Final Day in Paediatrics

For a few weeks I had been craving a type of food.

There was delivery service for that food, but it was a little pricey, and I thought, maybe when I get my next month's salary (that was June 24th).

A day or so before June 24th, as I was writing a review of one of my patients at the ward counter, one of the mothers rooming in with her baby came by, greeted me and dropped a packet almost on my note. "Nah Dr, ni boleh share 2 orang. Saya memang niat nak beri pada staf wad sini." And as I looked astounded and thanked her, she handed out several more- about enough to feed 15 people.

IT WAS THE FOOD I HAD BEEN CRAVING.

Needless to say I spent no money that day and got the chance to eat something I've wanted to eat for a long, long time- and it was awesome!

I remember having to ask the mother for permission to bring her baby over so I could insert an IV line for her for the umpteenth time (the baby was super active and likes to 'self-debranulate' almost every day). She looked so upset, telling me that we have poked her child so many times. And I don't know how much gentler I could be when I coaxed her and told her the line was needed for her child to be better. IV antibiotics have to be completed, yo. And I can tell you poking human beings isn't fun especially cute babies- but someone has to do it.

I told her, I didn't like repeatedly doing it to her child, but I will try my best to be innovative and make sure the line lasts. I told her I tried my best to really secure the last line, but maybe something innovative has to be done this time around. Together with my nurse, we tried several different line-protective methods- gauze-wrapping, socks-using, blanket-bundling, getting input from one another. I think the socks helped in the end, though the mother preferred the gauze wrapping. We had to persuade her to keep the socks on her precious child and notworry too much about it swelling as the nurses will always look after branulas.

My point is, patience does wonders.
And patients can do wonders, too.

Today, I went to the ICU and saw that the patient I bagged was in a much more improved condition. The parents smiled at me. I am unsure if they remember that I was the one who bagged their son; watched as they went to their son and said encouraging words, oblivious to the fact that he was heavily sedated as I helped to pump oxygen into his lungs, silently holding back my own tears. I  watched as they cried when my boss told them his heart stopped, and then performed CPR and gave him a dose of adrenaline until his heart beat returned. I watched then. I was too stunned after what I did earlier possibly being the major cause of his complication.

But the complication can be corrected and he is alive and improving.

I wanted to inquire about his further progress, but I was too busy having my logbook and leave forms signed, and then I felt too awkward to ask. It's kinda stupid.

But there it was.
The patient I helped resuscitate was alive despite our initial fears.

The feeling is beyond words.

So many things happened in the last few weeks/days of my posting in this amazing posting.

Today is the last day, and I know, I know very dearly, that I will miss it so much. Though I doubt I would want to be a paediatric MO or further- all those tiny veins and flat babies!- I miss being a house officer here. During the time that I was in this department, it was rather heavenly.

I am so very grateful for all the people I met- my senior HOs, lovely MOs and SNs, and of course the specialists who never got absolutely, insanely mad at us for no reason.

Which will not be the case in my next posting.
My most dreaded posting. The posting that got me into a depressive episode back in my final year of medical school.

MEDICAL.

End of Posting (EOP)

I have passed my first posting, alhamdulillah.

Next up- the toughest posting since medical school, at least for me.
Medical.

I chose it. I was the first person to request my next posting among my batch, and I had the option to choose as there are many of us. And I chose medical.

On my last Post-call shift I participated in the resuscitation of a patient.
It was... traumatic for me. I wanted to write the details here, but even thinking about it now makes me tired.
But it was the first honest-to-goodness resuscitation I've done for a paediatric patient, as others were neonates.

Kind of like a welcoming introduction to Medical, as everyone has said.

My last day in Paediatrics is coming soon before my EOP (end-of-posting) holidays start.

Stuff to have settled prior to EOP:

1. Logbook completion

2. Final assessment

3. Inform posting captain and MO in charge of HOs of your last day

4. Leave forms

5. Logbook to be handed to HOD

6. Completion certificate (copy) to the Admin

I'll miss the camaraderie in this posting. The amazing bosses, the kind and helpful seniors, my juniors (some of whom are senior posters)- they're all great colleagues, some very dear friends.

I'll miss how huge a crush I had on Cute MO (still cute, though he is now a dear boss more than anything), the MOs' teasing and friendliness and how they helped out, and covered for us most of the time. Their guidance, unfailing patience with my newbness, honing me to be efficient and (slightly more knowledgeable.

I'll miss the tiny sliver of dread I would feel when I know my HOD will do rounds, but then how she will laugh at my flubbed-up sentences (I always end up flubbing at least one sentence when presenting to her, but not to other specialists)!

How the nurses joked and helped me greatly when I can't find stuff (most of the time), or couldn't find the right vein for line setting (quite some times), or mainly when I'm emotionally disturbed and needed their coddling (only a few times, eheh).


These are not things I could expect from my upcoming posting, but I'm sure they won't be totally absent.

One more day :(

Off-Day Thoughts: Achievements?

It's really flattering when your boss asks you to take her blood when there are many others around to potentially do it, too.

Thanks for the trust, boss. Also thank God I got it in one stick and filling the tube barely took a few seconds.

*****

I was a total vampire on the last call.

I poked no less than 15 babies. Maybe even over twenty, I'm not so sure myself. Some of them were for three tubes of blood (Day 1 Jaundice workup, ya know what I'm saying?). After a while you just stop counting and just watch the blood drip, drip, drip...

I'm pretty good at poking babies by now. My success rate at intravenous cannulation of babies is now once in an average of 3 sticks- this of course includes harder sticks. Okay, maybe it's 4 sticks. Or more. But this hospital has a policy of only 2 unsuccessful trials before asking for help.

I'm glad to say that for older paeds cases, I usually get it done within 1.5 sticks (yes including those who struggle like mad- so that's an achievement). Usually just 1 stick for non-neonates; veins are more easy in normal-sized children. Cherubic ones are another matter entirely >.<

Also, who the heck keeps track of their IV cannulation success rates?!
Me.
I do.
It's for self-improvement purposes.
The post I uploaded earlier did help!

