Why this patient is still in the ward?

This is one of the favourite questions asked during ward round, and HOs are also anticipated to answer it during round!

Some of the popular answers:

1. To complete IV antibiotics
2. Awaiting for operation / procedure
3. For pain management
4. For blood transfusion
5. Post major op day _
6. Patient developed complication from operation / an initially stable disease, thus requiring inpatient management e.g. septic shock, hypovolaemic shock
7. Logistic issue, no transport available yesterday
8. “Err … ” (Avoid this. It may indicate that you don’t know about your patient 😂)

Why the patient is NBM this morning?

This is one of the questions that you need to ask yourself during AM review, and you would need to anticipate that the same question will be asked again during ward round with MO / specialist later

Examples:

• For CECT this morning
• For OGDS / colonoscopy today
• For operation under general anaesthesia today
• The patient developed tachypnoea last night (KIV for intubation today if worsening)
• The patient had coffee ground vomitus last night

Miscellaneous

• One day when you are the only doctor in the ward, and suddenly saw a patient with this breathing pattern. This is not a normal breathing! This is gasping.
  • Gasping is characterized by short, labored breaths that often involve the throat, chest, and abdominal muscles.
  • If the patient is a case where imminent death has been anticipated and not for intubation / CPR, inform MO, KIV to start medications like IVI Fentanyl / IVI Morphine
  • If the patient is a case where death is not anticipated during current admission, it is a medical emergency!
    • Quickly call the MO in charge and give high flow mask oxygen.
    • Check vital signs.
    • Place the patient in the head-tilt chin-lift position to secure the airway while waiting.
    • The patient would need crash intubation for life-saving purpose

Introduce Yourself

“Who are you? Why are you here?” – asked by a ward consultant

This happened few days ago when my colleague, a new (senior) HO just started first few days of tagging in a new department. Subsequently the colleague was somehow ‘badly scolded’ for not introducing to the consultant in charge of the ward, and some more he/she is already a senior poster.

Moral of the story:
When you are new to any ward / any department, please put initiative to introduce yourself, especially to e.g. Staff Nurse, Ward Sister, MOs, Specialist, and Consultant.

They might or might not want to know exactly who you are. But your presence has to be acknowledged by them.

“If somebody who you don’t know before suddenly appears sitting in your house without permission, what would you feel?”

ASK

• Ask whenever you are not sure
• Ask the right person (for certain things you may ask your HO colleagues, while others you should ask the MO / specialist)
• Ask before complications had happened to the patients / to yourself

Unlimited Calls

Buy mobile plan with Unlimited Call (+++Internet data). You might be calling a lot to refer cases or to update cases to MOs of the same/other departments.
Some MOs prefer us to call using our own phone, so that they can easily contact us regarding patient’s update

Examples of Poor Attitude (that should be avoided)

• Consistently coming late
• Consistently taking MC / EL without valid reason and/or without informing other colleagues
• Back-stabbing others
• Being dishonest to colleagues / superior / patients

Sometimes actions speak louder than words and cause less harm to others.

• “Which university did you graduate from?” (asking while the colleague doesn’t know something that is common / doing something wrong) ❌
• Avoid asking this question ✅

• “You are very slow, need to catch up faster” ❌
• “How may I help you?” (while finding out what the colleague is struggling at) ✅

• “You are at which posting? Still don’t know this?” ❌
• Just show / teach him or her the correct way to do certain things ✅

There are many pros & cons between manual and computerized systems in the hospitals. Some people prefer manual system while others prefer fully computerised systems. Well, we have no choice on exactly what system to be used in our workplace, so we have to adapt fast to both systems.

Manual System

• Case note is handwritten: all reviews (AM, PM, Round seen by specialist or MO)
• Lab request form, dietitial referral, imaging request form, etc., all are handwritten
• Tracing lab result: some hosp has lab results available online; others have to get the printed results from lab
• Need to prepare a lot of BLACK ballpoint pens. Not because of writing too much, but because of higher tendency to lose pens 😂
• There might be difficulty to recognize certain words due to illegible handwriting
• Nurse and doctors are using the same BHT. Sometimes, we have to take turn writing in the BHT
• Tracing old notes take time, as we can get the old notes within seconds like the electronic medical records
• Easier to remember the cases because you write it by yourself
• Easier to flip through the case notes
• No need to compete computers with colleagues or nurses, especially in certain computerized hospitals that have not enough computers

