I ask this question because this week I have been a 9 or a 10 all week on the VAS for anger. I am beginning to think that I may have anger management issues but if I give you an example of what makes me mad perhaps you can judge for yourself.
This week I have been at a small hospital following up on SAM screening & triage, as well as doing some opportunistic ER coaching. On the morning of my departure I was having a conversation with a most verbose medical assistant (MA) who is particularly resistant to any advice, training or coaching from a certain female Barang doctor. Although mildly irritating this was not what provoked my current anger.
Whilst we were discussing how to conduct a Clinical case review (CCR) or in reality I was being treated to a one man monologue, a mother rushed into the ER with her toddler son. The mother was very distressed & anxious, her son had accidentally ingested her appetite stimulant medicine. Her son however looked completely well but soon got upset with the child unfriendly reception from the Cambodian ER nurse on duty & a scary Barang lady doctor.
The MA I was with, without even examining the child or asking for vital signs, told the nurse to put in an IV & give Atropine. R - my co-worker/translator & a Cambodian nurse - didn't need to translate this for me (not because my khmer is so good but rather because the medical terms & drugs are mostly in French) so I immediately chipped in that this child had no signs of a cholinergic syndrome & we had no idea yet what he had actually ingested but it certainly wouldn't be organophosphate in an over the counter medication.
I was aware that me doing this in front of the parents was not exactly conducive to the saving face culture however I was very keen for the child not to receive an unnecessary dose of Atropine. The MA smiled through gritted teeth & agreed to no Atropine but put up an IV line & gave fluids because here in Cambodia EVERYBODY needs IV fluids!
I went outside to pack my bag to leave & 5 minutes later another MA, who was actually on duty, called me back in to check on the child who had deteriorated.
I went in to find the child on his mothers lap with an IV running. He was twitchy, delirious - picking at imaginary things, crying but with no tears, large pupils, dry mouth & dry hot skin, the pulse was 180/min - tachycardic. In short he had all the symptoms of an anti-cholinergic syndrome, what a well child who has been given Atropine would look like.
I asked them - has this child had Atropine? - I was told emphatically - no.
In that case - I told them - we need to do an internet search to find out what is in over the counter appetite stimulants. Their smart phones remained in their pockets so I got out my laptop. Meanwhile I asked them to tell me what they found on examination to coach them about anti-cholinergic syndrome. The nurse told me the pulse was 180/min - the first MA had slunk into a corner at this point, the MA on duty just shrugged. What does his skin feel like? I asked, Cold - came the response, he was stood less than a metre away from the child but was too lazy to even touch him to find out.
I then went on to explain what anti-cholingeric syndrome was & how it presented clinically, all the time a sneeky suspicion was growing in me. I ended by saying that everyone should examine this child as he was such a good example of the anti-cholinergic syndrome, which is the same as if you were to give Atropine when not clinically indicated to a previously well child.
I received impassive, unthinking, thousand yard stares.
We had to leave but I implored them to please refer the child if his condition deteriorated further & to take regular observations.
In the car back I thought about the events of that morning, how well the child had been initially & how quickly he had deteriorated after the IV line was put in. They had denied giving Atropine, they had smiled & agreed it wasn't indicated but I couldn't shake the feeling they were lying & had broken the hippocratic oath first rule - first do no harm.
I asked R - who was sulking but
that's another blog - & he sulkily told me that he had told them not to give Atropine & the reason why, the MA had agreed it wasn't indicated. Why would I think such bad things of the health workers? He made me feel like I was the most judgmental, awful, hateful person on the planet.
That afternoon I received a text from R - "I just called to ask the staff, the patient was injected atropin as what you thought. And iv D10 & glucose 50% then charcoal. The patient's conditions still the same."
You want to know what makes me mad?
How about uneducated, unskilled, low knowledge health workers ignoring my good advice?
How about those same health workers then intentionally harming an 18 month old child unnecessarily despite my pleas for them not to?
Then how about being repeatedly lied to when the child was deteriorating in front of their eyes & I am just trying to help?
How about all this happening without any one taking any responsibility, the patient having no rights & there being no come back for their negligent dangerous actions?
Or finally what about being right about things when I wish I was wrong?
Yep - that'll do it......
