This is generally how things go.
Arrive at hospital to find a patient in the ER, initially came in shocked & was resuscitated with IV fluids & transferred to the ward. 2 days later became unwell with shock again so was transferred back to the ER. In the UK this would be seen as retrograde step in the patient pathway, which would never happen or be tolerated but as the ER is the only place in the hospital with oxygen cylinders, suction machine, airway equipment, nebuliser machine (donated by URC), ventilator (new from MoH) & cardiac monitor (new from donor) this was actually the best move for this patient.
In my experience if I get involved too early in patient care the medical staff will get really defensive & aggressive or just ignore my advice. I have learnt to let them run their clinical course, reach a diagnosis or management dead end & then they might ask me for help. They are pretty stubborn & proud so this can sometimes be days. DO you have any idea how hard this can be when a patient is really sick but you know if you do something or try to help if will just make the situation worse as they may deliberately do the opposite of what you suggest?
This time it took 2 days.
Early on the second morning I found her in the ER with no one observing her so I took this opportunity to take a history & examine her myself.
These were my findings - she had a 2 week history of total body pain which all started with a painful & swollen left leg. She had then developed breathlessness & pleuritic chest pain. When she first presented to the hospital her blood pressure was unrecordable & she had collapsed at home. Her heart rate had been a persistent sinus tachycardia of 120/minute for the last 3 days.
I had bought some ECG dots for the hospital (I buy great presents!) & used her the day before to demonstrate how to use the monitor, she was happily throwing off atrial ectopics & having runs of atrial bigeminy. I tried to show the medical staff this but as they don't fully understand what a p wave is yet this was a bit of a struggle. They looked at the monitor with the same intensity as parents in PICU. I have often thought it would be good to have a TV playing behind the vital sign wave forms on these monitors so at least people would understand something that was on the screen.
She had a raised JVP & a parasternal heave. Her oxygen saturations were 89% on room air.
All of the evidence was pointing towards her having a pulmonary embolism - PE.
Just as I had finished my examination one of the more amenable MAs came in & I relayed to him my findings & my differential diagnosis - or as my nurse friend likes to call it "best guess"!
He agreed & wanted her to be transferred to the referral hospital but said the other MAs did not agree so could I help him. We went to the hospital morning meeting together & afterwards I went through my history, examination & investigation findings with all the medical staff. I explained that the patient's initial treatment with oxygen & fluids was excellent but she needed a 12 lead ECG & ECHO, which were not available at this hospital. Like all chest pain she should receive aspirin but also needed heparin, which was not available at this hospital either. Her current treatment of IV dextrose & vitamins was probably not going to be very affective for treating her sinus tachycardia.
Rather than agree to transfer her or ask questions about the signs & symptoms of PE the deputy director attacked me. "All patients are liars, they are poor & stupid, they do not tell the truth, you can't believe them that is why we only exam them & make are decisions with out bothering to talk to them, you know nothing about Cambodia etc etc etc"
When he had finally finished his tirade - he is a verbose man. I smiled sweetly & calmly explained that this is why objective data is so important. The patient had been shocked - cardiovascular collapse is a symptom of massive PE, the patient was hypoxic - PE, the patient was in a sinus tachycardia with runs of atrial bigeminy - PE, she had a parasternal heave - PE, respiratory rate of 38/minute - PE, left calf swelling & tenderness - PE......
The room was silent then the deputy director triumphantly said - but her white cells are elevated.....PE came my response.
DO you think they listened to me? DO you think they believed me? DO you think they followed my treatment plan? DO you think she was transferred the referral hospital to get further investigations & heparin? DO you have any frigging idea how frustrating it is that the answer to these questions is always & relentlessly NO?
Later that same morning I was in OPD trying to do TB follow up without a translator whilst also doing some informal triage & SAM follow up coaching. The nurses are warm, friendly & open to learning - it was just I was a little limited in my explanations in khmer back to them.
A 9 month old boy came in grunting away giving himself auto-PEEP & with signs of severe respiratory distress. All the other patients & relatives stepped back to let him be seen by the triage nurse first, self triage, murmuring in awe "breathless" (only in khmer, which is "Hot")
He triaged red, which means he needed to be seen immediately because his pulse was 180/min, his respiratory rate was 60/minute & his oxygen saturations were 81%. The triage nurse looked to me for reassurance as she ticked the box - yes I nodded that's correct, he really is sick, she beamed back at me. Nurses are so much easier to work with than doctors. I walked over with the nurse, mum - in floods of tears & the head bobbing little boy, to the ER.
I contacted my work colleague on the ward to tell him I needed his help in ER - it was 9 15.
