Discharged At Own Risk

I had my first case of discharged at own risk today. The patient came in for vomiting for investigation sometime after 12 noon. Upon arrival at the ward, the admin staff showed her to the room. Then the in-charge and admin staff quickly arranged for the AXR to be done stat. HCA K sent the patient down for the AXR. As I was busy with my medication rounds, I did not note the exact time of patient's arrival at the ward and return from AXR.

At 1:10pm, the specialist reviewed the patient at the ward, wrote up the IMR and left. Around 1:20pm, I reviewed the IMR and noted the specialist's orders. Domperidone suppository was ordered. As the ward admission interview was not done yet, I did a quick check with the mother on the child's condition. She was carrying the child and walking up-and-down the corridor and talking on her mobile. The mother replied quickly that the child had vomited once before admission, but not since. Then she looked somewhat unhappy to be interrupted and went back to her phone conversation. Seeing that the mother was busy and not wanting to be interrupted on her phone, I explained to the mother that we will not give the child the suppository yet. That was my mistake in my judgement.

Around 2:20pm, the child vomited. The mother called the specialist to complain that we had not done any intervention for her child since her arrival 2 hours ago. At 2:30pm, the specialist called up and instructed me to give the supp Domper stat, which I did immediately. As the shift handover report was in progress in the treatment room, SSN Y who was in-charge in that afternoon instructed that I only call the MO to follow-up with the IV cannulation after the shift handover report was done. When the shift handover report was done around 2:40pm, SSN Y arranged for the IV cannulation to be done by the MO. Meanwhile, the afternoon staff interviewed the patient for ward admission.

At 3pm, before the MO arrived for IV cannulation, the mother came to the nurses' station and demanded to be discharged. I called the specialist for his agreement on the matter, the medication for discharge and his fees. Meanwhile I had a hard time searching for the AOR form, so SSN Y helped me. Although we received the X-ray report via fax, we had not received the X-ray film yet. The admin staff called X-ray department to ask for their delivery of the X-ray film, but their porter was overloaded too. It was around 3:30pm when we received the patient's admissions record (with the patient's ID stickers) from the admissions department. It turned out that the mother only registered her child's hospital admission at around 1:30pm.

We quickly did the billings and documentation labelling for this patient. While we were doing so, the specialist came round for a second visit. SSN Y, as the in-charge, accompanied the specialist for his round. The specialist returned and signed the required IMR and billing papers. Then SSN Y sent the afternoon runner SEN MY down with the relevant documents for the pharmacy and the billing office. According to the specialist, the mother is herself a staff nurse at a restructured hospital. She is also a friend of our ward staff SN J, who was not on-duty today. This is really strange to me, because as an SN herself, she should know the workings of a ward and the priorities of investigations/interventions.

It was almost 3:50pm. The NO returned from her meeting and the admin staff updated her of the AOR discharge. The NO said that from the way the patient's mother was on the phone almost all the time since arrival at the ward, the NO suspected that her claims of a 2 hour delay in intervention was not the main reason for her AOR discharge request. Anyway, the NO went to talk the mother for service recovery. According to the NO, the patient's mother was about to start complaining when her husband signalled for her not to. They even rejected removal of Emla cream from the child's hands. When the NO returned, she instructed me to remove the Emla cream which I did, stopping them as they exit along the ward's corridor to do so.

In the end, the NO reviewed the case with me. She instructed me that in future, for new admissions, always give the medication first to avoid such claims of no interventions done. Fortunately, my colleagues had sent the child for AXR which was completed with report, in-time for their discharge. Thus the mother's claim of "no intervention done" does not hold water. Later, SSN Y advised me that if I was too busy to handle admissions in future, I should seek the NO's help. Lessons learnt.

Busy day

My team started with 11 patients this morning, including 2 that were just admitted with interventions to follow-up. There were 2 discharges. Then there was another admission by mid-morning. At around 12pm, 1 patient upgraded to a double-room and was moved to the other team, while I continued to manage his medication. Then, there was another admission which discharged at-own-risk subsequently.

The ward manager (NO) was in-charge. SSN Y and I were taking the teams near and far from the nursing station respectively. Initially SSN F from the adjoining ward helped as runner. She helped to empty a colostomy bag on my side. Then SSN Y got her help with her team's medications while SSN Y cover as in-charge, because the NO was busy in her office. After that, SSN F was re-deployed to the adjoining ward, which was opened to accommodate new admissions because my ward was full. On my side, the runner was HCA K was great with the HCA duties, but cannot help with EN level work and does not do admissions. On SSN Y's side, the runner was SEN S who is still not quite familiar with my ward.