I'm pretty sure I had a better idea for my post today but I forgot. Too much sleep during the off-day will do that to you.

*****

Last few calls ago, I had the opportunity to hold an ultrasound probe and perform a bedside echocardiogram, thanks to Cute MO (YES I KNOW). I didn't even ask for it; he just told me to do it and as I asked "Are you serious?!" he replied with "It's easy, just point the probe and if you see something, you're doing it right." And he gave his trademark cute chuckle after saying that. And yes, he talked and guided me through the entire thing as I was clueless; though I knew what I was looking for, more or less, because I watched a lot of my bosses do it, and one of them even showed me in detail what to look for once- he will forever be one of my favourite MOs and will probably make a great specialist and lecturer in the near future.

But Cute MO did say I was good and suggested that it may be the start of my career as a cardiologist. We both laughed at that (I did most of the laughing, he just cute-chuckled with me).

See, not only are my MOs cute, they're also really encouraging and helpful.

I took photos of my first echo snaps. Baby's First Echo!
Literally, because that baby had his first echo done then. Hehe.

*****

My biggest achievement has got to be the fact that I have been able to gain weight during the entirety of this posting. I'm not even kidding. I gained like 4 kgs- that's like 1 kg per month!

And my final assessment is coming up soooooonnnnnn
I should be studying!

So those are my random train of thoughts for this post.

I have feelings, too...

On the verge of tears, I told my groupmates on the next shift that I was sorry.

"I had no time to do a proper passover... I was so busy until now, and now that things have gotten a little calmer all I can do is stare into space and simply... breathe."

*****

I went up and down a flight of stairs, carrying heavy items in my arms, with the adrenaline rush propelling me- the adrenaline rush of possibly having to resuscitate new lives; possibly having to see a limp, silent, blue baby- and changing it to a moving, crying, pink monster (in the best way possible). Without a drop of liquid to ease my parched throat or soothe my cracked lips, I ran around and dealt with clerking sheets, blood taking, stand-bys; Heard loud crying that soothed each of the worrying wait.

When I finally got back to the ward and had time to sit and do a review of the patients admitted, I was met with people asking me to explain my management, or confirm them, or those who simply wanted to know the condition of their children.

I tried and mostly succeeded at being positive, smiling at every one at least once.
When they questioned me repeatedly, I tried to keep my cool. I did, even.
(Then I slumped down in my seat behind the counter and held my head in my hands, holding in the pounding headache, before trying to continue my written work again- only to be interrupted within a few sentences, until visiting hours were over).

Then, after countless emergency calls and sudden orders for blood taking- over 13 hours of it, among others- I went into a cubicle where a baby, connected to various machines to monitor its well-being, lay, precariously, on some water-filled gloves. Those of you who have been in this situation probably have an inkling of what happened to the baby. My MO suddenly asked me to take its blood after asking it earlier from someone else who went away to attend another case.

I asked permission from the SN in charge of the cubicle if I could take the baby to the procedure room to take its blood. Politely. It is, in my experience, the proper thing to do- sometimes we take the baby without informing them, and get into trouble with the SN in charge for 'stealing her children'.

And the SN retorted: "Dr, takkan itu pun nak tanya saya? Dr dah berapa lama kerja kat sini? Ambil je lah, asalkan Dr letak semua benda balik dekat dia. Jangan jadi macam tadi, drip pun tak jalan lepas ambil darah!"

From at least 2 different SNs, these remarks were made to me from across the room, in different voices and tones and words.

Perhaps I intruded in their post-iftar discussion on things that didn't involve ward work. Maybe some of them were tired, too.

But none of them came as early as I did; in fact all of them arrived at most 6 hours after I started work. None had to run around the hospital and all stayed in the comfortable, air-conditioned setting of the ward. And I certainly wasn't the one who did not continue the drip. In fact, in other wards the SNs acknowledge that they will be in charge of restarting the drip and are too happy to help us do so- but that's another thing entirely.

Now, I'm usually rather bubbly. One SN in particular in the ward is constantly reminding me of how cheerful and generally polite I am. But hearing that, instead of dismissing it as usual with my apologetic grin, I kept quiet and immediately got to removing the many monitoring wires on the baby in an effort to push it to the procedure room. I could feel my expression changing. I could faintly feel the stinging of tears behind my eyes.

I was so emotional I got upset at myself.
Why was I weighing my effort against theirs? I shouldn't do such a thing! I try every day not to do it, in fact. But when someone speaks so offensively to me, I can't help the negative rush of emotions that flooded me in self-pity. That made my sincerity flicker, even just a little, into pettiness.

Perhaps noticing my change in demeanour, the SN who was most vocal almost immediately said that she was flustered with all that's been happening (in Malay terms), though it was far from an apology. I did not respond in fear of having them hear me sound upset; I kept my mouth shut and gently handled the baby, finally pushing it to my destination, as the SNs returned to their discussion.

Once there, the new tagger in the ward asked me what I was doing, and other things. I kept my answers short while trying to not sound rude. By then, in all honesty, I was thinking bitterly of how carefree the tagger is, feeling less responsible for the bulk of the work that day and not having to run around for the mere fact that she is new and not familiar with the work. But I thought again that I shouldn't be bitter; the entire time, I thought that maybe, unlike me, she is more shy and that is why she rarely asks to help around, instead asking only when she thinks she can do something. Maybe, somehow, I intimidate her. And at the very least, the small amount of help she offers me is better than no help at all- even if it came at the end of the day.

I was being very bitter, and honestly I was disappointed in myself. I might not have been so different if the ward were that busy during my tagging period.

So I concentrated on my task at hand, and succeeded, and then returned the baby to the cubicle. This time, when I asked something to the SN, she did not snap. I managed a weak smile at one of her remarks.

