finally from your district PKD to your KK. They will also need a copy of Touch&Go transaction, the original invoice of the first three-day hotel stay, a copy of your car VOC (vehicle owner certificate), the letter from the JKN and the letter from SPA. They will calculate how much you can claim, taking into factor of your car type (mine is less than 1000cc, so it's a C class or something) and they will also include meal allowance.

"Finally, all documents are here!"

But once all those done and dusted, just wait for the claim process to be approved in a week. The claim is noticeably more than you had spent. It's more due to the fact that we do not take into account about the meal allowance, lodging and etc. I'm not complaining, though, cuz I need that money HAHAH. This whole transfer thing just sucked all my savings into oblivion. So, a word of advice, do a bit of saving 3-4 months prior your transfer!

It's funny how much screaming I have done whenever I went to the ATMs

Another very, very important aspect that you need to highlight quickly during reporting in is that to REQUEST FOR THE WHOLE FIRST WEEK OFF! Again, I remind you, this is very important. Know your right to request. I was fortunate to ask one of my ex-colleagues at my previous hospital about the whole process of transferring. He said that not all PKD or the KK allow for day-off request, which is totally absurd and cruel. He had to argue at the PKD and threatened not to come to work anyway if he was denied the off-days. He eventually got it. Imagine you just had travelled tens or hundreds of kilometres, even, and they had the audacity to ask you to work the very next day? You don't even know the area, you don't have any place to stay, where to find food, etc. So do the sensible thing - ask for the whole week off.

I quickly asked for the week off on behalf of all of us. We are lucky that there is no KK that operates past 5pm on weekdays and none have to work on weekends, so our weekends is pretty much untouchables. We were granted the whole week off except on Thursday and Friday as half day as we had to attend an orientation course for the monthly new staff transfer. That's cool.

After the business at PKD concluded, I decided not to visit my KK just yet. It was already late in the afternoon and I did not have any place to stay yet. A quick thinking and I decided to find a budget hotel to stay at Bukit Mertajam, Penang. I didn't care that it was far. I didn't care that I had to pay toll and had to suffer traffic jams. The sight of Starbucks, McDonalds, and Xin Fu Tang (even though I stopped drinking boba teas long time ago and never join the bandwagon) just somehow soothed my soul and calmed my mind. I found a sensible hotel there and booked for a two night stay. I had a quick dinner, showered and went to bed.

The next day then was the start of a brand new day which is The Hunt for a rental house. This will be covered in the next blog post, so that's it for now!

(read Part One - The Long Journey here)

Jul 23, 2019

Part One - The Long Journey

It has been almost a month since I received the transfer letter and started working at a new place. A month filled with multiple burnout drives back and forth, travelling to far and near places. The long travel, the reporting in, the hunt for a place to stay, and the settling in has kept me much occupied that I neglected to blog here. I've been meaning to write the whole experience of the transition between a floating MO to a regular MO post-transfer and now I got a bit of time to do just that.

I'm sure my batch's experience is different from the previous MOs because we are the first batch of contract HOs being offered a permanent posting as an MO. Everything is digital, too, with the offer letters and the transfer letter just needed to be printed. Once all the forms and letters are ready, I packed my essential belongings that can sustain me for a month, shoved them all into my tiny Viva car, bid my farewell and start driving.

I have to make multiple entries because there's so much to tell so here we go.

Part One: The Long Travel

When we first got transferred, we are supposed to come to the health state department (Jabatan Kesihatan Negeri) of the state that we got. I departed from home very early as I estimated it would took me 2 hours to reach there and it was. Upon arriving to the meeting hall, I was surprised to see there's a huge number of us (122 people!) got a transfer in this state and all I could think of was, uh oh.

Usually JKN people will receive around 20 people reporting in for transfer in a month. And there I was, among the sea of a hundred people and few colleagues who got the same state as I was, waiting for them to hand in the official transfer letter that tells us the district we are transferring to. A few of us managed to call the JKN beforehand to know which district they've got so no suspense there but to majority of us, we were all waiting anxiously for that damn letter.

