Heart or brain?
Sometimes, we have to make hard decisions in life, especially if it involves the life of another person.
When I graduated, I remembered being told that I would now have to make decisions, sometimes difficult ones, regarding another person's life. I may not have to take full responsibility for that now as I am still training, but the day will come when I will be responsible for my patient's welfare during my treatment for them.
Today I was feeling angry, sad and disappointed all at the same time regarding one of my patients.
I am now in neurosurgical. I initially dreaded doing this brief posting as I thought I would be tormented to do things which I'm not keen or interested in. God proved me so wrong. I learned a lot during my near 2 weeks in this posting about looking after critically ill patients, and I got to assist in a craniectomy and witness first hand on how a brain surgery goes on. I have never felt nauseated during any operation during my surgical posting, but in a brain surgery, I actually felt like throwing up at one time when the surgeon did an incision and flipped the skin of the patient to reveal the skull. I felt even worse when they started drilling 4 holes in the skull and then started sawing off a chunk of the skull to reveal a pulsating brain.
Thank God the patient was covered so I would not have to see or remember his face. At the end of the surgery, my medical officer gave me the honour of closing up the scalp :) My surgical skills are really nil but I managed.
But today, I was upset. The medical team had referred a 56 year old lady to us who had a subdural haemorrhage secondary to medication (overwarfarinization). The problem was that she also had chronic rheumatic heard disease and her mitral valve replaced in 1999, with a history of stroke as well, and was on warfarin (anticoagulant) medication since then as she had atrial fibrillation as well. *pardon the medical jargons*
They referred her to us on day 6 of her admission as she had complained of headache and they did a CT brain, and noted the bleeding. She had initially been admitted due to overwarfarinization i.e she had an increased tendency to bleed, which lead to the spontaneous brain bleed. The first problem was that there was a miscommunication between us and the medical team as they thought we had no plans for operating on her, and hence, started heparin infusion on her (another anticoagulant) as she had been off warfarin for about a week since they discovered her problem.
We were unhappy as no consultation was made before starting this medication, and patient's symptoms became worse: she started having vomiting, nausea and her headache increased. We suggested that the heparin be stopped, but no one heeded our advice. They only stopped the heparin at midnight because she was due for a scope the next day, which eventually got canceled because there was no physician to do the scope.
We took the opportunity and operated on her on Thursday evening to drain the blood accumulating in her brain-- Burr hole. She was sent to the high dependency ward (HDW) for recovering and she recovered well. I was happy to see her happy and she told me yesterday afternoon that she was feeling a lot better. She was actually sitting up in bed, and having porridge.
That was the last time I saw her conscious. About 16 hours later, I went to HDW so see her during my morning rounds and was told she was transfered back to the general ward. I went up to see her, and I was shocked to see the curtains closed and her being intubated and manual bagging being done. My colleague told me she was apparently transfered in at 12.30a.m and no one knew she came in cause the nurses did not inform the doctors on call until she had difficulty breathing and complained of headache, and vomited once at around 5a.m. She subsequently became unconscious and had to be intubated to save her lungs from collapsing.
What made me so furious was that upon checking her case notes, I found that the cardiologist had made rounds the previous night and saw this patient. The same cardiologist who started her on heparin the first time without consulting us, did it again- he started her on heparin, barely 24 hours after her brain surgery. So, this poor lady, had spontaneous bleeding again, only this time it was intraparenchymal ( deep in the brain) where no surgical intervention is possible, hence the deterioration of her condition at 5.30a.m. To add a funny twist to the predicament, she had been WRONGLY transfered to the general ward as the medical officer claimed in the notes that she was suppose to be transfered to the cardiac unit due to the patient's heart problem for close monitoring.
The irony was that when I saw her (intubated and all), the heparin infusion was still on going but reduced. Her brain drain recorded 300ml of fresh blood since her transfer in from HDW. She was going to be transfered back to HDW at that moment.