I wanted to run to the bathroom and cry because I was so tired and the snappy remarks they made at me were the straws that broke my back. But then my next shift came, and the understanding remarks from my colleagues- nay, dear friends- made up for it.

For as I apologetically told them that I did not do a proper passover, they patted my shoulder and told me they understood. That they've been there just yesterday, and that they will look over everything again, and that I shouldn't worry. I should just go home and rest for tomorrow.

Tomorrow.

Sometimes, all you need is a little bit of kindness...
And a place to vent.

Intravenous Cannulation Tips & Tricks

I decided to put this here so I can easily access it later! Much thanks to the original writer, editor, compiler, uploader and site (source below). It is a foreign nurses' site, so mainly addresses nurses, but IV insertion is largely the onus of the HOs in this country. In any case, the advice is mostly usable, although we lack many of the more advanced equipment in the post and there are always personal or regional preferences and SOPs to consider.

A side note from me, given from other seasoned healthcare practitioners: You can (and should) try your best to minimize your patient's discomfort, but do not feel too bad about the none-too-occasional vein searching and multiple pokes. IV cannulation is 80% skill; 20% luck (and 40% mood)!

Starting from the link below, the contents are not mine.

Source: http://nurseslabs.com/50-intravenous-therapy-iv-tips-tricks/6/

Most complaints that are received from patients and their significant others even before the start of a shift are swelling and infiltrated intravenous sites.

Intravenous therapy (or simply IV therapy) is one of the most basic treatments given to almost every patient admitted to every hospital, and the skill of intravenous catheter insertion must be remembered by heart by every nurse therapist. To avoid these complaints and giving undue pain to your patients, take a look at these tips on how to become a sharpshooter in every intravenous insertion that you make.

1. Stay calm and be prepared. Hitting the bullseye on one try will depend on the nurse’s preparation and skill. You and your patient should be composed as a nervous, and rushed procedure will likely result in failure. Allay anxiety by explaining the procedure to the patient and determine the patient’s history with IV therapy. Ensure the patient is comfortable and sufficiently warm to prevent vasoconstriction.

2. Exude confidence. Believe in yourself and reassure the patient you know what you’re doing. The patient will be encouraged by your confidence and you too, of course.

3. Assess for needle phobia. Needle phobia is a response as a result of previous IV insertions. Symptoms include tachycardia and hypertension before insertion. On insertion bradycardia and a drop in blood pressure occurs with signs and symptoms of pallor, diaphoresis, and syncope. Reassure the patient with a comforting tone, educating the patient, keeping needles out of sight until the last minute before use, and use of topical anesthetics can help manage needle phobia.

4. Observe Infection control measures. Use sterile gloves in inserting a cannula into the patient. Intravenous insertion is an invasive procedure and requires sterile technique and proper infection control measures. Wipe a cotton swab or alcohol pad on the insertion site to minimize microorganisms in the area and also to visualize the chosen vein more clearly.

5. Assess the vein. Before inserting a needle into a patient’s vein, you have to assess its condition first. A well-hydrated person has firm, supple, and easy-to-reach veins. Well-hydrated veins are bouncy, making them the right fit for insertion. Some patients need intravenous therapy but are dehydrated, so it is a challenge to hit the vein in one go. To avoid injuring the vein, always assess first that you are aiming for a vein that is not frail enough to blow up during the insertion. The following tips can help you with that.

6. Feel rather than look. If you can’t see a suitable vein, trust your fingers even more than your eyes. It’s also an excellent opportunity to familiarize yourself with a suitable vein. A tendon may feel like a vein but palpating it through a range of motion may prove that it is not.

7. Ask your patient. The patient may know more which veins are suitable basing on his previous IV history.

8. Use appropriate cannula size. Match the needle and the gauge of the cannula to the size of the patient. You can hit a vein that is smaller than your needle, but it would be injured and would blow up because the needle is bigger than it is.

Parts of an IV catheter.

9. Consider the use. Put into consideration the type of infusion that is needed when you choose your cannula. Needles with smaller gauges could not accommodate blood transfusion and parenteral feeding. Needleless equipment is now widely used to minimize injury to the vein during and after insertion.

Recommended gauges for different conditions.

10. Insert at the non-dominant hand first. Consider inserting on non-dominant hand first so the patient can still perform simple functions using the dominant hand. However, if you cannot locate an appropriate site or vein for insertion in the non-dominant hand, proceed with the dominant hand.

Vein Selection

11. Start with distal veins and work proximally. Start choosing from the lowest veins first then work upward. Starting at the most proximal point can potentially lose several sites you could have below it.

Common sites for vein insertion.

12. Use a BP cuff rather than a tourniquet. If the patient has low BP, it would be best to use a BP cuff inflated to appropriate pressure to make the veins dilate. This technique can also be useful for older patients and those with veins that are too difficult to access. For patients with hypovolemia, use a larger vein as small veins collapse quicker. Inflate the cuff to the lowest pressure first and see if the veins appear.

13. In using a BP cuff as a tourniquet. When using one as a tourniquet, invert it, so the tubings are away from the limb giving you a clear view of the site and removing possibilities of the tubings contaminating the site. The BP cuff lets your patient have a wider, more comfortable tourniquet that compresses evenly and efficiently and can be adjusted to the exact pressure needed to dilate the veins.

14. Puncture without a tourniquet. If the patient has adequately filled but fragile veins, proceed with the insertion without using a tourniquet. Pressure from the placement of the tourniquet may cause the client’s delicate vein blow out upon puncture.

Making it more visible

15. Gravity is your friend. Let the patient’s arm dangle down on the side of the bed if no veins are observed to promote venous filling. Gravity slows venous return and distends the veins. Full and distended veins are easier to palpate and are always an excellent option for insertion.

16. Use warm compress. Apply warm compress or warm towels over the area for several minutes before you insert. A warmer temperature would enable the vein to dilate and make it more visible to the surface.

17. Do not slap the vein. Some nurses have a bad habit of slapping the site of insertion so that the vein be more visible. Though the practice is helpful at times, veins have nerve endings that react to painful stimuli causing them to contract, therefore, making it harder to locate the vein. Please don’t make an already painful procedure even more painful.

18. Flick or tap the vein. Rather than slapping, use your thumb and second finger to flick the vein; this releases histamines beneath the skin and causes vein dilation.

19. Feel the vein. Wrap a tourniquet above the site of insertion to dilate the veins and gently palpate the vein by pressing it up and down. Use the same fingers in palpation so you would be able to familiarize the feeling of a bouncy vein. Tap the vein gently; do not slap it to avoid contraction of the vein.

20. Fist clenching. Instruct the patient to clench and unclench his or her fist to compress distal veins and distend them; this helps in venous filling.

21. Use the multiple tourniquet technique. By using two or three latex tourniquets, apply one high on the arm and leave for 2 minutes, apply the second at mid arm below antecubital fossa. Collateral veins should appear. Use the third one if needed.

22. Vein dilation using nitroglycerine. To help dilate a small vein, apply nitroglycerine ointment to the site for one to two minutes. Remove the ointment as you make your final disinfection of the site with alcohol.

23. Flow where you want it to go. When disinfecting the insertion site, rub the alcohol pad in the direction of the venous flow as to improve the filling of the vein by pushing the blood past the valves.

Rub the alcohol pad in the direction of the venous flow

Cleaning or Disinfecting IV Sites

24. Clean vigorously and widely. To have the tape and dressing adhere tightly to clean dry skin. Disinfect a wider area to in case another vein shows up.

25. Use a vein locator. Veins can be very hard to find in infants or small children, equipment like transilluminator lights and pocket ultrasound machines can illuminate vein pathways so you can have a visual direction of where you should insert your catheter. Be wary of burning skin and limit the duration of contact.

Example of a vein locator: Accuvein.

Insertion of the Catheter

26. Stabilize the vein. Pull the skin taut just below the entry site to support the vein for needle entry and this also lessens the pain the patient may feel upon insertion. Make sure that the alcohol has already dried on the skin before inserting because this may become more painful for the patient.

27. Insert the IV catheter directly atop the vein. Initiating it from the side of the vein can push it sideways even if it’s anchored by your hand.

28. Prevent kinking. Sometimes, if the vein is hardened or scarred, there is a risk of kinking the cannula. Otherwise, one can get through the scar to a usable portion of the vein by using the following technique:

29. Twirl the catheter hub. Mild obstructions, tortuosity of the vessel, vessel fragility, and frictional resistance can be overcome by “twirling” the catheter hub. To do this insert the IV with a slight rotating motion to help glide over some parts of the vein.

30. Bevel up. Make sure the bevel of the needle faces upwards as this is the sharpest part of the needle. Believe me, the needle will glide easily if inserted this way.

31. Make the shot at a 15-30 degree angle over the skin. Hold the catheter in a 15-30 degree angle over the skin with the bevel up and inform the patient that you are going to insert the needle.

Additional techniques for IV insertion.

32. Feel for any resistance. As you insert the needle, feel for any resistance from the pain. If no resistance is felt, advance the needle carefully. If there is resistance felt, discontinue your insertion because you might disrupt the vein and injure it further.

33. “The Flashback.” Once you can see that there is a backflow of blood (i.e., “Flashback”) from the veins, remove the tourniquet and completely advance the catheter and remove the needle altogether. Secure the catheter to the patient’s skin correctly and open the infusion line to start the therapy. It’s one of the best feelings in nursing!

Rejoice!

34. Don’t go all in. Know when to stop advancing your catheter, once you hit the vein and see a flash of blood back, stop and lower your angle of approach. Advancing it further may puncture through the vein.

An inside look at a vein with an IV catheter.

35. Don’t rush into starting the IV fluid. Once inserted and secured, initiate the IV infusion slowly as if you’re working with fragile veins. Rushing to start the fluid might blow the vein.

36. Release the tourniquet first. Once you have ensured the catheter is within the vein, untie the tourniquet before advancing the catheter to prevent it from blowing due to increase in pressure.

Securing the line

37. On taping the IV tubing. Improper taping of the I.V. tubing across the cannula and the vein beneath it will later cause pain during infusion. Tape the tubing away from the cannula site. When taping the catheter should be secured and accessible.

You can also use this specialized dressings for catheter securement.

38. Limbs in motion? When the patient’s limbs are on the move (i.e., inside an ambulance), secure the IV site by locking the arm in extension and blocking the flexion at the elbow.

39. Go with the flow when taping. Tape down the tubing while considering the natural movements of the body; thus running all tubing laterally on the limb in the direction of the motion. You can prevent the tubing from coiling or tangling by “going with the flow” of the body.

40. Stress tape to prevent accidental yanking. Use one or two stress tapings to avoid a direct pull from an IV site if the tubing is snagged. Do not tape down excessive loops or coils which shorten the length of the tubing. One should not tape on the proximal side of a flexing joint; it’ll just be removed easily. Do not wrap the tubing around a digit when taping it because when the patient clenches his fist, it can easily pull out or alter the flow of the catheter. A double-back of the tubing with a short loop will secure it well.

Securing the catheter by adding a stress loop.

41. If it leaks. If a small leak occurs at the point and moment of insertion, the vein may still be usable if the catheter tip can be fully advanced proximal to the leakage. Observe a test infusion of non-irritating fluid for any extravasation carefully before other use.

42. Do not probe for a vein. Also called “fishing” or “vein searching”–this is painful especially when the nurse unintendedly probes into muscle or tendon. If you don’t get a flashback, don’t not let your needle dig for a vein by moving it around. When this does happen, this may be a sign that you’ve missed your target, and your needle has been deflected by a rolling or hard veins. Sometimes, you may only need to pull back the needle and insert in another direction, doing so is better than starting the procedure over again.

Special Considerations

43. For older patients and pediatric patients. They have smaller and fragile veins than normal adults do. Use small gauges that can still aid proper venous flow. Choose the right site for insertion. Probably the safest location is in the hands, but be sure to stabilize it because pediatric patients are fond of gesticulating, and elderly patients are prone to falls.

Veins of older patients can be tricky.

44. For patients who have dark skin tone. You can use a blood pressure cuff and inflate it to visualize the vein more clearly due to distention. The trick of wiping a cotton swab in the direction of the vein also helps to visualize the vein better for pediatric, elderly, and dark-skinned patients.

45. For veins with valves, use the floating technique. There are some people with prominent valves in their veins that can hinder insertion. These valves feel like little bumps along the vein’s track and is common among weightlifters and sculptors. If you have difficulty inserting the catheter to this kind of vein, use a floating technique to open the valves. Floating method is done by attaching a primed extension tubing to the cannula and gently flushing the tubing with normal saline via a syringe while advancing the catheter.

46. Bifurcating veins. These veins have a noticeable inverted V-shape and are less likely to roll during insertion. However, the vein should be accessed below the bifurcation with the highest probability of cannulation success.

47. Call the “vein whisperer”. After some reasonable unsuccessful attempts to insert the IV catheter, it would be best for the patient that the nurse calls for another healthcare provider to try inserting the IV. Staff in NICU, Anesthesia, or vascular surgeons are sometimes needed for some patients. Call on those who may have the best chance before all veins are used up.

48. On the use of restraints. Infant and children may need to have their limb splinted or restrained before starting the IV as they may be uncooperative during the insertion. Do not forget to place your tourniquet before securing the splint as not to have to delve it through beginning the venipuncture.

49. Restraining using Papoose or Mummy wrap. It can be wise to restrain using a “Papoose” or a “Mummy” wrap for some children whom agitation and potential combativeness cannot yet be safely relieved. Though unsettling to the family, explain that you want to make the best possible chances of success in the first effort.

50. Learn the art of distraction. Children can be uncooperative during procedures and use of distraction methods like letting the patient blow bubbles, sing or count are sufficient techniques.

Intravenous insertion may be one of the basics skills a nurse would learn, but it could be one of the most difficult if you lack the practice and the confidence to do it. Most of the sharpshooters have gained their skill through continuous practice and plenty of experiences in this field. A lot of factors may affect the way you insert an intravenous catheter, but you have to control them and bend them to your convenience. Never rush on any nursing skills that you still not have, or take a shortcut just to achieve your goals. Nursing practices must be accurate, precise, and learned not only by the brain but most especially by the heart.

With words by Marianne Belleza, RN

Zeal-y Thoughts

Assessment done and passed.
First lone call done and passed uneventfully, thank God and everyone else with me those 30-ish hours.
Arrangements mostly made.
Leave forms sent!

My first Cuti Rehat after about half the posting is coming up soon! :D

And although CR is very much awaited for, I have just begun to like the posting a lot. When it's not too sad. Like I said, miserable days do come, but so do easier, better days.

People who were giving you grief could turn out to be those who would be nice to you later. And vice versa. It happens.


I have also majorly learned that medical student habits die hard.

Reading is required, but reading too much and overdiagnosing simple cases into complicated cases... Not too fun for your superiors- some are more vocal about it than others. Sure you might get creds for knowing stuff, but you're a doctor- you're SUPPOSED to know stuff. The important thing is the ability to distinguish the stuff into what's more important and likely, and what is significantly less so. And in the real world, most things you see are the common things.

My HOD actually affirmed that excessively reading the textbooks doesn't really help with HO life.
Also, that no medical graduate, no matter your institution of learning, or your ranking in said institution, will start housemanship and immediately be great at it. Everyone starts confused and in need of guidance.

Everyone.

Do not mistake your achievements in medical school for how you'll turn out in the hospital. Just because you aced your clinical years doesn't mean you'll ace your first posting as a houseman. Although good working habits in clinical years are a good indicator of good actual working habits, it doesn't mean you'll immediately be as good as your more senior HO colleagues.

This also goes to how you view your colleagues- do not think you're superior.
But also, do not be overzealous in your respect for your superiors. Respect has to be present, but too much is never good. This came from a person whom I overzealousy respect (and am actively trying not to be too zealous about).


Also, Cute MO is cute.

Off-Day Thoughts: A Rant on Intentions & Many Other Things.

I lost something valuable in the wards within last week.

When I let the information slip to my MOs, they went to the ward sister about it (I didn't want to say anything to avoid exactly that).

When the ward sister was about to reprimand me for leaving my valuables somewhere unsafe, they immediately defended me and asked instead why she wouldn't provide lockers for HOs in the ward.

And proper rooms for our on-calls.

And other things but I left because I felt awkward for indirectly demanding stuff.

Point 1: I am not blaming the Sisters for it; it was my fault. Also, I don't mind napping on the floor. It's not like I ever slept more than 3 hours straight in that ward.

Point 2: My MOs (like 99% of them) are amazing.

Yesterday someone told me my valuable has been found. I'm not sure if it's really mine, but the brand is the same so I'm 99% sure it is. I am so excited.

99%.

********************

I try to control my words, but I can't really control my facial expressions. I try hard, I think, but I haven't mastered control over my face when I'm exhausted and/or stressed.

This is called moodiness and it really intrudes into professionalism.

Actively trying to combat it. It's easy to talk about now, but when I'm tired it's another thing entirely. And let's face it, one gets tired a lot in this line of work and people often get irritating, too.

So. Let's see if this will be less of a problem a few months down the line.

Maybe years. But I'm trying to be optimistic.

********************

It's weird being the person taggers look for to do procedures or ask about things when the're unsure, but that's part of being a senior- even if you're only a first poster and the other person's in his/her third or fourth.

I am glad to say I was of some service. Heheh.

The SNs start to look for me instead of my senior too, now. And so do my MOs.

I am beginning to be trusted to attend calls alone.

It scares me, the prospect, but I know of many friends who have been attending calls alone for weeks by now- ever since they went off-tag, actually. I've just been privileged enough to attend calls with other people so far.

********************

I feel... I feel like I'm still sub-par. There are questions my consultant asks me that I cannot answer and, in retrospect, were super easy. Ones I can answer are simple and I still sound doubtful that even my consultant notes that doubt in my tone, with amusement. My consultant isn't mean, in fact she's amazingly encouraging despite her strict work ethics, but I respect her so much that she intimidates me.

And this is stupid, guys. 

Do not be intimidated excessively by anyone, especially if that person isn't even mean. It just blocks your thinking process with self-doubts and imagery of unnecessary repercussions. Take it from me.

It's okay to make mistakes. It's okay to not know stuff- sometimes.You're only human.

But make sure you know things you're supposed to know, and do not repeat those mistakes.

Do not care too much what others think about you- it's half the reason why you're so scared of getting scolded, maybe even more.

But I know, I know: It's easier said than done.

Like I said, sometimes I ask my seniors to tell me where I fall short, toughen my heart for the criticism, and take it into stride for future improvement. I care too much; some just adopt a more easy attitude and let things slide while still improving, which is amazing but realistically something I cannot relate to.

So I see some improvement in my work. I better; it's almost been half the posting already.

But there are still multitudes of things I have to improve upon.

Reminder to self on this almost halfway-mark to EOP:

Focus on your good traits. Do not focus on your feelings when making mistakes, rather focus on how you could improve yourself once those mistakes or shortcomings are identified. Do not dwell on what others may think of you, positive or especially negative. Do your job, and improve, for yourself and for an increasingly better service towards mankind.

Intentions must be kept noble, at least at heart. It's okay to be selfish in times of most stress, though- you're only human. But remember the ultimate goal of why you joined this field instead of taking, say, Geology or English Lit.

Your father invested a lot of money and effort into you.

Don't let it go to waste.

Make your family, friends, and teachers proud.

But don't focus on that pride because it will destroy you with a persistently-inflated ego.

Intentions, intentions: Keep them pure. Keep them noble.

Not the Best of Weeks.

It was an eventful on-call period.

Almost twice the actual capacity of the ward.
Calls every other hour.
Malfunctioning equipment.
Weirder cases than most days.

What even.

It doesn't help that humans are humans, and some are more snarky than others and make it a point to call you out on your shortcomings- like they're the only ones who are swamped with work. All they care about is getting their work done on time.

Luckily I had a nice colleague and an understanding and super helpful MO for that call.


I had a mortality case that involved me.
It involved me days before the mortality happened, and it hit me hard, being one of the first people to see that patient when he/she was stable. Even though my management was sound and the patient remained stable for many days afterwards- even if the patient didn't deteriorate while I was directly in charge of his/her care. My mind was full of 'What if's for at least a couple of days afterwards.

It took me a while, and several different people of different ranks, for me to get over it. To stop mainly blaming myself.
"Mainly"- because a small part of me, inevitably, can't help but feel responsible no matter what people say.

It pains me to know that the caretaker of that patient lied to my face about one of the patient's symptoms- at least one of the symptoms. And though for that caretaker the lie seemed small, for us it is significant. It could have meant a different investigation; a totally new approach.

It could have meant saving the patient's life.

But what's done is done.
The patient is gone. To a better place.

And I'm still here, forever remembering my first mortality.
But dwelling on "What if"s wouldn't help anyone most of the time- least of all myself.


It hasn't been the best of weeks, so here's to hoping tomorrow will be a better day.
Even though I'm so tempted to just collapse from all the work I had to do despite the hours of sleep I had since my post-call; So tempted to take a leave to avoid having a day like the last on-call I had... But like I have told myself again and again, there's no telling what tomorrow will bring. Perhaps more days like the one I've had; but perhaps it will be one of those great days which are mainly uneventful and just filled with great people and enough time to sleep instead of 30+ hours of staying awake, zombified.

Until I experience the day I do not know.
So hope for the best and expect the worse. That is how this life will always be.

Off-Day Thoughts: Volunteering

I made a fool of myself in front of my colleagues and some of my superiors today.

I did it by volunteering for something I was unprepared for... because no one else wanted to do it.

I can't look at my kind MO and just leave him hanging with imaginary cricket sounds in the air when he asked, 'So who among you first posters want to go in front?' It's unfair to his time and honestly I have to do it anyway in the future. It's not like I got assessed...

Actually maybe I did but now it's too late to think about that.

Anyway, I volunteered because I can't NOT volunteer.

When everything is over and people have laughed their fill (because I'm a goof when I don't know things so far), in the end a friend questioned why I volunteered when I said I was unprepared. She was like 'Why, I thought you were so keen to go.'

But like I said, I knew I wasn't prepared. I just knew delaying the inevitable isn't helpful, and I tend to have this tendency to offer myself when no one else volunteers for something you may consider good.

I have to say though, you learn a lot from your own mistakes. It's better to learn from others' mistakes when you can, however, so don't look forward to mistakes! Just take them as they are when they happen and try not to repeat them.

Also, all things considered, better goof and panic during a role-play than the real situation :)


Also at the end of everything my MO said 'Good!' to me, so my goofing must have counted for something...


On that note, I've been forcing myself to be increasingly independent. Passing over cases to the superiors in the morning on behalf of my group, handling the ward alone while my colleague goes somewhere, doing obviously not-so-easy blood taking and clerking. I'm not as fast as senior posters or HOs, but I can see myself progressing both in skill and knowledge. Not to the extent that it's braggable, but enough to make me want to work more.

Enough to make me feel more at ease with the working environment.

Except I'm still clueless in many things. In the end, barely a month of experience cannot compete with a year or more spent in the hospital in various postings- not entirely. I would ask my group mates to tell me where I fell short, although I know I would not be too happy to hear them, so I can improve. A major part of this is putting my stupid ego aside and just listening, and internalizing those facts so that I may be better to myself and to others.