Fully Computerised System

• It can be challenging initially to learn how to order medication, investigation, imaging, trace blood result. If you are slow/ not good in typing, this could be another challenge for you. Your superiors might not have enough time to wait for your typing 😂
• Good, in terms of ability to copy & paste. Very easy and fast, and your reviews can be done faster. Please use this function wisely. Be careful when copying the info — Monday was 38 weeks 3 days POA, Friday was still 38 weeks 3 days POA, due to copy & paste 😂
• Tracing old notes within seconds. Easier for doctors working in ED, as we can know patient’s underlying comorbidity more accurately if he / she has visited the same hospital before this.
• There are periods where the hospital system is down, i.e. everyone can’t assess the Hospital Information System (HIS)

Search Commonly Used Abbreviations:

Tips

• Each department / hospital is supposed to have an approved abbreviations for routine use. Refer to that document if available.
• Do not use uncommon abbreviations to avoid medical error

Some Facts about Tagging

Perhaps, different department & different hospitals have different timing / rules of tagging

1. 7 am – 10 pm: Come to work before 7 am (usually arrive hosp about 6 am or earlier) & go back home after 10 pm
2. Lunch & dinner in hospital: if your department is busy or lacking of HO, you might unintentionally skipped your meal
3. Preparedness: You are expected to function as other HO, can do normal ward works without much guidance – clerk new case, AM review, round with MO / SPECIALIST, order investigation, blood taking (except for GSH in certain hosp), order imaging, assisting in OT, etc.
4. The more you try to do on your own with supervision by seniors / the more you help seniors, the better you are adapting to the system.
   (Nice seniors will ask you to do less job; Wise seniors will give you some routine jobs and guide you along the way)

Tagging is not just Shadowing / Following Your Seniors

Dear first poster taggers, don’t expect that tagging is the period for you to shadow/follow your seniors.

If the ward/department is lacking of manpower, you will be straightaway put into the ward schedule and expected to carry out most ward work/responsibility together other HOs, starting on the first day itself. Seniors might not have time just for teaching purpose. A lot of time we learned by encountering problems then we consulted seniors.

All the best 😁

Guidance: Expectation VS Reality

When i was a tagger in ward X, only me with one senior HO. I was ‘terkapai kapai settlekan ward work’ because she was so busy and had no time to guide me.

When I was more senior in ward X, one new tagger was ‘terkapai kapai settlekan ward work’ and I was focusing on other ward works at the same time, no time to teach. By the the I had time to teach, both of us were already exhausted.

I’m tagger from O&G ward, referring a case of …

I still remember there was a friend who called to medical MO to refer a case from O&G, and I was beside him: “Good morning dr X, I’m tagger from O&G ward X, I’d like to refer a case bla bla bla …”

You know what happened? The medical MO immediately asked him to call the senior to refer that case. He wasn’t given chance to continue even the next sentence. 😂

Therefore, just introduce yourself as ‘HO’ from which ward, instead of ‘Tagger’. If MO thinks that your presentation isn’t clear, then it’s okay, and at least you’ve learned some keypoints that should be presented to MO for such a case.

Don’t know how to spend night time while waiting to go back?

👉 Help to do oncall review / post op review / transfer in review, then ask senior to double check for mistake

👉 Assist senior to attend medical emergency e.g. hypoglycaemia, hyper or hypokalaemia / collapsed pt (how to recognize / what to give / what to do / who to call, e.g. anaes for intubation / what further Ix to be taken)

Remember, after off tag, we are the ones who will be attending these situations OURSELVES, while awaiting for MO to come.

Tagging Task / Tagging Logbook

There is a relatively benign department in Hospital X, where completion of tagging sheet is compulsory for junior & senior HOs. As long as the tagging sheet is not submitted, you will not be given a date for end posting exam (the date of exam is about 7 weeks after official offtag). As a result, some HOs did not manage to off tag on time despite working perfectly, but unfortunately being extended due to this late off tag / late exam.

Otherwise, it has a good working environment with nice MOs & specialists.

Therefore, your target during tagging in such a department is to complete the tasks in tagging sheet (e.g. case presentation, blood taking, branula insertion etc.), by hook or by crook 😇

Common cases in the ward

Obstetric ward

• PPROM
• PROM
• IOL for (IUGR, SGA, PROM, GDM/DM, Pre-eclampsia etc.)
• Active phase of labour
• Latent phase of labour
• Medical problems
  • Maternal tachycardia for investigation
  • Maternal thrombocytopenia for investigation
  • Maternal obesity (±OSA)

Gynaecological ward

• DM complicating pregnancy // Uncontrolled overt DM for insulin commencement or BSP optimization
• Miscarriages: incomplete, complete, septic // 1st trimester, 2nd trimester
• Abnormal uterine bleeding e.g. fibroid, DUB
• Anaemia in pregnancy
• Ectopic pregnancy // Pregnancy of unknown location
• Nausea & Vomiting in pregnancy / Hyperemesis gravidarum
• Uncontrolled hypertension in early pregnancy
• Wound breakdown (post LSCS, post SVD with tear or episiotomy sutured)
• Gynae cancers (e.g. ovarian cancer, endometrial cancer, cervical cancer). Many of these patients will be referred to centers with gynaeoncologist for further management.

Workstations in O&G

Might be slightly different in different the hospitals

• Obstetric wards
• Gynae wards
• Patient assessment center (PAC)
• Early pregnancy assessment unit (EPAU)
• Labour room // Labour delivery suite
• Maternity OT (for obstetric cases)
• General / Gynae OT (for gynae cases, including early pregnancy cases)
• ICU / HDW / OHR for O&G

O&G real life situation in the ward

All these can happen concurrently or within minutes.
“Dr comment CTG”
“Dr CTG ini tak cantik lah, kena call MO nie”
“Dr., bed 3, bed 5 discharge” “Dr, husband patient bed 20 dah lama tunggu dah kt kaunter pembayaran! Cpt buat discharge summary utk pt ini”
“Dr patient katil 10 contraction 3:10, tolong VE this patient”
“Dr nanti endorse ubat premed utk patient ini ya”
“Dr patient katil 13 headache & high BP 148”
“Dr bed 7 FBC stat”
“Dr OT dah call patient bed 30 utk Caesar”
“Dr dua new case in, bed 15 dan bed 16, nanti clerk this patient ya

Some examples of being independent in O&G posting

1. Set IV branula & take blood successfully (can be initially very challenging to first posters)
2. Know what to type/write for AM review, PM review, NRVE entry, IOL entry, transfer in review (post LSCS / post SVD / post VAD), discharge summary
3. Know the IOL plan. Sometimes bosses are very busy, so you might be expected to know the plan / template for prostin IOL & Foley catheter IOL. After IOL, they might quickly move to other patients.
4. Know how to interpret CTG well, and its urgency to call superior. (i.e. able to do basic management for suspicious CTG such as left lateral position / hydration. Inform immediately the suspicious CTG) ❗️❗️You might be in trouble if inform suspicious CTG late…
5. Know how to use the system in your hospital. How to order certain medications or investigations.
6. Know the work culture/style in your department. Different wards/workstations of the same department might have different working culture/style/rules.
7. Basic medical knowledge e.g. BSP control, dx of GDM, normal values of common lab results.
8. Referring cases to same / other departments

If you are good in all these basic stuffs within a short period of time, you will be good and less depending on your seniors or even superiors. Sadly, seniors might not have enough time to teach you due to the busy work.

Sometimes only 1 senior HO + 1 new comer taking care of one ward. If you as junior can’t function well, then the senior HO has to take over the job of 2 ppl 😢.

We can do it! 💪💪

Others

As long as you are still seeing patients in the ward, you can’t run away from ward work, whether you are a House Officer or a Medical Officer. When I was a House Officer, I thought ward work is only for House Officers while MOs would not need to do those ward work. Soon when I became MO, me and my fellow colleagues (MOs) are still doing majority of the ward works. Sometimes / In some places, we have staff nurses / MA to help in certain ward works such as taking some routine bloods, tracing investigations results, etc..

Tips in Reviewing Patients

• MUST review vital signs (BP, PR, RR, SPO2), I/O charting. Look for any abnormalities then inform superior/MO
• Don’t blindly write back/copy everything from old notes/previous review

Tips in Doing Procedures

• Know your limitation. It depends on what procedures you are doing as well. Maximum number of attempts for branula insertion / blood taking is usually 2 – 3 times only. More than that, it’s better to ask for help from senior (HOs are supposed to get help from MOs not the other HOs)

Tracing Investigation Results

• Click here to read further

Miscellaneous

• Always remember that what I’m doing now is for the PATIENT, not for myself or for the superior
• This is how you can easily syinge out solution from vials (e.g. water for injection, heparin saline, Dextrose 50%, lignocaine etc.): https://www.youtube.com/watch?v=RTxpHJji5Vk&t=2m7s (not many people know or would tell you this trick)

Related Posts

1. Clerking a patient
2. Referring cases