Hospital Pasir Mas

Its been a few days since I was posted in Hosp. Pasir Mas. Life here was really different than that in USMKK. Arrived here on thursday, I found the scenery here rather peaceful and quiet. There were 17 of us, 6 guys and the rest girls, one house for each. Two dutch students from Holland came and join us in this district posting. Wow, our life here will be much more interesting with their presence. The house was dirty, so the first day was all cleaning and mopping. One good thing we found is that, the previous groups left a map of Pasir Mas in our house, showing those popular food restaurants in Pasir Mas. These restaurants were also rated, imagine that? How creative they were?

The next day, we set out to check out those ‘hot’ restaurants in Pasir Mas, but unfortunately most of the reataurants are closed on fridays. We wanted to eat the ‘Lian Hong’ Loh Mee, but it was closed too. So we just settle down with wan tan mee nearby. That day was also one of our coursemate, Zie’s wedding party. Including her, there were already 4 ppl in group who are married, one of them is already a mother! I am still single.:-( So jealous of them… Anyhow the bride was so beautiful tat day. She was always pretty, but tat day was just extraordinary beautiful. We had another lunch at the wedding party and then took photos with the newly wed couple.

On day 3 which was Sat, We spend the whole day online, chatting, downloading movies. The line here was quite fast, so our computers were on most of the time. I brought my keyboard along and Viki brought his guitar. I taught Toh Jeng, my coursemate to play ‘My heart will go on’ on the keyboard and he was diligently practising it since then. Occasionally his gf (who is also our groupmate) will drop by listen to him playing. How sweet…:-)

Yesterday, was just the usual briefing, running in the wards, doing procedures. We are supposed to go Barkas in the evening, to do some research on the water in Kelantan but due to technical error, the trip was postponed. Tis morning, I went to the Labour room, and there was this patient, 28 year old female, gravida 2, para 1, about to give birth to her second child. No painkiller was given to her. Her active phase of labour was long and she was having difficulty pushing her baby down. Possibly due to her short contraction pain. It took almost 1 hour before finally the the baby’s head came out. Here in Pasir Mas, unlike HUSM, they dont give painkiller to pregnant ladies in labour. Imagine the pain they go thru? I really salute these ladies who choose to deliver in Pasir Mas.

Life here is rather slow paced, unlike in HUSM. People here are more relaxed and not in a hurry. I dont feel so much pressured here.

Massive Oncall

Yesterday I had a massive oncall at A&E, HUSM. It was exciting and eventful. Even my buddy, Vikinesan was there with me, undergoing the challenges of A&E life. For the first time, I forgot for a moment my lonesome, depressing life in USMKK. I was in the A&E from 10pm til 3am.

There was this patient in red zone. She is a 62 year old Chinese lady. She actually came to HUSM tis morning for her regular follow-up. During the follow-up in clinic, the doctor there noted her blood pressure was high. She was then discharged with medication for her high BP. She went back and took the medication. But then she later develop headache, dizziness and chest discomfort and came to the A&E at around 2pm. She was stable and placed in yellow zone before suddenly she collapsed. She was quickly brought to red zone and an emergency ECG was done. ECG shows ventricular fibrillation (VF). It was a sudden cardiac arrest. They started CPR on her she was defibrillated for 10 times before her heart started pumping again.

I went to A&E around 10pm and saw her lying in one of the bed in red zone. Viki told me that the medical side has reviewed her and couldn’t do any definitive treatment for her as she is unstable. She was diagnosed acute myocardial infarction and started on IV medication. Then suddenly around 10.30pm, this patient who was already sedated, develop VF again. We alerted the doctors, and help them do the CPR on this patient. The doctors did defibrillation on her. Me and my coursemates takes turn to do chest compression on her, besides ambubaging and giving IV adrenaline. The patient regain her pulses. But then later, she develop VF almost every 10 minutes. Imagine having to do CPR every 10 minutes. Fortunately, the are many of us. This patient was supposed to transferred to ICU and her condition is unstable and A&E is not the place to monitor patient 24 hours. It’s the ICU. But unfortunately, all the ICU beds in HUSM is full last night. Even the ICU beds in Hospital Kota Bahru and Perdana in KB is full. ICU beds in Hospitals in Terengganu also full.