A lot of this is possible because my busy working environment is relatively stress-free. My superiors, as I have said repeatedly, are very helpful and kind. It is the perfect kind of environment to learn and grow!

And yes, by grow I also mean girth-wise :p

Cucuk.

"Tengok tu, doktor tu. Adik tak duduk nanti doktor cucuk."

"Doktor, tengok ni xxxx nakal sangat. Cucuk dia sikit!"

Parents, older siblings, aunties and uncles, grandmothers and grandfathers.

Please.
Stop this scare-mongering.

It doesn't help us, and it doesn't help you.
Sure you don't care how it doesn't help us...
But let me tell you why it doesn't help YOU.

Children are innocent. Naive.

When you promise them something, they expect it to be delivered.
Undelivered, they feel betrayed. They acknowledge- the more you do it- that what you say is rarely true. They tend to mistrust your words.
Hence they become belligerent and ignore your threats, because they already fathom that your threats are never carried out.

Get it?
Your child can become stubborn because of what YOU say; what YOU deliver.

Saying I- or my colleagues- will come over to poke them whenever they misbehave is clearly a threat never to be carried out. I don't know about your beliefs, but we only poke when we have to; we don't poke if your child misbehaves or throws a tantrum, no matter how tempted we get.
Sorry, we're only human.

So don't threaten your children using us.
It makes them mistrust us.
More importantly, no matter how small, it plants tiny seeds of mistrust on you, too.

And you're the person they will see for years and years after they leave the hospital.


"Adik kena makan, minum banyak-banyak. Kalau tak doktor mai cucuk." - this is sorta true, actually.
But don't force them to eat if they're feeling nauseous and tend to throw up. Rather, encourage them to eat, no matter how small. A few spoonfuls of porridge is also fine. Start slow.


In the end, if we decide they need an intravenous drip, or have to take their blood to run some tests, it's for their own good. Despite what you may think, we do NOT enjoy poking your children, or bleeding them. I have yet to meet colleagues or seniors who enjoy this task. We do it because we must; because it is our job. We are not experimenting on your children.

When you cucuk your children to be terrified of our presence, you make our jobs more difficult.
Thus making our job more slow.
Thus making your child's healing process slower.

And when calming your child takes up more time, that means time taken from other patients waiting, too.
And the burden- that dosa- is on you.

How's that for scare-mongering?


Please, don't cucuk your children to be scared of us.

Flipping BHTs at Warp Speed

"Present this case to the specialist. I am not familiar with this patient," said my MO to me during a morning round. My friend who 'covered' this patient in the morning review was nowhere to be seen, carrying out one of the many things we have planned earlier with other patients seen by the specialist. Contrary to what the MO believes, I wasn't that familiar with the patient.

But familiar enough.
I have been taught, since tagging period, to know all the patients.

So- flipping through the BHT as quickly as I could- I presented the case to the specialist.
He asked me why the antibiotic regimen was changed a few days ago.
More flipping, then I remembered that the patient had some abscesses and that was why the initial Abx regime was started. I almost forgot about the abscesses because the bandages covering them were gone now, since they were resolved.

I told the specialist that.
The specialist added, after more flipping, that it was because of that, but her condition wasn't improving, hence the change- and her condition has been improving since, hence sticking to the current regime.

It was like he was teaching me, indirectly.

He reviewed the patient, and the ever-grateful father thanked him a lot, saying he has been helping ever since the child was born (she was admitted into the NICU for various reasons).
My specialist smiled, gestured to the rest of us and said 'We ALL helped one way or another'.
The father thanked us all again.

After that patient, my MO patted my back/shoulder before moving to the next patient.
Small gesture, probably meant nothing, but it made me feel better.

This was also the specialist I presented a newly-clerked case to a few days prior, and he argued my diagnosis- raw and unfiltered by any MO- but then I justified my reasons for my diagnosis, and he listened, and after having looked at my plans for a while, said, 'Continue the plans, then'.

And my heart exploded with pride and gratitude.

I have moments when I feel horrible, but I'd rather not dwell on them. And to be honest, small horrible moments tend to fade if you don't focus on them.
I do remember a lot of more negative moments, too. I can't help it, I'm not like a colleague who easily dismisses negative things and moves on. I tend to dwell. But I'm trying.

Good thing my moments here are more positive than not.

My first month assessment is coming soon. God knows how scared I am.
I'm reading old presentations from medical school since I lost my paeds protocol.

I should read that too.

There are so many things to reeeaaaaaaaddddddd!

The One Who Just Went Off-Tag~

I went 'off-tag' a few days ago.

Now I am expected to function fully in the wards.

Except, you know, first posters and fully-functioning within the first month of working... Ain't so easy for the people around them. Be that as it may, it's been a nice first on-call with understanding groupmates and MOs, and thankfully a low admission rate- to the point that one of my seniors already labeled me 'Anti-J'. Hah!

I was sick on my first on-call. Coupled with the increased stress, this made me less chirpy and efficient than usual, and many people noticed. I tried my best to function well but it was difficult, at least on my terms. Fortunately, again, I had a very understanding senior, who told me to go to sleep at 1030 pm, and even told the nurses to not disturb me if anything comes up during the night as I was sick (and new) And because of that, I was able to sleep for about 7 hours!

Apparently there was one admission or two while I was asleep and both were attended by him.
He didn't even want to wake me up.

Thank God for understanding people.

This department has been heaven-sent so far. I am glad I went along with it.


Anyway for something more useful:

1) Learn to prioritize.
2) Learn to steel yourself and do procedures alone
3) Learn to present concisely, according to specific MOs' preferences
4) Learn to find a way to take care of yourself and enjoy work.
5) Learn to get along with everyone

As for point #5, it has been made easy for me owing to the department's famous HO-friendly surroundings compared to any other departments (or hospitals, come to think of it). I have to keep reminding myself that it won't be this easy in the future.