I called my neurosurgeon and medical officer on the spot to report what had happened to the patient. My neurosurgeron, not surprisingly, expressed his disappointment and said he did not want to take the responsibility for what happened to the patient. I would have done the same as well.
Needless to say, the patient had an emergency CT brain done again, and as we suspected, it confirmed she had a rebleeding. At this moment, she is now still in HDW, ventilated, sedated, intubated with her family members around her. We informed her family members that her condition is critical at the moment due to the re-bleeding, and she may go any time if the bleeding does not stop.
I was disappointed at the lack of communication between the surgical and medical teams. It being a weekend and in the middle of the night is a poor excuse as this patient could have survived. I expressed my sadness to my medical officer who said that it was a difficult decision to make both ways because from the cardiologist side, they were trying to save the heart. From our side, we were trying to save her brain. Which is more important?
Either ways, the patient is not doing very well. And I feel sorry for the family members and the patient, but I am helpless.
Every new day is a new learning experience. I thank God for the little lessons learned be it from my patients, my colleagues, my superiors or the people around me. I will be starting obstetrics & gynaecology on tuesday and I already anticipate a hectic time because my colleague told me in the first two weeks of March there will only be TWELVE house officers, of which every day, FIVE people have to be on call. If we do maths well, it would mean we would be doing back to back on calls and every other day on calls for some time. I am already planning to bring some extra clothes and things to stay in the hostel if needed once I finish my 9 days of tagging at the end of this month. I also will have to thread carefully as I have been warned that medical officers in this department are bitchy back stabbers- maybe it's the hormones..
Whatever it is, I am not going to be anxious about it.
"The LORD himself goes before you and will be with you; he will never leave you nor forsake you. Do not be afraid; do not be discouraged." Deutoronomy 31:8
When I graduated, I remembered being told that I would now have to make decisions, sometimes difficult ones, regarding another person's life. I may not have to take full responsibility for that now as I am still training, but the day will come when I will be responsible for my patient's welfare during my treatment for them.
Today I was feeling angry, sad and disappointed all at the same time regarding one of my patients.
I am now in neurosurgical. I initially dreaded doing this brief posting as I thought I would be tormented to do things which I'm not keen or interested in. God proved me so wrong. I learned a lot during my near 2 weeks in this posting about looking after critically ill patients, and I got to assist in a craniectomy and witness first hand on how a brain surgery goes on. I have never felt nauseated during any operation during my surgical posting, but in a brain surgery, I actually felt like throwing up at one time when the surgeon did an incision and flipped the skin of the patient to reveal the skull. I felt even worse when they started drilling 4 holes in the skull and then started sawing off a chunk of the skull to reveal a pulsating brain.
Thank God the patient was covered so I would not have to see or remember his face. At the end of the surgery, my medical officer gave me the honour of closing up the scalp :) My surgical skills are really nil but I managed.
But today, I was upset. The medical team had referred a 56 year old lady to us who had a subdural haemorrhage secondary to medication (overwarfarinization). The problem was that she also had chronic rheumatic heard disease and her mitral valve replaced in 1999, with a history of stroke as well, and was on warfarin (anticoagulant) medication since then as she had atrial fibrillation as well. *pardon the medical jargons*
They referred her to us on day 6 of her admission as she had complained of headache and they did a CT brain, and noted the bleeding. She had initially been admitted due to overwarfarinization i.e she had an increased tendency to bleed, which lead to the spontaneous brain bleed. The first problem was that there was a miscommunication between us and the medical team as they thought we had no plans for operating on her, and hence, started heparin infusion on her (another anticoagulant) as she had been off warfarin for about a week since they discovered her problem.
We were unhappy as no consultation was made before starting this medication, and patient's symptoms became worse: she started having vomiting, nausea and her headache increased. We suggested that the heparin be stopped, but no one heeded our advice. They only stopped the heparin at midnight because she was due for a scope the next day, which eventually got canceled because there was no physician to do the scope.