In any KKM organization at state level, us doctors usually work either under Medical or Public Health. Those under Medical means they will work in hospitals. It can mean a district hospital, a tertiary one or above. If you got Medical, you will be told which department you got once you report in at the hospital. Public Health doctors are the front-liners who work in health clinics (klinik kesihatan). We were told that in view of a large number of us transferring at the same time, half of us will be transferred to klinik kesihatans and another half will be sent to the hospitals.

Priority for a hospital transfer was given to those who passed (parts) of professional papers like MRCP, MRCH, etc. and those who are contract-based MOs. The reason being is that for doctors who have passed first paper of MRCP, for instance, they will require more training at tertiary hospitals under a specialist guide. Meanwhile, those who are contract-based supposedly will also be sent to tertiary hospitals because they will need to be evaluated by a specialist before being offered a permanent post.

After I received the letter and learned of the far-away district I've been assigned, I straightaway left the JKN building and started driving away. Afterall, it would take another 2 hours roughly from JKN to the next reporting place. I've learnt later that some of us stayed behind at the JKN for "haggling" - they tried to swap placement among themselves on mutual agreement. Some would want someplace more south or more north, closer to the east or to west, for instance, depending on their preferences or personal circumstances. Some succeeded while some did not. There's no guarantee.

Imagine this was me driving not under lamp lights but under the basking sun

The journey further north was a bit quiet with a whip of whirlwind perturbing my mind. After all I was, at that moment in what I would call uncharted waters. I was wondering throughout the drive about what is it like working in klinik kesihatan in a less populated district. Would I be left frustrated, unable to cope with the limitation of a clinic setting? Would I be wondering aimlessly, go in and out of work without the crazy rush of emergency I normally had back when I was in ED? What about my future? My aim for a paper? What about settling down? Having a family? How must I proceed?

It was a totally different kind of journey with a different kind of feeling. When I first left the house in the wee hours of 4 am, I had an endgame. I had it all planned and prepped. I googled JKN days before departure, finding out the best route and how long the drive was, determining where to change clothes and gauging whether my packed bags are sufficient or not for the months ahead. I was confident. I was ready.

The second journey was not the same. I did not know where the place was. What's the people there like. I know for certain there are a number of KKs there and I don't know which one suits me the best, or whether I can choose which KK to serve in the first place. The more I traveled, the more alarmed I felt about the future that lies in front of me. The weather was not endearing, either. It was cruelly hot and dry. I felt my lips cracking and my shirt sticking to my body. I definitely did not smell pretty. But I drove on and on, until I reached my second destination of the day -  the district health office (Pejabat Kesihatan Daerah or PKD).

(to be continued in Part Two - Reporting In)

Jun 18, 2019

The Half-submerged Duck

First and foremost, an apology.

I skipped blogging for almost two long months. During those time, a number of things had happened. Some days were monotonous while on some days events were taking place like a raging storm. Notably, again, I didn't write anything during the month of holy Ramadan. Nothing enticing happened, either. This is the second fasting month that I felt I could have done more but a sick spell made me feel weak throughout the month. This strain of malaise is particularly strong and I was crying out for mercy by the end of it.

I was really out of it for quite some time and thus, my laptop remained untouched. I felt the need to blog, to pour over my thoughts into the cauldron of strewn words and undulated stirred emotions was a bit too much for me to handle. Plus, I normally sit down and write with the company of a cup (or two) of coffee somewhere in the cafe anyway (wow, vogue) of which is unattainable when you are fasting.

Secondly, a brief recollection of memories.

Things pretty much had fallen into place. I am becoming more cautious yet confident in seeing patients. True, every mistake is a great tool for learning. I disapprove that mistakes are the greatest teacher. They are simply the tool for you to improve. You still need someone, or sometimes the whole faculty of a department, to tell you what are the things you do wrong and why is it so and what to do instead in the future. They are your teachers. They can be anyone, from consultants to the medical students, so I learnt to be humble and swallow down my ego. Only the other day I learnt how to do a HiNT examination from a houseman (also a colleague) and I'm forever grateful for it. Being arrogant doesn't lead you anywhere, only backwards.

I learnt to stop antagonizing every little thing that irritates me. Sometimes I succumbed in my stress, but alhamdulillah, I feel that I score well in that department. I amazed that all my anger or frustration or annoyance stem out from my colleagues rather than my patients. Well, I only curse to myself about the patients that are abusing the service in green zone. I do managed to find bits and pieces of satisfaction when working in ED or at locum clinic, tho. Patients who thanked me, wishing me well, or those who simply still being civil after waiting for hours for consultation - they are what makes my job here bearable.

