Is there a doctor on board?

“If there is any medical doctor on board, please make yourself known to cabin crew as soon as possible.” 

I knew this day would come. Three years from graduation with an MBBS behind my name and many flights later, I have heard of many heroic and horror stories of flight emergencies. Fortunately, I had never once encountered them personally. Now, 13 hours from the John F. Kennedy airport and barely 3 hours till my transit destination, the time had come. I had mentally prepared for it before, the NEJM review paper was pretty helpful. Still, that did not stop the thought of sliding low into my chair and disappearing into thin air from popping up in my mind. I stopped my movie (No Reservations, great show), and hesitated.

“I haven't practiced for 5 months. Am I covered by practicing insurance? What can I possibly do on an aircraft? What if I do something wrong?” 

Also, of all the flights in my life, I had opted to wear pyjamas (track pants) on one of the longest flights I've ever taken. No one is going to believe I'm a doctor in this attire! I thought. Excuses, one after another.

After about 30 seconds, I knew that if I didn't respond, I would live to regret it for the rest of my life. I unbuckled my seat belt and stood up, shuffling slowly to the aircraft galley to look for some crew, but there was no one there. Looking around, everyone seemed to be hurrying towards an elderly Chinese gentleman some 10 rows behind me in the next seating section. Cabin crew of higher authority were gathered (could tell from their more distinguished uniform). There were another two gentlemen there as well, probably doctors who were more prompt in identifying themselves as medical doctors. I walked gingerly along the dark aisle towards the commotion.

“Did anyone page for a doctor?” I asked one of the senior stewardesses.

“Oh there is one already there attending to the patient. You are...?” 

“I'm also a doctor. Alright, if you need additional assistance please let me know. I'm seated at 45G.” The stewardess took down my seat number.

Heng ah, I thought to myself, walking away. No point crowding around an already very congested walkway with two doctors readily available. Looking back at the commotion again, one of the two doctors had a stethoscope swung around his next. Well prepared, I thought. The other Asian doctor in a neat collared shirt and pants was sort of hovering around, not doing much. They both looked far older than me.

“They probably have more than enough years of experience, hands and brains”, I thought. As I comfortably settled myself back into my movie, I saw them wheeling the patient from his chair to one of the cabin stowaway areas. He looked pale, dazed and didn't seem to be responding. The patient looked bad, definitely failing the Eyeball Test.

Then I overheard a crew member say, “We are moving him to the back, so we can do CPR there if necessary.” 

I said a prayer for the gentleman.

10 minutes later, another announcement was made. 

“Would ALL medical doctors or nurses please identify yourself to the cabin crew as soon as possible.” 

This announcement was different. There was a heightened tone, a sense of panic, and clearly a call of distress.

With no hesitation this time, I walked briskly to the galley again. There, I met the two doctors who had been attending to the patient so far. There, the patient lay on the floor with a pillow supporting his head. He looked Bad. The older doctor (whom I later got to know as Dr K) had been in charge of the medical decisions thus far, communicating with ground medical staff. The Asian doctor was still standing by the side, looking rather helpless.

“Are you a doctor? What is your background?” Asked the Asian doctor.
“Internal Medicine, Singapore.” I replied.
“Great! I'm an eye doctor. You're the right doctor to be here now!” 
(That was the last I saw of him)

On hearing about my internist background, Dr K looked thoroughly relieved, although I repeated emphasized resident in training. He was a pediatrician by specialty training, but has been in public health research, with minimal clinical practice, for the past 25 years! It was then that I noticed that the stethoscope swung around his neck was a pediatric stethoscope :p

He gave me a brief description of the patient and all the information that he had gathered so far. He had been having ?chest pain for an indeterminate amount of time prior to calling for assistance. By now, the patient's femoral pulses were still present, but he was not responsive to calling, and his peripheral pulses were weak if not absent. He was cold and clammy. Dr K could not get a blood pressure reading. Shock. Could be MI, PE, sepsis? Whatever it was, all I had was saline anyway and he had definitely come to a point where IV access was required. Dr K clearly was not confident in doing so. He was ready to handover leading the resuscitation to me.

