Tuesday, April 27, 2010

Organisational professionalism

I posted a comment in Bone Collector's blog entry on professionalism. Thought it's worth posting here for reference.


Hi Bone Collector,

It's so strange reading your slow and steady grooming into your ICU role.

Over here in sunny Singapore, I have the opposite problem. I am less than 1 year into the nursing profession but there are times when I'm the 2nd in-line in "seniority" by job title [Edit insert: and/or years-of-nursing-experience, on that shift]. Officially, my ward is an acute paediatric ward, but we get dumped with all kinds of patients (as another ward's staff puts it, "Might as well call your ward the General Ward."). The management's refrain is "you are trained as a general nurse, you should be able to handle all these cases". But hey, who is responsible if/when a HDU case collapse at my ward when we are not staffed to handle such acuity levels? [Edit insert: Nor do we have the resources within the ward for the variety of adult patients we receive. The ward has only a limited amount of basic adult items e.g. the adult emergency trolley.]

I'm not joking. I have been lucky so far. Twice on my shift, we had severely ill cases arriving at my ward, thanks to the A&E doctor's mis-diagnosis.

My ass was saved once by the consultant arriving early and immediately recognising the severity of the case. We did emergency interventions at the ward, and sent the patient to ICU for further stablization, before the case was transferred to another hospital. The patient died soon after at the other hospital. [Edit: Note this 10-Feb-2010 case was admitted as "Febrile Fit", subsequently diagnosed by the consultant as status epilepticus, and came up in the 25-Feb-2010 local news as "5 year-old boy dies of H1N1"].

[Online news extracted from TODAY]
Five-year-old boy dies of H1N1 flu
By Zul Othman, TODAY | Posted: 25 February 2010 2115 hrs

SINGAPORE : A five-year-old boy has become the latest - and one of the youngest - person to die from the Influenza A (H1N1) virus here.

He was said to have caught the virus from his uncle, and was admitted to KK Women's and Children's Hospital (KKH).

The boy was in critical condition over the Lunar New Year holidays. It was not clear when he died, as KKH was unable to provide details at press time. It is also not known if his uncle has recovered.

The death is possibly the first since the Ministry of Health (MOH) downgraded its H1N1 flu alert status from yellow to green on February 12.

Before this, the youngest reported H1N1 victim in Singapore was a two-year-old boy, who died in November last year.

MOH stopped reporting H1N1 fatalities after the virus was treated as part of the seasonal flu strains circulating in the community. As of September, the number of H1N1 deaths stood at 18.

According to the latest figures from MOH, the prevalence of H1N1 among patients with influenza-like illness was 28 per cent.

Overall, there are no signs of a significant rise in influenza activity in Singapore, according to the ministry. Last week, a daily average of 2,799 patients sought treatment at polyclinics for acute respiratory infections (ARIs), compared with 2,421 the week before.

The weekly number of polyclinic attendances for ARIs has also largely been below the epidemic level since early August last year.

But the official advice for those who have yet to get immunised is to get their jabs. As of early January, more than half a million vaccines remain uncommitted. - TODAY/ms

Another time recently, my senior staff nurse [Edit: SSN Y] happened to recognised the patient's Cheyne-Stroke breathing during IV cannulation and insisted that the consultant (a different doctor from the above) re-assign the "Acute Asthma" patient to ICU. We were informed that the patient deteriorated at ICU and needed to be intubated. He was subsequently transferred to another hospital.

My colleagues were not so lucky with incidents happening at their shift. As a result, each staff who has cared for the patient throughout his/her stay has to write a report of their assessment and care of the patient during their duty shifts. Those who were unlucky enough to be on-duty when the incident happened have to face management's (IMHO, "investigate and blame") process.
[Edit: E.g. SN L and SSN R who were hit with the 21-25 Feb-2010 "Febrile fit ?UTI" case that became lymphadenitis as diagnosed by the principal consultant (who is a very experienced paeds cardiac specialist). After being transferred to another hospital, the patient was re-diagnosed as "Atypical Kawasaki"* at the other hospital. According to the principal consultant's sources, even with the revised diagnosis, the new hospital had difficulty pinning down the actual diagnosis and were treating "blindly". Luckily for SN L and SSN R, the consultant also sided the nurses wrt the difficulty of caring for that case. Note *: Paeds cardiac specialists are especially familiar with Kawasaki disease due to its potential death from severe coronary/heart aneurysms.]

That's why I am eager to leave. I don't wish to put my nursing license at unreasonable risks. We are already fully stretched [Edit: more like overloaded] now. Yet, we will be taking more patients with the same staffing when the new patient rooms are opened for use.

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