Lessons #1

I made my fair share of blunders we made during housemanship (HOship). Some are just outright hilarious, some NOT so if you think about it. As a general rule, if it doesn't add up, something is wrong! Here are some mistakes I learnt during my HOship.

1. The Ass out of U and Me (Assume)

Lesson: Fundamentals are IMPORTANT. History and Physical Examination. 

It's middle of the night and one can be tempted to dismiss any complaints from patients because we assumed their issues have been resolved during the day. The motto for the night shift: "As long as everyone survives the night!" We try to dismiss every little issue without fully exploring or examining the patient. 

The most famous scenario would be giving analgesia for chest pain. Something more sinister could be behind that simple complaint, especially during the night when the patient isn't walking around and bumping into everything in their way (Logic #1). Even more so if the pain doesn't resolve after your first dose of analgesia! (Logic #2)

Perform vital signs (VITAL) and an ECG and your mystery will be revealed. Especially if the patient has risk factors for coronary artery disease AND has been through an acute, stress event (infection, surgery, hypoxia, etc). 

You should be handling these patients at night like a pro. Making split-second decisions on what to do, whom to call. Do NOT make the Ass out of U and Me (assume), it will cost someone's life. 

2. "Doctor! Patient desat!" 

Lesson: The common things are common. Tackle the simple things first.

This USUALLY happens if you have a patient with chronic lung disease in your ward. These patients can have a very hard time breathing during an acute event, hence immensely rely on oxygen support. If you notice a patient desaturating, ask yourself if this is due to:

a. the reason for admission => in which case, treat the cause, which is USUALLY common

b. baseline saturations => find out your acceptable levels

c. oxygen port is not connected, flow kinked or turned on! => Ensure supply is steady

d. a new acute event => find out WHAT / WHY (Think out of the box here)

More often than not, the first 3 reasons will be the key to your solutions. You do not have to crack your head to figure things out most of the time! Just assess! 

3. The Mystery of Lytic Cocktail: Part 1

Lesson : Primum non nocere. 

This is the oath all of us took when we join the profession. If what you do does more harm to the patient than its benefits, you should discuss with the patient and explain so. If you are not sure what you are doing, by all means, ask someone more senior. Even if you have to bug your specialist. 

This story was told to me by a colleague of mine. A man was admitted over the night in a surgical ward complicated with AKI with hyperkalaemia and metabolic acidosis. K = 7.2 and ECG shows the typical changes, so haemodialysis was definitely indicated. Urgent management was to spam lytic cocktails and repeating potassium & ECGs while waiting for a femoral catheter and urgent HD. Instead of giving 10units of insulin, an intern almost mistakenly gave 10cc of 100u/cc bolus to the patient. Imagine what would have happened if it was not detected by the senior in the ward. I would imagine the patient would be on IVI glucagon until the effects wear off. 

4. The Mystery of Lytic Cocktail: Part 2

Lesson: Label your drugs. Swiss Cheese Model. 

A lady was admitted to the HDU for AKI with hyperkalemia and a lytic cocktail (yes, again) was warranted. Instead of preparing him/herself, colleague 1 got the components from colleague 2. Colleague 1 proceeded to inject the drug thinking it was Calcium Gluconate. Halfway through the injection, the poor patient went into asystole and CPR was commenced. By a stroke of luck, the patient survived and retrospective questioning revealed the drug to be potassium chloride, which shouldn't be part of the component of the lytic cocktail. 

Despite being commonly and urgently used, components of the lytic cocktail can be dangerous if one is not careful. Always double-check and prepare YOURSELF.

Ensure that a system of counterchecks is available in your workplace. Always create the habit of counterchecking by questioning yourself on what you are doing.