“Uncle uncle! Can you hear me?!” E4V1M4. Rapid shallow breathing. Unresponsive to calling. JVP not elevated. Pupils reactive to light. Lungs clear. Heart sounds regular. Cold peripheries. Absent radial pulse. Femoral pulse strong. Cholecytostomy tube in situ, draining bilious fluid. Abdomen soft.
Time to get IV access.

Among the minimalist equipment that was available, we had ONE precious green plug and 1 pediatric IV plug. It looked unfamiliar, but I calmed my nerves as I swabbed the left cubital fossa with one of two precious alcohol swabs. How different can an IV get? Dr K had primed the IV line. All I needed to do was to get the line in. I only had one plug.

Boom. There was some flashback, and I threaded the cannula in gingerly. Thank God. Taping it down with primitive micropore tape, we ran the fluids, fast. There were only 2 pints of normal saline on board, nothing more.

“Oxygen, can we get some oxygen please.” I asked.

There were about 6 cabin crew, 2 doctors and lots of confusion. Things were flying around. Some were fixated on the AED as it threatened to shock a patient with a pulse (Everyone please note that the AED will almost certainly read VF given the moving nature of the aircraft!!). Others helped to make sure IV access didn't fall out. Another promptly gave me what I had asked for (gloves, torch, sharps box, oxygen, stethoscope) while another recorded the vitals and events.

I took the blood pressure. 130/80. The pulse oximeter read SpO2 95% on 100% oxygen and HR 48. Dicey. Don't collapse on me, please... Dr K conversed with ground medical support over the phone. He had requested for an emergency landing, and it was wise to have called for one early. Instead of Hong Kong, we were to land in Beijing in 15 minutes.

Slowly but surely, the patient seemed to improve. I felt his radial pulses return. He became deliriously agitated, struggling with our restraints. Groaning incomprehensible sounds. E3V2M5, needing three men to hold him down.

The captain of the flight came by, spoke with ground staff and briefed the crew. Only two doctors to stay with the patient during landing. All others to return to their seats and fasten their seat belts.

So there we were on a rapid descent, my ears popping like nobody's business, Dr K and myself, drip running with the man appearing to be awakening. We were told to keep low on landing to minimize the impact on hitting the ground. I sat on the floor in the galley curled up just holding his arm straight to make sure the IV didn’t kink. With nothing else left to do, we had a little chat. Turned out that Dr K is a renowned Public Health Professor at the London School of Tropical Medicine and Hygiene, and also holds a professorship with the Royal Children's Hospital in Melbourne. On discovering my interest in infectious diseases and Public Health, he offered assistance with any application to the London School.

The landing could not have been better, pilot did a great job. The second pint of NaCl 0.9% ran out as we taxied on the tarmac. In minutes, paramedics arrived. Then came the next challenge.

“Doctor, can you speak Chinese?” 

“Errrrr, a little...” I rehearsed what I needed to say in my head over and over.

In my terribly broken Mandarin, I recounted the history and events on board. They certainly gave me some puzzled looks in between but the message eventually got across. We helped to change the IV drip and bundled the man up in a down blanket. Dr K helped with the transfer off the plane. This was followed by some paper work and the man was scooted off to the hospital. 

It was snowing in Beijing.

All of the above sounds rather heroic indeed, but all I really did was to set an IV plug and ask for some oxygen. Dr K had made all the critical decisions to move the patient and to land emergently in Beijing. I was but a small fry in the grand scheme of things. Nonetheless, I'd admit that the feeling of having contributed a little is pretty satisfying.

Cathay staff were thoroughly grateful, almost to the extent of making me feel bad. They put us in first class for the next leg of the flight and gave us duty free vouchers to use. The flight manager and captain came personally to thank us for our help.

Both Dr K and I missed our connecting flights, so he invited me to join him in the business class lounge in HK for the time being (still in my terrible pyjamas btw). We chatted about his many previous in-flight emergency experiences and this being the sickest he’s ever had to deal with. We also discussed his work in pneumococcal disease and vaccines, and the many hats he wears as he works with WHO, UNICEF and the like. He left me his name card, and asked to keep in touch. I love Australians!

I’m not sure what happened to the patient in the end and I will probably never know. I hope he is doing well. To end off, I read this interesting article by Bob Wachter on his multiple encounters of responding to “Is there a doctor on board?”. He ends off with this paragraph.

