要多少忍耐

收拾一場失敗

So my patient today Miss TS, a young foreign domestic worker with no past medical history, comes in referred by the general practitioner for fever, headache, body aches for 1 week. For the past 3 days she’s also had some abdominal bloating and vomiting. She looked poorly, just like how any patient with a possible viral illness (?dengue) would look poorly this way with the exact same symptoms, until the viral illness runs its course.

The game plan was, as with all patients presenting this way, to do some blood tests, and see how serious their illness was, KIV for admission if there is an indication, vs discharge if blood work looks fine, and patient improves and remains well.

And then, I usually try to detail an icing on top of my cake, by additionally asking myself, what might be unique to the patient on top of this game plan, if anything at all. Sometimes it’s my noticing the patient had been lost to follow-up for her base of tongue lesion which was possibly malignant, and making a point to help her arrange for an early appointment so as to not miss or delay a diagnosis; sometimes it’s just something as simple as noting that the patient with the flu has sore throat but no cough, and so he gets lozenges, but not cough medicine.

For her, it was that her body aches included a neck ache, and if that doesn’t get better, I would want to ask for a CT of her head to look for a possible source of infection in the brain, that would cause fever, and possible meningism.

There is no icing on the cake to this story.

Minutes after I saw last saw her well, a nurse saw her well too, and did an ECG for her as I’ve requested. It showed sinus tachycardia with a heart rate of 100s, a sign of dehydration common in a viral illness. And minutes after that, another nurse transferred her to an observation area, because she remained well. There, patients were within 1-2 metres of a nurse, and each other, for close observation.

Within 20-30 minutes of that, her blood work had came back, quite unremarkable except for perhaps a hint of some mild inflammation going on. Seeing that usually meant nothing alarming for most patients, and that they could wait. In fact, it sometimes makes the disposition difficult because it usually meant they were well enough for discharge, but symptomatically not improved yet and wanting to stay and be observed longer. Nonetheless, I decided to pop by her to say hi and check how she’s feeling - something not obliged of anyone, and something not everyone would do at this juncture.

I arrive by her trolley bed to see her lying down on it, alongside other patients, and within 1 metre of a nurse. On closer inspection I saw her eyes half open, and with foam coming out of her mouth. I try to rouse her, then I try to shake her awake - no response. I check for a pulse, because it’s presence or absence would drastically affect my next move - it is thready but present. I do not need to jump on her to start CPR. I shout for a nurse to push her to the resuscitation bay, and I shout at myself to call my seniors for help.

In the resuscitation bay, we all get busy. We find her having a malignant arrhythmia with a heart rate of 300s, a finding significantly different from the ECG just 30 minutes ago. We defibrillate her, and we get a slightly more normal rhythm back in her heart. Her tone is stiff, we do not know why, whether she’s had a seizure or some other neurological insult. We intubate her to secure her airway, and we sedate her to do so. Yes, she turned unresponsive to begin with, but now she goes into a coma we put her under, that I wonder if she will ever come out of.

There is no question that she needs the brain scan now. I arrange one, asking myself if I had truly missed a source of infection in the brain such as meningitis. But the brain scan instead shows a massive brain bleed in her cerebellum, one so big it was pushing the rest of the brain out of her skull and into her neck - a finding of poor prognosis and possible imminent brain death. I call a bunch of people to come sort out her issues, but the one party I could not call was her family, for she was a foreign worker and her family remains uncontactable at the moment in another country.

This kind of brain bleed is one of those where people possibly just collapse with little warning signs. Yet, because I had seen her well just minutes before, I keep wondering, could there have been something I could have possibly done? I know that the answer is no, and that the truth is because she was my patient, I will keep wondering, could I have somehow changed her fate?

I also keep thinking back to when she told me how she is here for work, which is “to look after ah ma”, and how when she was saying that, was blood already gushing out and filling her lateral ventricles?

I also keep thinking about how as she was crying due to her headache and fever, whether it was actually because her cerebellum was undergoing liquefactive necrosis?

Well, just now on the drive home, I recalled her employer saying that her agent supplied a number of her next-of-kin, which is her husband. She’s 36 years old. Did she have a young kid like me? Is she going to leave behind a young kid? Has she already left them behind??

Now as I’m finally home and taking a cookie for a night snack, I wonder, 1 week ago, whether she could have reached for a night snack the same way, after a day of “taking care of ah ma”?

And now that I’m off duty and alone, I finally get to produce tears that I can fight back, from thinking and thinking about all this.

So I guess this is what losing a patient feels like. When you know the answer to the question “what else could I have done?” was “nothing”, but you wonder that for the rest of your life anyway.

今天一整天 這一整個月都在下著熱帶雨⋯

i’ve been feeling so restless, since the start of this wet season..