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?

Sigh.

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.

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?