We took the opportunity and operated on her on Thursday evening to drain the blood accumulating in her brain-- Burr hole. She was sent to the high dependency ward (HDW) for recovering and she recovered well. I was happy to see her happy and she told me yesterday afternoon that she was feeling a lot better. She was actually sitting up in bed, and having porridge.
That was the last time I saw her conscious. About 16 hours later, I went to HDW so see her during my morning rounds and was told she was transfered back to the general ward. I went up to see her, and I was shocked to see the curtains closed and her being intubated and manual bagging being done. My colleague told me she was apparently transfered in at 12.30a.m and no one knew she came in cause the nurses did not inform the doctors on call until she had difficulty breathing and complained of headache, and vomited once at around 5a.m. She subsequently became unconscious and had to be intubated to save her lungs from collapsing.
What made me so furious was that upon checking her case notes, I found that the cardiologist had made rounds the previous night and saw this patient. The same cardiologist who started her on heparin the first time without consulting us, did it again- he started her on heparin, barely 24 hours after her brain surgery. So, this poor lady, had spontaneous bleeding again, only this time it was intraparenchymal ( deep in the brain) where no surgical intervention is possible, hence the deterioration of her condition at 5.30a.m. To add a funny twist to the predicament, she had been WRONGLY transfered to the general ward as the medical officer claimed in the notes that she was suppose to be transfered to the cardiac unit due to the patient's heart problem for close monitoring.
The irony was that when I saw her (intubated and all), the heparin infusion was still on going but reduced. Her brain drain recorded 300ml of fresh blood since her transfer in from HDW. She was going to be transfered back to HDW at that moment.
I called my neurosurgeon and medical officer on the spot to report what had happened to the patient. My neurosurgeron, not surprisingly, expressed his disappointment and said he did not want to take the responsibility for what happened to the patient. I would have done the same as well.
Needless to say, the patient had an emergency CT brain done again, and as we suspected, it confirmed she had a rebleeding. At this moment, she is now still in HDW, ventilated, sedated, intubated with her family members around her. We informed her family members that her condition is critical at the moment due to the re-bleeding, and she may go any time if the bleeding does not stop.
I was disappointed at the lack of communication between the surgical and medical teams. It being a weekend and in the middle of the night is a poor excuse as this patient could have survived. I expressed my sadness to my medical officer who said that it was a difficult decision to make both ways because from the cardiologist side, they were trying to save the heart. From our side, we were trying to save her brain. Which is more important?
Either ways, the patient is not doing very well. And I feel sorry for the family members and the patient, but I am helpless.
Every new day is a new learning experience. I thank God for the little lessons learned be it from my patients, my colleagues, my superiors or the people around me. I will be starting obstetrics & gynaecology on tuesday and I already anticipate a hectic time because my colleague told me in the first two weeks of March there will only be TWELVE house officers, of which every day, FIVE people have to be on call. If we do maths well, it would mean we would be doing back to back on calls and every other day on calls for some time. I am already planning to bring some extra clothes and things to stay in the hostel if needed once I finish my 9 days of tagging at the end of this month. I also will have to thread carefully as I have been warned that medical officers in this department are bitchy back stabbers- maybe it's the hormones..
Whatever it is, I am not going to be anxious about it.
"The LORD himself goes before you and will be with you; he will never leave you nor forsake you. Do not be afraid; do not be discouraged." Deutoronomy 31:8
posted by yeoslian at 9:57 PM
2 Comments:
Siew Lian, I see you have grown stronger and wiser. I know I had said this before but I must say it again - I am so proud of you. After reading about the lady, I too, feel sorry. Human is indeed complicated. Every part of the body is equally important. Well, apart from medication, we could only pray for her. Cheer up, girl.
Hey there, I dont know you but Ive came across your blog. An interesting one! this post reminds me of my grandpa in the hospital. Anyway, its really sad that sometimes due to lack of communication, people's life is in jeopardy. I hope she'll recover in no time=(
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