“Answering the “is there a doc on the plane?” call is one of the purest expressions of our Hippocratic oath, and our professionalism. We have no obligation to respond, and no contractual relationship. We worry a bit about liability (though the protections under Good Samaritan laws are fairly robust). No money changes hands (the airlines sometimes credit you with a few thousand frequent flyer miles or give you a free drink), and there are no CT scanners or fancy consultants. It’s just you, armed with your wits and experience, a sick and scared patient and family member, and about 200 interested observers. 

That’s why, despite the angst and the time (all told, I’d estimate that I’ve spent more than 20 hours providing clinical care on airplanes), I answered that call on Thursday, and I’ll keep doing so in the future. I hope you will too.”

Emergency Medicine, 5 years later

I have a day off.

I came back from sending SJ (I had initially typed the hubs and then corrected it) to work with a whole list of to-do things but here I am typing this. Three days to the end of ED! As much as I respect my ED friends and seniors and the hard work that they do, all I can think of is how many shifts I have left to the end of my posting. It has been a...less-than-satisfying experience. I also stumbled upon my 5-year-old (!!) blog entry on Emergency Medicine, and I honestly heave a sigh of relief that the winds led me away from choosing Emergency as a career. I guess my lacklustre posting experience may be confounded by the fact that (1) it is a 1-month posting in which we IM residents come and go and hence no one is understandably interested in training or teaching us anything (2) I am in semi-ORD mode and (3) too many things going on like MERs-CoV and enterovirus breakouts in nursing homes on everyone elses minds.

I must say that my ED colleagues really have to deal with a whole lot of crap on a daily basis. I think out of all the patients that turn up at the ED, about 5% of them are real P1 emergencies, 50% of them are subacute kind of problems that probably required admission or greater looking into, and the rest of them are really like ZZZZZZZZ (x10000).

I had a 20 year old boy who came in with the worst headache in my life and was thunderclap in onset. I asked him about 5 times, ARE YOU SURE it is maximal intensity in onset? It is VERY important that you remember correctly, think first before you answer. And he was consistent is saying yes, yes and yes. And my next question was, have you taken any panadol? NO. -_- One very unnecessary CT scan and 2 panadols later, he was up and spiritedly and asking to go home. (waves fist around)

Then there are the really weird things like, Doctor I feel like there is something in my foot. That's why I am here. (Sir, does that sound like an emergency to you?) Did you step on anything? No. Do you see anything? No. Is there a cut or any possible point of entry? No. Well...then I guess there is nothing? But since you are here and you have paid $105 maybe we should do an X-ray just to be sure there is nothing. D:

On top of all the good speedy work that my ED friends do reducing dislocations, saving the uncle with acute urinary retention and stitching up wounds, they still have to bear with angry patients, what?! the bed wait time is 6 hours?! But my case is an emergency you know? (Actually 6 hours is like super good already compared to last week when it was 50 hours..) and the Can you please seen my husband NOW?! he has been waiting for 1 hour with a bleeding nose!!!! He is going to die!!! (No M'am, he will not die from that little bit of bleeding from his broken nose...).

I feel bad because honestly there are that 55% of patients who really need good attention but half of our manpower is just there to see these non-emergency cases...and also half the time spent walking around the ED to look for seniors to clear cases or looking for a bay so I can do a rectal examination. It's so frustrating...and also I don't think I am very good at setting plugs ||-_- Then there is the doctor 2 who is literally summoned to resus as and when they need, and I have to drop anything and everything that I am doing (in the middle of a patient consult that is going well) to send the patient to HD/ICU/scans. Am clearly a fish out of water in the ED.

I'm sure this is a highly skewed perspective given my short stint, and I'm sure my ED friends would have many more motivational patient encounters that keep them going. For me, 1 month is more than enough, and just 3 more shifts to go.

Gone too soon

A 47 year old man died before my very eyes, brain hypoxia can be such a traumatizing thing.

Outstanding things

Once again, I feel like I'm trying to catch up with my own life. I often feel that I surrender my time to things that I overcommit to. On the other hand, the moment I have time to spare I feel that I am wasting my youth.