I managed to get into good rapport with most staff here in ED. Some of the MAs really like working with me in the same overlapping shifts because apparently I "work fast and confident in discharging patients" .Well, I do take it as a compliment although I know that they really like it because the more I discharge, the less patients they have to attend to LOL.

I was scheduled into roster with other newer floaters and it felt really weird for them to come to me to discuss cases. I accepted it with grace - overall, the more cases I know of the more I could learn from it. Although not many, I do helped out the housemen as well. I think I did okay - no condescending tone, no harsh words, encouragement given etc. Well if any of you reading this felt eh, poyo, this is far from the truth! - forgive me for being a bitch.

The only concern for me is that for this long 6 months of working in ED, my exposure in working in resus (red zone) gradually waned. I only worked twice in this half year in red zone, and I am afraid I will be stuck in limbo when true emergency happened in front of me. If you recalled, I am still very much poor in intubation, in handling ventilation settings and in administering emergency medicine boluses. With other things in my mind and my decision to drop from taking FRCEM Primary paper this year, I pretty much had neglected opening up any book to study.

I think it's prime time for me to turn things around. I just need a few adjustments, a refresh outlook of way of life, and a rekindled spirit to resume my chase for the professional paper. These all take time to materialize, partly because I was so busy in these past two months, and another reason is because I was waiting for the next chapter of my life. Of the latter, which now brings us to this,

The third matter and at long last, an update!

  • On 30th May, right out of the blue, there's an update from the semakerjaya website regarding the contract or permanent offer. You can imagine the mounting pressure and trepidation when opening the website and logging in to check your status. Alhamdulillah, I got the permanent offer as a Medical Officer UD41 (not 44, wait, there's more to this). Some of us did not make it, and based on what I knew so far, the first cohort of us here who completed the housemanship program without a day of extension managed to get a permanent offer. 
  • But there's some outliers here. I've heard people from some hospitals weren't as lucky as we are. I don't pretend to know what's going on exactly, but my most educated guess is that there's simply way more qualified doctors than the permanent position available to be offered.
  • Those who were offered either contract OR permanent position as a medical officer UD41 were unofficially called the first cohort. Those who their names are still not in system are in subsequent cohorts, depending on the order of who finished the housemanship first and had their documents all sorted out.
  • On 13th June, again there was an update from the semakerjaya, but this time regarding the placement place for those in the first cohort, contract and permanent alike. I was praying like crazy not to be transferred out to East Malaysia and guess what, I got my second choice!! I mean, okay, I actually didn't think much of the state and there's some out-of-reach areas there but hey, not bad indeed. 

  • Yesterday, we received further emails regarding accepting the position offered and more documents to be filled like usual. Now, this is entering our usual territory of paperwork so no issues there.
  • Yesterday as well, six of us floaters from ED who got the placement prepared a farewell party to all the ED staff. Well, five of us, seeing that I already went back home to enjoy my week holiday LOL.
  • I am supposed to settle a few checklist with my hospital's admin before leaving it for good. In this short week as well I would need to do a medical check up and get an akuan sumpah form stamped and signed by a Commissioner of Oath. 
  • I tried calling the people at the Jabatan Kesihatan Negeri about any chance of me finding out the exact placement in the state (whether it's a KK or a hospital, a district or a tertiary) but after a few excuses I had a strong suspicion that they will only release my exact placement on the day of reporting in, which is on Monday the 24th.
  • Regarding the offer itself, it is of UD41 although we had completed our housemanship. It will take some (a year, roughly) of working as an MO before your grade will be changed officially to UD44, together with some adjusted added salary. My advice is, don't fret about it as it will happen eventually.

That's it for now. I guess this will be the last entry of mine under the label floating MO. It has been a long, but fulfilling experience working in ED here. Till we meet again, see you when I see you~!

Apr 21, 2019

The Light in Their Eyes

Here's a quick update: I've been floating as an MO in ED for exactly 4 months now. Last month a colleague of mine had called the KKM and was told that the placement would be out in April. Now came April and another colleague told us that KKM will only inform us about the placement in May. Considering that this sounds exactly like a wolf cry and we are going to enter the month of Ramadhan anyway I would take this news with a pinch of salt. 6 months or a year, even, bring it on!