At 9 25 the ER nurse finally managed to get oxygen on the child at an enthusiastic 6 l/min through nasal specs. I have seen glass creep faster than the speed this ER nurse worked but as my work colleague & translator was no where to be seen I was making do with my limited khmer to reassure the crying mother, take a basic history & coach the nurse how to not blow away the poor babies nostrils.
9 30 the male nurse called the doctor to tell him about the category red child in the ER.
9 50 my work colleague rocked up, shrugged when I asked him if he could help me with translation, telling me "you can manage without me, you seem to be able to understand most things anyway"
I had to go for a little walk at this point - the child was stable & waiting for a doctor & I was in danger of killing my work colleague. The grounds of this hospital are very picturesque with views of mountains & surrounding fields. It is a little brighter than before as they have just cut down two large trees. The blossom is beautiful. There was a cool breeze. Breath.
When I came back at 10 10 the 2 ER nurses were having a long protracted conversation about nursing documentation with my colleague whilst the mother clung to her baby crying as no one (except me who doesn't count because she couldn't understand me & another relative had to translate my khmer for her) had explained what was going on with her child who lay limply in her arms, grunting, head bobbing, recessing & generally working very hard to breath.
Where's the doctor I asked?
Don't ask me, how should I know? my work colleague shrugged. It had actually been a request for translation - I snapped - but clearly nursing documentation is far more important than actually nursing a hypoxic & distressed child. Credit to the cluelessness of Cambodians my work colleague still failed to detect any anger or sarcasm in this statement & continued to coach on observation charts for another 10 minutes.
The child was doing much better on the oxygen but was still quite wheezy & even though less than 1 years old could probably justify a nebuliser if I could find a doctor to prescribe it. I am not allowed to prescribe drugs because I went to a proper medical school & have had extensive post-graduation professional training instead of being a khmer rouge medical assistant for 30 years, so clearly I know nothing.
We had to leave at 10 30 at which time a doctor still hadn't arrived to see the child.
In the car my work colleague asked me if I was angry with him - at least he worked this out in a shorter period of time than it took to Doctor to come to see a category red patient in the ER.
When I first started going to this hospital the nurses wouldn't have started treatment, including oxygen, until the doctor arrived. Wheezy children were all given IV antibiotics & they didn't even consider giving a nebuliser delivered via the new machine.
On my request my work colleague called the hospital to follow up on the child. The doctor had finally arrived at 11 am - he prescribed a nebuliser but no antibiotics. The child was breathing better when we called. This is how things go.
As an emergency physician I find the pace here & rate of change deeply soul destroying.
Arrive at hospital to find a patient in the ER, initially came in shocked & was resuscitated with IV fluids & transferred to the ward. 2 days later became unwell with shock again so was transferred back to the ER. In the UK this would be seen as retrograde step in the patient pathway, which would never happen or be tolerated but as the ER is the only place in the hospital with oxygen cylinders, suction machine, airway equipment, nebuliser machine (donated by URC), ventilator (new from MoH) & cardiac monitor (new from donor) this was actually the best move for this patient.
In my experience if I get involved too early in patient care the medical staff will get really defensive & aggressive or just ignore my advice. I have learnt to let them run their clinical course, reach a diagnosis or management dead end & then they might ask me for help. They are pretty stubborn & proud so this can sometimes be days. DO you have any idea how hard this can be when a patient is really sick but you know if you do something or try to help if will just make the situation worse as they may deliberately do the opposite of what you suggest?
This time it took 2 days.
Early on the second morning I found her in the ER with no one observing her so I took this opportunity to take a history & examine her myself.
These were my findings - she had a 2 week history of total body pain which all started with a painful & swollen left leg. She had then developed breathlessness & pleuritic chest pain. When she first presented to the hospital her blood pressure was unrecordable & she had collapsed at home. Her heart rate had been a persistent sinus tachycardia of 120/minute for the last 3 days.
I had bought some ECG dots for the hospital (I buy great presents!) & used her the day before to demonstrate how to use the monitor, she was happily throwing off atrial ectopics & having runs of atrial bigeminy. I tried to show the medical staff this but as they don't fully understand what a p wave is yet this was a bit of a struggle. They looked at the monitor with the same intensity as parents in PICU. I have often thought it would be good to have a TV playing behind the vital sign wave forms on these monitors so at least people would understand something that was on the screen.
She had a raised JVP & a parasternal heave. Her oxygen saturations were 89% on room air.
All of the evidence was pointing towards her having a pulmonary embolism - PE.
Just as I had finished my examination one of the more amenable MAs came in & I relayed to him my findings & my differential diagnosis - or as my nurse friend likes to call it "best guess"!
He agreed & wanted her to be transferred to the referral hospital but said the other MAs did not agree so could I help him. We went to the hospital morning meeting together & afterwards I went through my history, examination & investigation findings with all the medical staff. I explained that the patient's initial treatment with oxygen & fluids was excellent but she needed a 12 lead ECG & ECHO, which were not available at this hospital. Like all chest pain she should receive aspirin but also needed heparin, which was not available at this hospital either. Her current treatment of IV dextrose & vitamins was probably not going to be very affective for treating her sinus tachycardia.
