Mea culpa

This is one story I've never told before. Not to anyone. Not to my peers. Not to my juniors. Not even to my wife.

Even now, I'll admit, the story makes me squirm.

It was a hot summer afternoon over ten years ago, shortly after I had got my membership title in medicine. There were membership examination study aids stacked waist-high in my office, all shrink-wrapped against the gathering dust and pale in comparison with my overflowing ego. I was running around the hospital to see my patients. By noon, several dozen new patients had been admitted to our department. As the medical beds within our department were being used up, patients had to be shuffled. That means patients from one overcrowded department would be moved to another department. That's never a good idea. And there's more to patient safety than inconvenience. I didn't even know that one of my patients had been relocated until late evening.

I was intrigued, and furious. "Who in the right mind would want to know how a doctor can handle patients staying in one building, and at the same time, those far far way?" I wished to change the situation and decided to make some written complaint out of my hectic schedules. I wrote a complaint letter on behalf of my patient and coaxed her to sign it (to be submitted to the hospital). After I finished the letter, I thought I'd done a wonderful job, even more satisfying than publishing a paper in a prestigious medical journal.

At the end of the day, I was caught red-handed and received a serious reprimand. I can still remember the stern face of my boss, and the lesson sticks like Velcro to my memory. Now, decade later, I've learned to tap into my social brain, preparing myself better for the ups and downs. Much as we teach our kids to reframe an upsetting moment (like the old saying "No use crying over spilt milk"), I make use of similar wisdom to deescalate emotional storms.

In the Dark

It's the human nature everywhere, including the medical profession, to learn the know-how by habits.

We practice medicine by copying what our predecessors do, though we're unwilling to admit this. After a while, it's second nature and we keep our routine doggedly. And if a bold student comes to ask why, there comes the dismissive reply, "Simply because we've been told to do so."

This morning, I went to see a patient whose large blood vessel developed a tear and began to rip. There is a good chance that my patient can die if the blood pressure are left unchecked. High blood pressure can weaken the wall of that broken vessel, further tearing the outer wall. His team doctor had started him a drug labetalol intravenously. I thought I'd do the same, too. But I was stupefied to see a "naked" tubing infusing the medication. By naked, I mean the tubing was not covered like how we wrap a candy.

"How come? We should have wrapped it to protect the drug from light," my resident shared with my view and shook his head. "We've been taught to do so since graduation from school."

We started to worry that naked tubing could have exposed the drug to excessive light, making it ineffective. It would appear that I should pull evidence to show the nurses why they should cover the tubing. What stunned me even more was that I could not find any evidence to prove them wrong. Not a bit of it. And then the pharmacist confirmed that it's perfectly fine not to keep the drug in the dark.

I gave a vague smile but could think of nothing to say. If I am candid, I'm among the ones kept in the dark.

Heart

I was asked to examine the first-year medical students yesterday.

The way simulation driving test gives novices an idea what driving is like, medical school examination teaches students how to behave like a real doctor. I handed out a detailed description that would begin something like this: "A 45-year-old man with the chief complaint of chest pain over several works came for clinic assessment. He worried about a heart attack. Please examine his heart and demonstrate to the examiner where you place the stethoscope to listen to his heart sounds." Heart sounds, by the way, are produced when blood is being pumped through different heart valves.

Unfazed and without losing a beat, the students meticulously showed me where they located the landmark to listen to the heart sounds. That said, I concede that, it isn't really what a real doctor like me usually do in flesh-and-blood patients. Rather, we make a cursory examination and back up with tests like x-rays and echocardiography. Unsettling as it is, it may be hard to resist the temptation to read the x-ray and ECG before listening to our patient's heart, and not the other way round. My daughter has been fascinated by the stethoscope and she often takes mine to listen to the heart sounds. Believe me, she spent more time with the stethoscope on the chest than I did on my patient.

Which brings me, somewhat uncomfortably, to my recent encounter with an elderly woman in the hospital. Her blood test showed that the body didn't do well to seal off any bleeding in case a blood vessel is injured. I dutifully followed the logic I learned in the medical school, and came up with the conclusion that the patient's liver was not doing well. I turned to the page of liver function test to find out the abnormal figure, which indeed it was. "Her liver is enlarged," I told my resident after pressing on that patient's tummy. We went on to see the next patient after making sure an ultrasound scan of the liver has been requested.

After the weekend, my resident told me the ultrasound scan result. The patient's liver appeared large because it was engorged with blood. Another doctor listened to the elderly woman's heart and then a cardiologist asked for an echocardiography. It turned out that the patient's heart was failing because the blood could not be pumped out through the left ventricle into the aorta, thus filling up the liver. Neat answer - to which I'm afraid I didn't think of. I kicked myself, but it's too late. My shoulder sagged, face fell, and heart sank. It would have made a heck of a difference if I had listened to the patient's heart - and it only takes a few minutes.