The MO then asked me to explain things to the patient’s son who was also in the red zone, watching her. I told him there is no bed in ICU, and the patient is very unstable and will frequently develop VF. We might have to resuscitate her until next morning. Even if we send her to ICU, the ICU doctors will do exactly the same thing. But ICU has staffs tat will monitor her for 24 hours. I asked him whether he still want us to do CPR on her if she continue to develop VF. He then insisted that we resuscitate her until he call all his family members to HUSM. So then, the MO let us take care and resuscitate the patient by ourselves. I really feel like im a doctor, being able to manage patient with my coursemates. But when I look the the patient’s son, I feel for him. He is very depressed and everytime his mother goes into VF, he broke into tears.

Finally, at around 3am, one patient in CCU passed away, leaving one bed empty in CCU. The MO then decided to send her to CCU. I accompanied her family members to CCU. I wonder how is she now.
Besides her, there was also another 2 patient in red zone. One 64 year old man came with shortness of breath and another 59 year old woman also came with shortness of breath. The man was diagnosed with Myocardial infarction and the woman was diagnosed with diabetic ketoacidosis secondary to urosepsis. It was a extremely busy night in the A&E.

Causes of respiratory distress in term infants

PULMONARY CAUSES

Common

Transient tachypnoea of the newborn – Caused by delay in the resorption of lung fluid and is more common after birth by C-section. CXR may show fluid in the horizontal fissure and additional ambient oxygen may be required. Condition usually settles within first day of life but can take several days to resolve completely.

Less common

Meconium aspiration – Meconium is passed before birth by 8-20% of babies. Rarely passed by preterm infants and occurs increasingly the greater the gestational age, affecting 20-25% of deliveries by 42 weeks. Asphyxiated infants may start gasping and aspirate meconium before delivery. Meconium is a lung irritant and results in both mechanical obstruction and a chemical pneumonitis. In meconium aspiration the lungs are overinflated, accompanied by patches of collapse and consolidation.

Pneumonia – Prolonged rupture of the membranes, chorioamnionitis and low birthweight predispose to pneumonia. In this kind of case, we usually start broad spectrum antibiotics early

Pneumothorax – May occur spontaneously in up to 2% of deliveries. May occur secondary to meconium aspiration, RDS or as a complication of ventilation

Milk aspiration – More frequently in preterm infants and those with respiratory distress or neurological damage. Babies with bronchopulmonary dysplasia often have gastro-oesophageal reflux, which predispose to aspiration

Persistent pulmonary hypertension of the newborn – This life-threatening condition is usually associated with birth asphyxia, meconium aspiration, septicaemia, or respiratory distress syndrome. As a result of high pulmonary vascular resistance, there is right-to-left shunting within the lungs and at atrial and ductal levels. Cyanosis occurs soon after birth. CXR may show pulmonary oligaemia. Most infants require mechanical ventilation and circulatory support in order to achieve adequate oxygenation. Inhaled nitric oxide, a potent vasodilator, is often beneficial. Extracorporeal membrane oxygenation (ECMO), where infant is placed on heart and lung bypass for several days, in indicated for severe cases.

Other rare causes

Diaphragmatic hernia, Tracheo-oesophageal fistula, Pulmonary hypoplasia, Airways obstruction, Pulmonary haemorrhage

NON-PULMONARY

Congenital heart disease, Intracranial birth trauma, Encephalopathy, Severe anaemia, Metabolic acidosis

News from Neonatal Intensive Care Unit (NICU)

I have been in NICU for bout 2 days. Its really terrible and saddening to see those newborns admitted to NICU. Some of them are jaundiced, some with breathing difficulties, some with Down syndrome and even some with congenital heart disease in failure. Some of them got ill due to maternal problem but some just got it without any reasons. Imagine you are a parent who just got a child and suddenly the doctor who delivered your child suspect your child to be Down syndrome. How do you feel? It really an agony to hear that, just like the world is crushing on you.

Today while oncall, I got to meet parents of a newborn in NICU. It was their first child, and the child was infected with multiple organism, both fungal and bacteria. The doctors suspected it to be immune deficiency and started the newborn on multiple antibiotics to cover fungal, gram positive and gram negative bacteria. The father seems to be in distress, asking me questions bout his child. But im doesnt really know the child and its problems, although the child seems stable currently. Then the father went on saying that some parents just throw their child away after giving birth but he and his wife has been trying hard to get a child. And when they finally got a child, it was not without problems…

I guess that’s how the world functions. Things that are easily obtained are owiz being unappreciated…

Recently Im beginning to accept those selfish kiasu coursemates of mine. My dad once said to me, these people are non-christians, many things they dun know and dun understand, we should pray for them. These kiasu ppl, I cant change their behavior, being upset over them is not going to do any better either… So now Im learning and trying to accept them as they are, hoping that one day they will realise wat they have been doing…