Needless to say, I had a busy day. 2 morning medications leftover from the night shift (excluding the new admissions), 7 IV medications (including 2 discharges which needed IV antibiotics and removal of IV drip before discharge), 1 IV helplock, 4 patient education on medications, 1 new admission done by me, 2 IV cannulations. This is on top of following the doctors' rounds, pharmacy orders for top-ups and non-ward-stock items, answering call bells, assisting patients, 3 cases with nebulization, and medications for all. Would not have been so bad, if not marred at the end by the AOR discharge. In the end, I completed all my paperwork and billings, and left at 5pm! Thankfully, I managed to have a 15 minutes lunch break in-between.

Who's in pain?

As a paediatric nurse, I find myself learning about parenting do's-and-don'ts through observing real life cases along the way. One such interesting example is the mother of a recent GE case.

The mother was very agitated and fretful over her 3 years-old son. She rang the call-bell almost every 5 minutes for assistance and to highlight repeatedly that her child complained of pain. The mother varied her indicated location of the child's pain -- abdomen, IV drip site on the left hand, anus, generalized pain or some non-specific location. Here's my observation during one of those call bells.

I saw the child watching TV and the mother talking to the child.

“有沒有痛？有沒有痛？”, the mother kept pestering her child repeatedly, raising her voice and tone in agitation with each repetition of her question. ["Is there any pain? Is there any pain?"]

Her child was watching TV calmly. When the mother started raising her voice, he looked worried and confused at his mother. Finally, he lowered his eyes.

“是不是手？是不是手？” the mother continued in her agitated tone. ["Is it the hand? Is it the hand?"]

Then the child looked at his left hand with the IV drip in-situ. He seemed somewhat confused.

At this point, the mother then concluded, “Nurse 啊！Nurse 啊！我的兒子一直講他的手很痛，leh！” ["Nurse! Nurse! My son kept saying that his hand is very painful leh!"]

I walked over. Meanwhile, the mother walked away to the toilet. I asked to the boy calmly. “你那里痛？跟姐姐講。” ["Where do you feel pain? Please tell me."]

The boy looked at me calmly and then continued to watch his TV. No sign or complaint of pain whatsoever!

Reducing your child's fear

Had a good day today. SN L was in-charge, SEN L and I taking teams near and far from the nursing station respectively. SEN IV the runner for both teams. My team started with 5 patients, including a new admission done by the morning staff with the investigations, medications and IV cannulation outstanding. Admitted 1 more case later in the afternoon. Thus, I ended with a total of 6 cases. With some help from my runner SEN IV (who did the 2nd admission) and the in-charge SN L, I had time for dinner and toilet breaks, completed all work items and taped my hand-over report. I even wrote out some pharmacy "please supply" slips for the next morning's staff, so that she will know which items need re-supply. At the end of our shift, SN L, SEN IV and I left on-time and walked to our bus-stops together.

Fortunately for me, both new admissions today were not fearful of hospitalization. Neither the 3 years-old boy nor the 7 years-old girl cried during IV cannulations. Emla cream takes away the pain but not the fear. [Some of the children cry, mainly due to fear.] Both took their medications in their stride, even the yucky Klacid syrup antibiotics. My colleague SN L remarked that the parents of both children are rather calm about their hospitalization, and somehow that influenced their children. I agreed.

This reminds me of a GE case we had recently.

Code Blue Drill

We had a code blue drill yesterday.

I have re-certified my BCLS, Basic Cardiac Life Support, recently. I have yet to attend the LSCN, Life Support Course for Nurses, although we were taught the required skills in school. For my ward's code blue drill, I was designated as the second nurse-to-arrive, i.e. responsible for the chest compression.

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To prepare for the drill, my ward manager (NO), held code blue rehearsals on the day before and the morning before the code blue drill. At our first rehearsal, NO was role-playing the first nurse-to-arrive. When the code blue alarm sounded, I rushed into the room with the emergency trolley. Then the NO painted the scenario to me, "You see me trying to resuscitate the patient, what do you say?"

Thanks to my BCLS training, I automatically replied "I know CPR, can I help?"