Rather than agree to transfer her or ask questions about the signs & symptoms of PE the deputy director attacked me. "All patients are liars, they are poor & stupid, they do not tell the truth, you can't believe them that is why we only exam them & make are decisions with out bothering to talk to them, you know nothing about Cambodia etc etc etc"
When he had finally finished his tirade - he is a verbose man. I smiled sweetly & calmly explained that this is why objective data is so important. The patient had been shocked - cardiovascular collapse is a symptom of massive PE, the patient was hypoxic - PE, the patient was in a sinus tachycardia with runs of atrial bigeminy - PE, she had a parasternal heave - PE, respiratory rate of 38/minute - PE, left calf swelling & tenderness - PE......
The room was silent then the deputy director triumphantly said - but her white cells are elevated.....PE came my response.
DO you think they listened to me? DO you think they believed me? DO you think they followed my treatment plan? DO you think she was transferred the referral hospital to get further investigations & heparin? DO you have any frigging idea how frustrating it is that the answer to these questions is always & relentlessly NO?
Later that same morning I was in OPD trying to do TB follow up without a translator whilst also doing some informal triage & SAM follow up coaching. The nurses are warm, friendly & open to learning - it was just I was a little limited in my explanations in khmer back to them.
A 9 month old boy came in grunting away giving himself auto-PEEP & with signs of severe respiratory distress. All the other patients & relatives stepped back to let him be seen by the triage nurse first, self triage, murmuring in awe "breathless" (only in khmer, which is "Hot")
He triaged red, which means he needed to be seen immediately because his pulse was 180/min, his respiratory rate was 60/minute & his oxygen saturations were 81%. The triage nurse looked to me for reassurance as she ticked the box - yes I nodded that's correct, he really is sick, she beamed back at me. Nurses are so much easier to work with than doctors. I walked over with the nurse, mum - in floods of tears & the head bobbing little boy, to the ER.
I contacted my work colleague on the ward to tell him I needed his help in ER - it was 9 15.
At 9 25 the ER nurse finally managed to get oxygen on the child at an enthusiastic 6 l/min through nasal specs. I have seen glass creep faster than the speed this ER nurse worked but as my work colleague & translator was no where to be seen I was making do with my limited khmer to reassure the crying mother, take a basic history & coach the nurse how to not blow away the poor babies nostrils.
9 30 the male nurse called the doctor to tell him about the category red child in the ER.
9 50 my work colleague rocked up, shrugged when I asked him if he could help me with translation, telling me "you can manage without me, you seem to be able to understand most things anyway"
I had to go for a little walk at this point - the child was stable & waiting for a doctor & I was in danger of killing my work colleague. The grounds of this hospital are very picturesque with views of mountains & surrounding fields. It is a little brighter than before as they have just cut down two large trees. The blossom is beautiful. There was a cool breeze. Breath.
When I came back at 10 10 the 2 ER nurses were having a long protracted conversation about nursing documentation with my colleague whilst the mother clung to her baby crying as no one (except me who doesn't count because she couldn't understand me & another relative had to translate my khmer for her) had explained what was going on with her child who lay limply in her arms, grunting, head bobbing, recessing & generally working very hard to breath.
Where's the doctor I asked?
Don't ask me, how should I know? my work colleague shrugged. It had actually been a request for translation - I snapped - but clearly nursing documentation is far more important than actually nursing a hypoxic & distressed child. Credit to the cluelessness of Cambodians my work colleague still failed to detect any anger or sarcasm in this statement & continued to coach on observation charts for another 10 minutes.
The child was doing much better on the oxygen but was still quite wheezy & even though less than 1 years old could probably justify a nebuliser if I could find a doctor to prescribe it. I am not allowed to prescribe drugs because I went to a proper medical school & have had extensive post-graduation professional training instead of being a khmer rouge medical assistant for 30 years, so clearly I know nothing.
We had to leave at 10 30 at which time a doctor still hadn't arrived to see the child.
In the car my work colleague asked me if I was angry with him - at least he worked this out in a shorter period of time than it took to Doctor to come to see a category red patient in the ER.
When I first started going to this hospital the nurses wouldn't have started treatment, including oxygen, until the doctor arrived. Wheezy children were all given IV antibiotics & they didn't even consider giving a nebuliser delivered via the new machine.
On my request my work colleague called the hospital to follow up on the child. The doctor had finally arrived at 11 am - he prescribed a nebuliser but no antibiotics. The child was breathing better when we called. This is how things go.
As an emergency physician I find the pace here & rate of change deeply soul destroying.
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