Two months of MICU have gone by. I have had several thoughts on life and medicine in these 2 months. The usual rotation requires residents to do 2 months of ICU, usually 1 month at each go. With no weekends or public holidays and intensive daytime work, the resident is usually expected to be able to handle about 1 month of toilsome labour at a go. How I landed up doing back to back postings was somewhat a choice of my own, but no regrets nonetheless, and I would have done the same thing all over again. After two months, I was tired, but not more tired than I had expected.

What I found myself feeling at the end of MICU was a strange disappointment at medicine and how doctors often claim too much credit than it is due. There is really only so much that medicine can do, and all we do is often delay the inevitable that is death. In between, we inflict pain (tubes, lines, needles) and exert restraints (cannot move limbs, cannot move body, cannot eat, cannot talk). The life is saved perhaps, but was it worth saving? Often found myself finding no answers to these questions, and in my mind a clarity of how I would not give up talking and eating just to be alive. The body is amazing, and heals itself much more than we give it credit for. Many a time, we take credit for what improvement may have occurred even without intervention, and attribute it to the thousand and one interventions that we throw at the patient to cover all ground. 

I was once asked a question pertaining to my work, "What defines a good day at work?". My answer then was, "When I have helped someone to realize their mortality." My MICU posting has made this all the more resonant within me.

Started my ED posting about 2 days ago, and a culture shock would be an understatement. Finding order in the chaos stresses out the poor multitasker in me. I have about 500 outstanding things on my to-do list now and shift work really is not helping.

Time to study for the next exam.

Emergency Medicine

Most people love Emergency Medicine, and I can imagine why. The cases are exciting, the turn over is fast, you get the wear scrubs all day long, the working hours are fixed, and going home brings little worry or stress. I thought exactly the same way before I did my 4 week posting at Changi General, having had a little experience a couple years ago in SGH's Emergency Department. The doctors were inspiring, and the cases I saw gave me much thought for the day. I was really looking forward to this posting.

Strangely enough, having gone through the past four weeks, my impression of Emergency Medicine has somewhat changed. Sure, the above mentioned benefits of working as an ED physician remain, but I've also seen many things about it that makes me not sure if I want to pursue it as a career. I don't think it was the hospital or the teaching program (though it could be), and I'm glad I did my posting at CGH as well, because I thought it gave me a realistic picture of what it would be like as a speciality. In contrast to Joy's 10 reasons for Emergency Medicine, here are my top 5 reasons against Emergency Medicine, just 5 :p

1) I think my greatest gripe about Emergency Medicine (EM) is that it barely scrapes the surface of medicine. (Granted that I say this as an inexperienced medical student who has gone through a pathetic 4 week posting) Management of the patient is always divided into Supportive and Definitive, and at least 85% of the work that EM Physicians do fall into the Supportive category. (But by no means is supportive treatment unimportant) What is the underlying problem? Are we fixing it? The EM answer to that will always be - We'll leave it to the physicians in the wards / the surgeon will fix it. What I missed very much as I went through 4 weeks of posting was the medical dilemmas that doctors face - we want to treat X, but the patient has a superimposed Y! How?! Let us try putting M and N together, and hopefully X will become Z and Y will not be affected. Sometimes I feel that EM provides little in terms of appreciating the little intricacies of human physiology.

2) In the 4 weeks I've been at posting, I've hardly noticed anyones names. The cases come in as...just cases. The collapse case, BGIT case, abdo case. Though we see this patient stereotyping prevalent in the wards as well, it has become even more stark in the ED. The first thing that I look at when I get my hands on case notes is what the patient came in with. In the ED of course, that is of utmost importance since everything needs to be some correctly and quickly. But I stop there - I never go back to find out what that patient's name is, and no one addresses them by their names. Every patient is an uncle, auntie, makcik or encik or some variant, tied up together with their presenting complaint.

3) I appreciated being at CGH because it was the only hospital that made the students follow the tutors schedules, be it day or night shifts. On average, we did 2 night shifts a week, and another 2-3 day shifts. Every night shift extends from 11pm to 8am the next day, after which you get a rest for the rest of the day, though you could still be on the 8am shift the subsequent day. I understand that in other hospitals, night shifts are either few and far between or non existent. I hadn't realised it, but shift work really kills you. The immense fatigue that comes along with it is astounding. I found that it sounds great on paper (free day off the next day!) but the way it messes up with your sleep cycle, and how I constantly feel disorientated to date and time (GCS fail) is really something that I'm not sure I can cope with. Having an off day on a weekday sounds fantastic, but if you're really tired from a night call, and you have to make up for it by being on shift during periods where everyone else is off work (weekends, public holidays etc) then I wonder if it is really worth it.