"Of course you know CPR, you're a trained nurse!"

Ha ha. This became a joke that greeted us at work the next morning.

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JCI visitors paid a surprise visit to the ward just before our code blue drill. We, the staff nurses, prayed very hard that they would leave before our code blue drill started. Thankfully, our prayers were answered.

The code blue drill proceeded as rehearsed. I was focusing on the chest compression. There was a visiting admin staff who was trained on BCLS. She took over my compression after the "switch" count. Then all of us stood clear for the defibrillation. After the defibrillation, I continued with the chest compression. I continued to pump away until I felt a gentle slap on my buttocks.

Apparently the doctor had declared sinus bradycardia rhythm. I was so focused on the chest compression that I was still pumping away on a "patient that had recovered". My colleague SSN R, playing the role of the defibrillation nurse, gave me the discreet slap on the butt to signal for me to stop.

Good days and GE cases

Had a series of good days at work. We had a surge of GE (gastro-enteritis) cases for the past 2 weeks. GE cases are rather simple in their oral medications since most cannot take much orally. The main focus is to ensure their hydration e.g. with IV drips (with or without KCl added), monitoring their intake and output (vomiting, diarrhoea and any blood in stools). IV medications, if any, are usually antibiotics and the optional anti-emetics. The odd cases include bowel wash-out, daily weighing (for infants). Some have combination of diagnosis that include respiratory tract infection.

Learnt something from a consultant last week. He had a reputation for being a strict doctor and would monitor his patients' pulse and respiration himself when he reviews them, a full-minute for each vital sign. He happened to have a 8 month old infant with GE. He instructed the parents to keep a soiled diaper sample for his review. Upon looking at the soft greenish stool with light blood stains, he explained that the stool is typical of Salmonella infection.

For the past 2 days, the same staff were on duty with me. SSN Y was in-charge, SN L was the other team leader and SEN IV was the runner. The other runner was either SSN F (from the adjoining ward) or HCA K. Glad to have SSN Y and SN L around. They are really very supportive to colleagues. I am very lucky to be assigned SSN Y for preceptor-ship. SEN IV and SSN F were also very helpful as runners. HCA K is very experienced and effective at her work. Thus, I had a good time for the past 2 days.

Migration medical check-up

Just received the letter requesting me to go for a medical check-up for my immigration application. The letter was dated 2 weeks after my IELTS results were out. I am impressed by the quick processing.

At our last gathering, 2 of my nursing kakis who are born-and-bred locals, expressed their view that Singapore does take care of its poor. They cited cases of destitute in-patients in public hospitals who are allowed to stay as in-patients until the hospital's medical social workers (MSW) successfully assigned them to a community home. In their opinion, that shows that the government is taking care of its people.

Perhaps I am expecting too much of the world's highest paid ministers by far. I find it unacceptable that the government resources come into play only when one is hospitalized and homeless. In addition, community homes are not exactly environments where in-patients can enter or leave at will. Thus, the destitute person is practically imprisoned in such homes. Based on my observations, there are homeless or poor elderly who are not sick enough to be hospitalized, struggling to survive by collecting scraps. I do not find it acceptable that a rich "first world" nation does not have open and integrated social support policies.

This is yet another example of how I feel that I share less and less in common with the typical locals. Even the PRs at my workplace praise the Singapore government for its efficiency, non-corruption (after all their multi-million pay is openly announced at parliament), and cleanliness.

SSN vs SEN

I had a rather pleasant day at work today. SSN Y, my preceptor, was in-charge. SSN R and I were taking teams, near and far from the nursing station respectively. SSN F and SEN L were our respective runners. I had 7 patients, no admissions or discharges during my shift. Of these cases there were 4 on IV drips, 4 IV medications to give, 2 cases of 4 hourly nebulizers.

There was 1 case which required hourly monitoring of a finger's skin-graft post-operatively. Unfortunately due to the child's movements, the protective dressing around the forearm fell off. Thus the specialist decided to bring forward his dressing change from tomorrow morning to this afternoon instead. Thankfully, SSN Y and SSN R were around. SSN Y prepared the dressing trolley. Both SSN Y and SSN R supported the child while the specialist was doing the dressing. I helped with opening of sterile dressing materials. When completed, SSN Y billed the items used.

As mentioned before, I noticed a change in SEN L's attitude. These days, she orders me to attend to patients rudely instead of informing me politely about their situations. In addition, she advised me rudely or wrongly accused me of mistakes.