A number of things had happened this month. I had to prepare and present a maternal mortality review for one pregnant patient in labour who was referred from Banting for meningoenchephalitis (brain infection). The baby was delivered fine but the patient later on succumbed to death a week later. The patient was in ED for only 4 hours, but as all who were involved are required to attend the meeting, for my department I was told to prepare the slides and presented it.

It's kinda of scary, to be honest. Those who were involved include from the very first point of contact the patient encountered to the last person who saw the patient. Each department or organization level had to present and the rest will raise questions and asked why so and so were done or not done etc. It was kinda uncomfortable because there's an aggressor present in that meeting. They (he or she is not revealed) will blame everyone, including themselves, but they will blame others more. Of which, by the way, is not the objective of such review meeting. 

I was glad that from ED there's no question asked about our management as the referred team, O&G was informed almost immediately when the patient came to our red zone and was attended to in mere minutes by them. I was further relieved when I didn't have to present at state level (all maternal and dengue mortality have two-tier review meeting, hospital and state level). All is well. Inalillah.

Remember the mishap I've had last month when I missed a fracture from an x-ray? Since then I was feeling down and from time to time I had doubts upon my own competency being a doctor working in this ED. The first few weeks after the incident I felt that other registrars or EP no longer trust me nor my judgement as much as I used to think they did in the past, that some of my plans may be questionable or downright wrong. I get the feeling of the looks they sometimes give me, and while it's all in my head - I might be wrong completely and they are not actually act or feel that way - these doubts are gnawing inside of me and I feel hollow.

Subsequently, it led to a shaky decision to drop from taking FRCEM Primary paper I initially aimed to take this December. It was too hasty and I am too green for it and there's no chance of passing it if these dark clouds of despair are storming in my mind. I noticed from the weekly timetable I am being assigned to more and more green zone and secondary triage. Some of my colleagues have already been assigned to work in specialized yellow zone areas alone. Again, I am assuming the worst. Maybe I am not good enough to take care of the semi-critical yellow zones? And if I do, there's no way they trust me to work there alone, don't they?


Moving on, there's a new aspect of being a medical officer (MO) that is rarely being discussed or mentioned that is doing locum work. I only started doing locum work at a private GP nearby for a month or so and I will talk about it more in my next entry later on. What I can say right now is that doing locum exposes you to a whole lot of new perspectives of what being a doctor is all about and how much of an impact you really can be to your patients. This time, by doing locum in the clinic has helped me a little bit to come into terms on my work at the hospital.

Ever encountered patients of foreign nationalities with poor language understanding at work? Imagine that your workplace, either in the ward, in ED, or in a clinic, is packed choke-full with patients. You are pressed for time. There's a difficult patient who demand a lot of things, angry relatives who shout at you for having to wait for hours, patients demanding MCs for silly things. And then come a foreigner who can't speak well either in English or any local language.

Most of us, myself included, will feel an immediate exasperation. You don't understand a thing they said. You ask the whys and they answer you with a what. You simply don't have time for this. Attempting in communicating in itself is exhausting. You know you will obtain poor history. Detailed presentation of symptoms will be missed. What they want, their concerns, their understanding of the illness, gone out of your inquiry. You are lucky if you even get a chief complaint.

These build up into an unnoticed kind of racism which is racism towards all foreigners (except the whites, because we just simply worship their advancement in society) who come to hospital / clinic to get a healthcare treatment. You think they don't notice your sigh of contempt, the glare that you give to them? Of your harsher tone and loud voice, as if by shouting at them will make them understand you better? Of the lack of explanation to medication that you give or the illnesses that they have?

The other day at the locum clinic I met a foreigner who came because her toddler developed a simple febrile fit. She came with her aunt who is more fluent in Malay language, complaining that they had went to a different GP earlier and were confused when they were prescribed with syrup Paracetamol with the dose of 5ml four times a day. They know that the toddler shouldn't get too much of the medication. The weight of the toddler was never measured, the consultation was brief, and the mother did not even understand anything about febrile fit.

And so I did what I thought was right. We weighed down the kid, get the correct dose, and I sat them down and explained to them what febrile fit is and what to do when it happened. All those training during Paediatrics rotation paid off here. I made sure they understand what is going on, and before they left the room the aunt thanked me and quietly said that just because they were foreigners they shouldn't be treated any less than other people. That hit me hard.

Since then I tried to be extra patient to the foreigners. A Rohingya couple came to ED the other day with the wife complained of both hand numbness, among many others. She had had a stroke in the past and after much difficulty grasping what they were trying to tell me, I managed to gather that she's worried that it might be another stroke. Her blood glucose was high but not acidotic, and foreigners or not, I did the whole nine yard work up for her before arriving to a diagnosis of peripheral neuropathy secondary to diabetes mellitus. I wrote a memo to KK (klinik kesihatan) for further diabetes management at primary care and they thanked me before they left.

I admit I too had encountered foreigners and dealt with them not as well as I should have done. As usual, this is something I need to reflect on and strive do better in the future. This is why I write this down in the first place. Let this be a lesson for me and to you all to be a better and kinder doctor in the future.

Lastly, if you think about it, it takes them a considerable amount of courage to seek treatment in the country they are not accustomed to. They well already know that they will not be treated as proper as the locals. That their financial strain will hinder them from being able to pay for admission, for detailed imaging such as a CT brain scan or an MRI, or simply for a suture or two for their injury. But when you do them right with everything that you have in your power, you will see back the light in their eyes as they thank you sometimes with words, gestures, or even warm smiles.

photo credit: Annie Griffith

I may feel less than a person when working in this ED, but these encounters had helped me to keep moving forward. May God bless us all.

Mar 25, 2019

To Be or Not to Be?

After what I considered a low point of mood I'd experienced last week at work, I feel undecided on what to do next. I thought I was so sure on what I want to become, what I aspire to be, but heart is such a fickle thing, oh Qalbun, that what I once knew what to be only become a mere maybe.

I feel that as much as I like working in ED, there's a big part of me that tells me that I am not meant for it. Consider that I am very poor on hands-on and my lack of success in doing RSI. I lost count on how many attempts I've tried but I can't still do it. What is wrong with me? Other people had succeeded in their first try. All I feel is that this is surely a sign that ED is just not for me.

I also decided not to pursue FRCEM Primary paper this year. It was.. haughty of me to dream that big when I knew so little. Many people will just say, "oh there's no harm in trying, just go for it," etc. but what I feel is that I am not even good enough with what I do at work right now. What the hell that makes me think that I should do more when the current me is so much lacking? It saddens me greatly that even at things that I like to do all I am is never good enough.

I am also contemplating on not to pursue any specialty at all. This obsession to be at the very top because you are already halfway climbing it to me feels like never ending. There's always more offshoot to climb and more challenges to face. But must I? To me the number one drawback in pursuing master/paper is the rota or the rotation that you have to go to to complete your requirement. All I ever wanted is a home to live in with people I want to live with. I want to plant my roots deep and to settle down having a family. I am already nearing 30. Life is already half gone by.

I just want to live.

Mar 12, 2019

Of Humerus Fracture & Swiss Cheese Model

Yesterday as I left the clinic I was suddenly overcame with a feeling of trepidation. I felt as if I had done something wrong somewhere but it's a vague sensation with some poor memory recollection of what actually had transpired in the first place. Later that day in the ED group there's an alert of a patient being wrongly discharged with a soft tissue injury following a fall where in fact she sustained a fracture of her right humerus bone. The doctor who was seeing her did not noticed the fracture from the x-ray. Turned out the doctor was ME.

I was utterly devastated. I was only informed of the error when I entered my night shift last night. I knew that the x-ray was somehow familiar but for the life of me I couldn't recall which patient I was seeing and whether I had assessed the patient properly before deciding that it wasn't a fracture and discharge her home with just painkillers. The x-ray in question is this:

There's an EP (Emergency Physician = specialist) who is in charge of reviewing each and every x-rays done to all patients who are discharged home without referral to any primary team (Ortho, Surgical, etc.) and he was the one who saw my mistake. To my (and everyone) horrid, I was alone in managing the case and I did not consult any registrar or EP regarding the x-rays and just took the matter on my own. The EP and his team managed to call back the patient after multiple calls made (God bless her, she was at school the whole day! KILL ME!), a U-slab was plastered on and patient was discharged with a referral to Orthopaedics clinic as outpatient.

Upon further asking colleagues around, it was determined that the patient I saw was in fact a patient who was halfway been seen by another colleague who covered for me when I went for Friday prayer. She had assessed the patient but at the time when I came back and did the pass-over the x-ray in question was not done yet. Add to the fact that I saw the patient near the end of my shift, there's a lot of cases that I still needed to see - the pressure and stress to finish it without extending my shift hours for too long had added to the error. It was my TERRIBLE MISTAKE for not reassessing the patient MYSELF and subsequently missed the fracture, leading to a wrong diagnosis and wrong management for the patient.

In Medicine, there is a thing we called Swiss cheese model of incident causation. Whenever an error is made, there should be a committee or someone in charge who will evaluate the whole situation in finding out everything about the said error, from the cause of it, the risk factors that can lead to the error, people or systems that are involved in facing the errors, and finally to the consequences the error caused. This whole thing is called a risk-stratification. I now will continue with my shameful but necessary reflection using this model. Sob.

Imagine a stack of multiple Swiss cheeses like this:

  1. Each layer of the Swiss cheese represents level in the organization involved who faces the potential error. Error here is the end result or the actual damage that happened. The arrows in the diagram above are the hazards, or simply put, a potential error.
  2. An error is made when every layer of the organization failed to stop the hazards from going through the emmental holes or the flaw in the system / organization (see the longest arrow above).
  3. Understanding what the flaws that exist in each layer help us to stop the hazards from going through, thus preventing it to be an error. A prevented error is also called a near-miss incident.
  4. Notice that in each layer some holes / flaws are bigger than the other. However, the smallest flaw can still permit a hazard to pass through unresolved. That hazard then can pass on to the next layer with a potentially larger flaw.
  5. In my case, the layers of cheese can be made up into three layers:
    • Green zone, where I first saw the patient
    • Registrar / EP on call, who are assigned to supervise the doctors in Green zone
    • EP in charge of reviewing all x-rays of patients discharged home of the day
  6. In this model there is also what we called latent failures and active failures.
    • latent failures are the system or environment that passively contribute into causing hazards. In my case: congested patients in Green zone, too few doctors to attend the case, among the few.
    • active failures are the one who directly causing the hazard. In this case, it's ME. I failed to assess patient myself, I failed, to correlate the symptoms with the imaging, I failed to notice the error, I failed to discuss with my bosses, among the few. In the future I would see myself ALL PASS-OVER cases that were handed to me. I will even retake the history and repeat the assessment MYSELF. Also, all imaging of high-risk patients I will discuss with my bosses, no matter how much I know it's gonna cost me more time and my patience.
  7. In the second layer, I would say the flaw was that I found it cumbersome to reach my bosses when it was too hectic. They are available to be reached for case discussion, but they can also be terribly busy at most times. I'm painfully aware it's MY FAULT anyway for not approaching them and in the future, I would discuss with them all cases that I find.. high risk.
  8. The third layer is when the hazard stopped. My EP noticed the mistake, made the patient to come back to the hospital to get the appropriate treatment, the mistake had been alerted and I had found it discerning but it is for my benefit anyway (sob!) so that I can reflect on it properly.
  9. I would say it is not a complete error, because the hazard was identified and correction was done promptly. An actual error (I'm trembling now) would be that there is a neurosensory loss and the arm of the patient was affected badly due to my incompetence. I would say I felt the steely haunting stare of Miss Rifa behind my neck, cursing me on my stupidity and wishing she had never passed my Ortho rotation viva assessment back then.

After my last night shift ended today on which I worked the whole early morning with such a gloomy mood, thinking that I am never gonna be good enough, that I should just quit being a doctor and cursing myself for even thinking of taking paper, or that I would never see patients in the clinic anymore - now that I wrote this down, properly reflecting on what I had done wrong and planning on how to avoid making the same mistake, I feel a bit better. Well, I still know I am stupid, but now with a renewed spirit to become less of an idiot.

Okay, that's it for now. Pray for no more error from me in the future. Ameen.

PS: What's the fracture and what are the nerve and artery that rarely but may be damaged?