4) Life and death are issues that we deal with face to face in the ED. When the patient comes in pulseless, it is the duty of the doctor to do his/her utmost to bring him/her back to life. Sometimes we have success stories to speak of, and others we don't. Regardless, we try our best, and for as long as possible. The biggest question still remains - How long is long enough? And have we really tried our best? I guess it plagues your mind to think that perhaps one more adrenaline IV push might have revived the patient, and the possibility that you could have tried harder.

5) Patients come and go quickly, which is no surprise, since the aim of the EM Physician is to quickly stabilize the patient sufficiently for him/her to get out of the ED. I would also think on somedays, the EM Physician would wonder over his meals, "I wonder if I should have discharged that patient...could he have died at home?" More often than not, we don't know how these cases turn out. We don't know if they recovered in the ward, were compliant with their medications, were able to pay their medical bills, had good family support to tide them through this tough time. Sure you can check all these things up on the hospital database, but it comes no where near having that special doctor-patient relationship that we've been speaking of ever since the first day of medical school. In the words of HanLong, "I came to medical school to talk to patients!!".

* * *

Some other thoughts about Emed:

I found it quite bizarre that as medical students, we often find ourselves finding as many opportunities as possible to be involved in procedures - plug setting, intubation, CPR, T&S etc. Granted that practice is always good and we have to learn and try somewhere, it also occured to me that there is so much at stake. When we all get excited at the opportunity to intubate an unconscious patient, I wonder if we realise that for every moment that we take to be unsure or hesitant in doing the task, it is another moment of brain ischemia and neuronal death. I also wonder if the doctors themselves allow us to do so because at the back of their minds, they know that the prognosis is bad. (The solution to learning how to intubate would be to do it in a non-emergency setting like in the OT during the anaesthesia posting).

Having said all that, I still am contemplating doing an elective to get a clearer idea of what I want, or do not want. I guess it comes as a reality check, as with most things in life. (:

The Other Side

Today I finally experienced what was on the other side. Beyond the green sliding doors that bring in people who experience severe, retrosternal, crushing chest pain, polytrauma and the collapse cases, I saw real people, real life.

The Resuscitation Room is like a haven. A haven for medical professionals I mean, but unfortunately not patients. It has restricted access, meaning no relatives are allowed in (or if allowed, only 1 per patient) unless under special circumstances. Doctors and nurses work without being under the scutiny of emotional friends, angry parents or agitated spouses. What we do, we do it in the best interest of the patient, but we by no means have the ability to bring the dead back to life.

So over the past 3 weeks, we've seen a handful of collapse cases. Most collapse cases refer to someone who has suffered an injury which has resulted in inability of the heart to pump sufficiently. This results in the absence of a pulse, and an indication to commence CPR to maintain circulation and most importantly blood supply to the brain. The previous cases that we've seen were typically a result of a massive heart attack. Having seen a couple of similar patients and dealt with them, we were familiar with the management algorithm of these patients. Their modes of presentation were generally the same.

Two of them came in last night, one just after another. The typical medical student reflex to be involved in resuscitation kicked in, and we all took turns to perform CPR. After a few cycles, there were intermittent period of a returning pulse that would drop after a few minutes. The poor prognosis just became more evident. Then, I noticed the doctor in charge leaving to speak to the relative of the patient.

I'd never seen the doctor speak to the patient's relatives before (I don't really know why) so I decided to accompany the doctor this time. I need to learn holistic management, I thought to myself. However, the moment I stepped beyond those green sliding doors, I felt a great sense of fear. I saw the patient's wife, alone and anxious. She was the one who saw him collapse, called the ambulance, and waited for 25 minutes by his side until the sirens finally drew close. Death comes quickly.