But hell, for these 4 months (hopefully!), I'll enjoy this posting, even with the occasional disastrous days!

First Gaji

Gaji dah masuk.

In a timely manner, my first salary has arrived in my bank account- with no proclamations or fanfare. I checked my account online and, lo and behold, my bank account was in its 4-digit state again.

(Yes, I was that broke prior).

Unless some very generous chap is donating money to me for no apparent reason, this is it, folks: My first ever salary is here~!


I'm telling you it feels like some of your blood, sweat, and tears, intermingled with the patients', is worth it.
Some la. 
The rest is left for your own personal job satisfaction.


Anyway, don't ask me how much I got for each tiny thing (the specific allowances, PTM allowance, etc). I'm not sure, and the first salary is usually larger than your subsequent salaries until your increment comes, because of PTM. Furthermore, it's not like I got the salary slip (slip gaji) yet- I'm not sure if that's something I get physically or online; something they send to me or I have to retrieve myself from the office.

Be that as it may, this will be a day to remember!

Alhamdulillah.




Although, owing to many loans and obligations... I won't stay this rich for long heheh.

Of Awesome MOs

*Large clock behind ward counter reads 0945 P.M.*

MO on-call: *sees clock then stares daggers at us two taggers* Eh, what are you all doing here? Faster go home la!

Me: Dr, cannot punch out yet, still not 10 pm...

MO: You walk slow-slow, by the time you reach the machine it's 10 pm already. Faster go go!

*10 minutes later we're still behind the counter doing stuff*

MO: EY! I already told you to go home what are you all still doing here?! Go home la!

Did I mention this is the third consecutive time this week that the MO on call told us (nay, shooed us is more precise) to go home on time? And each day is a different MO.

This department is so awesome I think I'm getting manjalitis.

"Doctor posting yang berapa ni?"

Sister: Doctor, posting yang keberapa ni?

Me: Posting first, Sister~

Sister: Ye ke? Laa, saya ingatkan dah berapa. Cara Doctor macam bukan first poster~

That simple remark just made my day.

And possibly my entire week.

Never underestimate kindness. Such an off-hand remark from a friendly ward sister and it was enough to make my heart bloom again; made me treat patients with a bigger smile on my face... 

The impact is astounding.

Also the 'Thank you, Dr!'s I got from patients and their parents. Today was filled with it- even though I only took care of the ward for two days. One even personally shook my hand and thanked me for the care I gave to her son.

Just... Amazing.

And to think just a few hours prior to that, I felt useless and felt I had no role in anything.

Today is one of those days that remind you of how rewarding this career is.

This kind of day is not guaranteed to happen every day.

I left my house crying today. For the first time since tagging, I really cried and wished I could quit. I considered taking emergency leave for my sanity. But someone saw me through it, and made me drag my butt to the hospital. For a while, the only thought in my head was "I should stop being selfish- there are people who need me."

And it was one of the greatest days I've had in a hospital.

There is no guarantee of what to expect.

Each brand new day is an opportunity for you to experience life's greatest pleasures, even in the most dire of times.

Believe in the silver lining. Believe that no good deed goes unrewarded, and that no bad deed goes unpunished. Just believe.

I don't intend to make this post braggy; I'm sorry if it sounds that way.

But it was an amazing day, and I know there will be more days like today- just like there will be more days like yesterday. But until and unless you wake up and bring yourself to greet the day, you'll never know what you'll miss!

And don't get me wrong, busy is busy. But there are types of busy that are more enjoyable, less hectic, mmkay. HOship is not a cakewalk!

Zzzz

Today, I got burns where my socks met the dorsum of my left foot.

I managed to drink two packets of Milo and eat some bread. That was it.

The food provided went into the trash.

What a shame.

But I know that I have got some good friends and superiors so that's amazing.

Also one of my MOs is super cute. Like, swoon-worthy cute.

Not that that registered in my head for more than a couple of hours before I got super busy and he left the hospital to do what cute MOs do when they're outside the hospital.

Also did I mention I'm getting married soon?

That said, I am now certain I do not want to become a paediatrician.

GUYS.

Buy lots of packet food for tagging period.

If you get hyper on coffee, GET IT. You need that extra energy.

Don't dwell on how horrible one superior makes you feel. Rather, try to put the feelings aside and focus on other things you have to carry out. Believe me, you're not the only one and not everyone else hates you for the same reason. Many people sympathize.

And be a total team player. #1 rule.

Also the occasional cute & kind MO does help a little.

This Posting is Sorta, Kinda Amazing.

Life is so amazing when you have helpful colleagues and superiors.

The hard tasks seem way more bearable.
Honestly. Sometimes I shudder to think of myself in other postings where the superiors aren't as nice. This department's reputation for nice superiors and colleagues and working system really exceeds expectations.

Even in the busiest of times, you do not feel too pressured. Don't get me wrong, the pressure is there. But knowing that your MOs will understand your business and help you with other tasks that are usually way below MO job scopes is a blessing. They do not force you to do rounds at a specific time. They know you're doing your job, and they do their best to help you, too.

When I ask for help or pointers, the worst reaction I can get is a slight remark in my need to study a topic- which rarely happens anyway. Most of the time they are just glad I asked questions pertaining the management of the patients, and explain their actions patiently. When I fail at a certain procedure more than twice, I can ask for their help to do it. Sometimes, I don't even have to ask- they'll just appear and volunteer to do it for me.

What. Even,

I haven't met all of the available MOs and senior HOs in my department, but I'm really happy with the ones I have so far. After tomorrow, though, I will be in a different ward... With different people. I'm kind of scared I'll do worse.

I'm not a super HO or anything, but I can find myself smiling as I do my work. The nurses are becoming friendlier and friendlier by the day. Everyone tries to help others in the ward.

This posting has so far been a great blessing. I was right; I wanted a different department initially, but thought that if I didn't get into that department, then God knows that's for the best, and I should stick to it.

I'm glad I did!