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After checking with the consultant, SSN Y applied an interim sterile field to the child's finger while awaiting for the consultant's arrival this afternoon. Unfortunately, the child managed to loosen his finger out of the interim field, right after SSN Y had left the room. I put on a plastic sterile glove to re-seal the interim sterile field. While I was doing so, SEN L said sternly, “不要綁得那麼緊” ["do not make it so tight!"] when she herself would not step forward to assist and instead commented as a "back-seat driver". I was not even applying any tension when the re-sealing sterile field.

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When SEN L is assigned the runner's role these days, she functions just like a HCA. She does not flush IV lines, change IV drips or other stuff that an EN can do. Instead, she even tries to push some of her hourly monitoring work to me. Somewhat sad to think about it. We started off so well together.

In contrast, SSN F volunteered to help me out with my medications and other stuff, even though she was assigned to be SSN R's runner. She even ran down to the pharmacy for an urgent order for SSN R when the pneumatic tube was down. Thumbs up for SSN F's humility and dignity. She was an SSN in a Medical/Surgical ward when I was a still a student on clinical attachments. In those days, she would sometimes be the in-charge overseeing the entire ward. Yet, when assigned to the runner's role today, she did not sulk nor acted as a HCA.

Ironically it was SEN L who mentioned the following chinese proverb to me.
“路遙知馬力，日久知人心。” ["One knows of a horse's strength after a long journey, one knows of a person's heart after a long period."]

Whirlwind discharges and admissions

Yesterday was like a whirlwind. I was on the morning shift taking the team far from the nurses station. Ward manger (NO) was in-charge, SN J and I were taking teams. Our usual admin staff had another admin staff to assist her. 2 staff from the adjoining wards joined us, SSN F and SN M. They were assigned to be runners for SN J and my team respectively.

I started with 9 patients. For various reasons, the night staff SSN A did not dispense the morning round of medications to 7 of them during her shift. Thus my morning started with a rush to complete outstanding doses of morning medications, on top of following the consultants on their rounds. Add to that, 3 of the 5 patients for discharge had their morning dose of medications outstanding and 2 of them had to receive IV antibiotics before discharge.

Just when I thought I could breath a little, 4 new admissions arrived to take over the single rooms emptied by the discharges. My runner SN M was new to our ward routine and was stuck with the daily bathing/sponging of the in-patients. She could only help with 1 admission assessment. Even the housekeepers were fazed by the whirlwind discharges and admissions, and forgot to refill the complimentary tissue pack and toiletries supplies for some rooms. Add to that 3 of the 4 admissions needed IV cannulations (one came with IV in-situ due to transfer from another hospital), and all of them needed IV drip or antibiotics. SN J had 9 patients (no discharges or admissions). She only assisted with the IV cannulations of 2 cases.

In short, it was chaos. I was originally call-backed to do double shift. Fortunately for me, unfortunately for SN M, SN M owed time and thus had to take-over the afternoon shift. I stayed till 5 pm helping her to clear as much items as possible.

I feel sorry for SN M. She was from the same nursing course as me, 1 cohort before mine. SN M had not been fortunate enough to be posted to the discipline of her choice (O&G) and ended up in a Medical/Surgical ward. That Med/Surg ward that she was posted to had a reputation of being unfriendly to newcomers. After about a year, she joined the adjacent ward when it opened. Since that ward is not always open, she was frequently re-deployed to various wards. Thus SN M was unfamiliar with my ward. It does not help that my ward staff somehow do not take kindly to the adjoining ward staff. I guess it's typical "in-group" behaviours.

Yesterday, in her frustration, she remarked loudly to me... knowing that the NO was within hearing distance,
“這麼忙，做死人。” ["So busy, overwork people to death."]

After AWARE

A friend of mine and I had a couple of email exchanges about how "mainstream media's reporting can sometimes be questionable" -- to borrow her description. She referred to her personal experience of it through the AWARE saga. My reply to her pretty much summarize my thoughts on that matter.

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Hi [edited],

If you are referring to the AWARE saga, I will only agree that the mainstream media had sensationalized the news. Otherwise, I stand by my decision to join AWARE to vote out the Christian dominated EXCO (call it the new EXCO) of which you were a part of. My decision is not personally directed at you, but based on the behaviours of the group and the self-declared feminist mentor.