The doctor spoke with her and explained the situation, leaving messages in between the lines, each sentence to prepare her for the worst, yet most probable outcome. No one can prepare for the loss of a loved one, regardless of how ill the patient has been for the past months. Composed to distressed to teary eyed to uncontrollable sobbing. Death is shocking.

Can you help me doctor? Please? Can you just try to revive him even if for a while? I've heard of this expensive injection that you can give? Please?

Even the most wealthy and educated are not spared from the trauma of death. 30 minutes later, we announce the passing away. There is more sobbing, and even more sobbing. Amidst it all, there is admin work to be done, papers to be signed and phone calls to be made. Death is troublesome.

As I returned back to the Resuscitation Room, all had returned to normal. The nurses were sorting out inventory, doctors doing administrative documentation and the medical students fussing over plug setting and history taking. Where is all this in the grand scheme of things?

A husband, a father, a son lost. Their lives will never be the same again.

Now listen, you who say, "Today or tomorrow we will go to this or that city, spend a year there, carry on business and make money." Why, you do not even know what will happen tomorrow. What is your life? You are a mist that appears for a little while and then vanishes.

James 4:13-14, NIV

Death Be Not Proud, John Donne

Death be not proud, though some have called thee
Mighty and dreadfull, for, thou art not so,
For, those, whom thou think'st, thou dost overthrow,
Die not, poore death, nor yet canst thou kill me.
From rest and sleepe, which but thy pictures bee,
Much pleasure, then from thee, much more must flow,
And soonest our best men with thee doe goe,
Rest of their bones, and soules deliverie.
Thou art slave to Fate, Chance, kings, and desperate men,
And dost with poyson, warre, and sicknesse dwell,
And poppie, or charmes can make us sleepe as well,
And better then thy stroake; why swell'st thou then;
One short sleepe past, wee wake eternally,
And death shall be no more; death, thou shalt die.

SCDF

Both my ambulance runs were less than action-packed. Save for some friday night action (AKA head lacerations, torn clothes, occipital hematoma, assault x1000) shuttling between the clubs/pubs and SGH, and another elderly old man who really just needed a ride to the hospital, the night shift was spent chatting with my paramedic. It was really interesting and enjoyable, to just be chatting in between calls in the wee hours of the morning, talking about the life of a paramedic and his dreams to further his studies and become a doctor! Everytime I meet someone like him, I find myself so pitiful and sheltered from the actual lives that real people are living (outside this elitist world that I live in). How ironic that it is from these conversations that I begin to experience the world. We talked about how paramedics were given firemen numbers (which is really quite odd), and the things in the system and policies that he felt really needed some working at. I learnt many things from him, not just about medicine, but about life.

My day shift was rather pathetic. In 14 hours, I went on 4 calls -_- and this time, my paramedic could not be bothered with me. Initially I was rather turned off by the way he handled things, and couldn't really be bothered to try to be enthusiastic. It wasn't until during lunch when we were chatting, that he shared that having been a paramedic for the past 5 years, he felt that the passion he had for helping people had been fizzled out by being torn between the public and the doctors, being at the receiving end of endless reprimanding. I guess I was too quick to judge. In the last 30 minutes of shift though, after the new team had taken over, there was a call and I decided to follow the new team. Turned out that this new paramedic had graduated from NTU with a mechanical engineering degree, and decided that she wanted to be part of the healthcare team! I would imagine that the salary that she was receiving would have been much lower compared to her peers receiving graduate pay, but that did not deter her from wanting to invest in something meaningful. I was really amazed at the way she was so conscientious about her work, and really took pride in doing her job to the best of her ability. Paramedics play such a vital role in pre-hospital care, but are really so underappreciated for their work.

If only everyone loved what they did, and did what they loved.

Mr CYH

First collapse I've seen. First real chest compressions I've done on a human. First time I've felt a pulseless patient. First time I've seen the pulse being brought back. First time I did an ABG.

So we brought back his pulse, after about 30 minutes of down time. Now what? Which is worse, to have a pulse and be brain dead? Or to be completely, absolutely and truly dead?

Ambulance Night Run

(Source: Keith Kerr)

Ambulance run tonight from 2100 to 0800 hours tomorrow at the Central Fire Station, our very own national heritage site. I've always wondered what lies behind those fierce red arcs. Let's hope for a good run! (: