Wednesday, 18 June 2014

Emergency Department

#ASAP - As Soon As Possible

Hi guys, it been a while since the last time i posted something here.
Although i have many things to share with you guys, like "basic ECG interpretation for houseman so that we don't look dumb" (hahaha). Yes, i may sound crazy but dont get me wrong, this is all based on my own experience, and you can benefit from my experience and be a better doctor in the future. Some of you, i know are medical students, still studying (or busy playing futsal, lol) hard for exams. Exam is exam, i'm not here to replace your 60 years old lecturer, neither am i doing this to benefit from you. In fact i don't have to do this if my initial intention is to get something from the readers, make any sense? So some of the content here, may sound very basic for you but for others, it may not. Just continue reading if what i am going to talk about, does not waste your time, deal?

My experience in Emergency Department,
in a Government Hospital setting.

p/s :-
intended for houseman & medical student only,
Medical officer and specialist, kindly click the
[X] button on the top-right for more info!

Currently, our ministry of health, requires you to undergo 2 years of housemanship, consist of 6 postings all together. Read my previous post, if you don't get what i mean.
So i have literally talked about 5 postings, o&g, medical, paeds, ortho, and surgical.Which is why i am going to talk about emergency department to complete the 2 years of housemanship. Cool right? (not really!)
(btw, you can choose between emergency department or anesthesia department for your final posting, you cannot do both)

Why Choose Emergency Department?
Some of you may ask why do i choose ED,
why always ask why? lol
There are many reasons for that, i did NOT just
choose ED after waking up from my wet dream, okay? :D
one of the reason is that, i hate the Operating theater, its too cold (i told you before), other reasons, cant tell you now, hehe..

Basics of Emergency Department
Emergency department (ED), is divided into several zones in order to make the initial treatment more effective and efficient. They divide cases based on severity or the level of emergency of that particular case, which i guess you guys have already know.

So basically we have :-
1) Triage : The very first counter/zone where all cases (i mean all) must pass by. Either the patient is walking, on wheel chair or brought by ambulance, all must be quickly assess by triage. Triage doctor/paramedic will then have to decide where the patient should go next (according to the level of emergency, remember?)

2) Green Zone : This is also known as non-critical zone. Most of the patient is seen here, by the medical officer / houseman. Patient who comes to emergency department, after being assess by triage, and is not critical will be sent here. Understand that this is Emergency Department, so emergency cases will be  given a higher priority! Doctors are human being as well, our ability in handling patients are limited. An average of 400-800 visits per day, depending on which hospital (in 24 hours time!). So green zone patient will have to wait. Even in Green zone, patient is seen according to several criteria, such as baby and older people will be seen first, it is NOT first come first served basis!

3) Yellow Zone : Also called semi-critical zone. Semi laa, not too emergency, not too well also, just nice, haha! Cases in yellow zone is attended on the spot, because semi-critical patient can deteriorate if not given medical attention on the spot. Houseman basically need to take history (from the patient, or family, or ambulance driver or whoever), take vital signs, withdraw blood and much more. Don't worry, because there are plenty of paramedics and nurses to help you, your houseman colleague, at least one medical officer in charge of the zone and ED specialist.

4) Red Zone : This is the critical zone. Where patient can die in the matter of seconds, or maybe already dying! I think the difference between red zone and yellow zone is the equipment. Since government hospital is a "developing hospital" like Malaysia is a developing country, we have limited supply (and fund) to have all the top notch equipment for every bed in yellow zone and red zone. So red zone should have intubation equipment, cardiac monitoring, defibrillator, ventilator and many more that yellow zone do not!

5) Asthma Zone : This is a place for asthma/chronic obstructive airway disease (COAD/COPD), bronchospasm patient, where they need a nebulizer ASAP. Most of them are discharge after several nebulizer given.

Example 1 :
60 years old patient comes with a severe chest pain,
with profuse sweating and look very ill.

Triage main concern is of course heart attack, right? So they will straight send the patient to Red Zone.

p/s : you will learn how to "triage" patient when you're there, paramedic (medical assistant) is your best friend! They are very well trained and is posted there right after they graduate, so learn from them!

How To Triage Patient
(for reference purpose only, may differ from hospital to hospital, use your intelligence as well :D )
** last updated 2013/2014, created by ED Specialist, not by Ministry of Health

Red Zone Criteria
- Always think of the most dangerous part first
- You can always consult your senior if you are not sure, this is not a one-man-show (even Cristiano Ronaldo cannot win the game by himself, lol)

Yellow Zone Criteria
- some criteria may not be here but that does not mean it is not semi-critical!
- always use your intelligence as there are so many disease nowadays! and to make things worst, sometimes they present with atypical presentation (just to confuse us!)

Green Zone Criteria
- Some patient does not even need Emergency Department visit, and thus can be "triage away" to the nearest Klinik Kesihatan.
- This is emergency department for God sake, please educate your friends and family, we should stop talking about politic and educate ourself more!
- if health is wealth, why bother read so much about politic anyway.

Note the G5 criteria!
- STO means to remove sutures, not an emergency, definitely!

A good rule of thumb,
#1 better consult your senior if you are not sure!
(imagine sending a patient to green zone, the patient waited for 4 hours only to find out that he/she is having a silent Myocardial Infarction! some damage is non reversible... careful yeah!

" Good Doctor is trained, Not born "
In case if you forgot, 
A specialist was once a newbie medical student, who may have failed and repeated his exams.
The Hospital Director was once a cute little baby, crying for mummy at night.
Our first Cardiothoracic Surgeon was once a houseman who failed branula insertion as well.

Never be afraid of failure,
learn from them and improve,
just make sure you don't kill someone in the process, lol

Robert Kiyosaki recently posted in his facebook timeline
" Do not let the fear of failure be Greater than the joy of success "

p/s :                                                                                                            
- For those who sent me emails, thanks alot, sometimes i dont have the time to reply but i read them.
- Those who enquire about the tax strategy, cant tell you yet as you are not ready, it is not without effort to do it, when the time comes, you will find out (sometimes, it is too much hassle to do it). Btw, i am not a tax expert, i have "someone" to refer to.
- sorry i have been busy to update this blog for the past several months, doing something that will change my future, as i don't believe that we can survive with only one stream of income, we need multiple stream of income.
- to newcomers housemanship, Good Luck and stay put. Finish your housemanship no matter what, because there are so many things you can do once you have the money, you can retire early as well, if you choose to do that (like me)!
- Do not share this, if this is a useless post, thanks alot, enjoy!