I was there at the entire event. It was obvious that the previous EXCO had more experience. Josie and her team's defensive and high-handed behaviour (while understandable from a psychological viewpoint of cornered persons) certainly does not win the crowd. Thio Su Mien practically destroyed any credibility the new team had left. I have seen the likes of Breama Mathi at other NGO activities prior to the AWARE saga. I believe in her sincerity.

As I have sms'ed you after the end of the saga, that the best way to contribute to an existing social activist group is to join at the rank-and-file to understand its workings and values before jumping into the top. My point is that a new comer has to assess if his/her individual mission aligns with the group's. Otherwise, one might as well start one's own group. In addition, if one has not been in NGOs before, one would not appreciate the different work cultures of NGOs. Ordering subordinates and firing while being the norm for corporate practices would hardly work in an NGO environment.

Finally, I do not buy the argument that the new AWARE EXCO joined because they were concerned about the content of AWARE's sex education and that they are speaking up for the conservative majority. There are alternative ways to lobby against the sex education syllabus, as illustrated by the successful Christian orchestrated lobby to MOE. No need to stage a coup of the existing NGO for it. As for speaking up for the conservative majority, I consider it the "Christian hypocrisy" which strangely I noted mainly only in "born-again" Christians in Singapore. This is because they don't seem to speak up when the bias favours Christianity. The conservative majority in Singapore is not all Christians. If Christians are really so concerned about issues affecting the conservative majority, why no lobbying to MOE to remove the Christian's Creationism from the secular schools' science book or advocating equality by including the theories of creation from other religions.
http://theonlinecitizen.com/2009/08/god-sneaks-into-our-classrooms-part-two/
http://theonlinecitizen.com/2009/08/god-sneaks-into-our-classrooms/

I will state upfront. I have LBGT friends, and I believe in supporting their right to happiness and equality. They are human too. I will support LBGT marriages if it ever come to pass in Singapore. Thus, this is another issue that we may never see eye-to-eye. I was at the Pink Dot event. Perhaps knowing them personally has opened my eyes to distinguish the sensational (e.g. Thio Li-Ann's infamous quotes) from the reality of LBGT.

As we have discussed before, we may never see eye-to-eye on your interpretation of Christianity. Thankfully there is much more to life and living upon which friendships can be built, other than religion or specifically Christianity alone.

Best Regards

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[Postscript on 17 September 2009]
A guest writer of The Online Citizen exposed another example of the mainstream media's poor journalistic standard today.

Atheist Comedian on Prayer and Teaching Creationism In School

Pneumonia aftermath

After my hospitalization for pneumonia, I had several follow-up reviews by the consultant. The follow-up CXRs showed the lungs clearing more at each review. However, my consultant's experienced eyes spotted a shadow line that escaped even the radiologist's initial assessment. My consultant advised a CT scan if I wanted a more definitive evaluation.

Perhaps it's psychological, I felt and still feel some degradation to my general health and performance since my pneumonia episode. For example,

• I seem to have shorter attention span when chatting with friends. Sometimes I could only be alert for the first 2 hours, then my attention degrades significantly thereafter. I was wondering if it was just me, being known to have short attention span in school. Or was it a sign of ageing? Or the after effects of illness?
• I seem to pant more easily upon physical exertion. Previously I would simply ascribe this to a lack of exercise.
• I seem to feel faint more easily upon heavy physical exertion or standing at a spot for too long.
• Occasionally, I seem to feel a stabbing pain from my left lung when I breath deeply.
• I seem to catch a runny nose more easily. Previously I would simply ascribe this to a temporary drop in immunity levels or sudden exposure to new pathogens.
• My quick thinking seems to have slowed down. I wondered if it is because I am now in an unfamiliar field. Or that my brain power had deteriorated.

Initially I kept delaying having the CT scan done and hoping to avoid it altogether to save cost. Then one week after I started working at the ward, I suddenly felt dizzy while I was standing and listening my ward manager's briefing for about 20 minutes. Apparently, I was pale to my lips which surprised my ward manager. She quickly sat me down, told me to rest my head at knee level and took my pulse using her skills in traditional chinese medicine. Then she told me that my pulse was very weak. That got me worried if there was a limit to my recovery. Thus I decided to bite the bullet and scheduled for a CT scan in mid-August. I decided to do blood tests for haemoglobin and vitamin B12 levels too. These are known problems for some long-term vegetarians. During the interim, I started taking daily iron and vitamin B supplements to boost my low haemoglobin count (upon my hospital admission) and to balance any lack of vitamin B.

Finally I did my CT scan and follow-up blood tests. The CT scan report indicated minor subsegmental atelactasis and mild scaring in inferior lingular segment. Both haemoglobin and vitamin B12 levels were within normal range. Based on that, my consultant discharged me from further follow-up. Thank goodness for the results.

Today I did a free online IQ test to address the final outstanding doubt -- whether the short period of under-oxygenation had any long term impact on my brain power. According to the test, my IQ level is still pretty much the same as the supervised test that I took 15 years ago. Thank goodness for that too!

30+ telling-off 50+ for bullying 70+

Something interesting happened at lunch today. I, a 30-something, told off 2 ladies, in their fifties, for bullying 2 ladies in their seventies.

I was at lunch at HDB Hub's basement food court. It was filled with the lunchtime crowd. I could hardly find a place for myself, a solo diner. Then I spotted a place at 2 adjoining tables. Table 1 with seats L1, L2, R1 and R2 and table 2 with seats L3, L4, R3 and R4.

L1 L2 L3 L4
R1 R2 R3 R4

R1 and R2 were taken up by 2 young ladies in office wear. The lady at R1 told me that L1 and L2 were also taken. L3, L4 and R4 were taken up by a family of 4 who were about to finish their lunch and R3 was vacated by one of their child. I asked the parents if I could occupy R3, despite the table being almost full of dirty dishes. The parents kindly shared their table with me. Soon enough the family completed their meal and left the table.

A lady, who looked like she was in her fifties and dressed in office wear, came over to asked me if seat R4 was taken. I indicated that she could have the seat. Then she went off to buy her lunch. She returned with her soupy meal, left it on the table and went off again to buy something else. Then she returned to her R4 seat. Let's call her Lady 50A.

Then 2 elderly ladies, dressed in casual, came by. They looked like they were in their seventies. One of them, facing me and Lady 50A, asked if they could occupy seats L3 and L4. I nodded that they could have the seats. Both of them sat down. Let's call the one sitting at L3 Lady 70A and the other sitting at L4 Lady 70B. Lady 50A did not make any remark.

Lady 70B decided to buy her food, leaving Lady 70A to reserve seat L4 for her with small plastic bag of things on the table. After a while, a friend of Lady 50A came by and stood next to seat L4. Let's call her Lady 50B. Lady 50B chatted briefly about the food with Lady 50A. Then Lady 50B turned to face Lady 70A, who was sitting at L3. Lady 50B pointed to seat L2 and said the following to Lady 70A.

“你坐那遍。我剛才坐那遍，你可以坐那遍。” ["You sit there. I sat there just now, you can sit there."]

To think that all 5 of us (I, Lady 50A, Lady 50B, Lady 70A and Lady 70B) are Chinese and the typical Chinese emphasis on value of respecting one's elders. I kept quiet, waiting for Lady 50A to correct her friend. Instead I was stunned by the deafening silence from Lady 50A and the "this is my seat" serious look on the face of Lady 50B.

Without complaining, Lady 70A moved over to seat L2. Lady 50B sat down on L4. Both Lady 50A and Lady 50B started eating lunch and chatting as if nothing had happened. These two 50-something professional looking ladies spoke in fluent English to each other, not Singlish. I looked at Lady 70A and gave her an apologetic smile, indicated to her with my eyes darting to Lady 50B and shook my head. Chinese body language for “那個人沒家教”。[Literary, "That person has no family upbringing."] Sometime later, Lady 70A moved further to seat L1 and her friend Lady 70B sat at another table, to the left of R1.

After a while, Lady 50B got up from her seat to get something from the stalls. To avoid Lady 50A from “丟臉” ["losing face"]， I took this opportunity while her friend was not around and feedback to her,

"Next time you should have informed that you are reserving the table for 3. We are all here to find a place for lunch, we should be kind to each other."

"My friend was sitting at there (pointing vaguely to the direction of L1 and L2). When I came over, I was expecting to be sitting alone." was her lame defence. By then, her friend Lady 50B returned and indicated with her body language to Lady 50A "what's going on?"

I looked at her and repeated, "I was just telling your friend that next time she should have informed that she was reserving the table for 3. Don't demand that an elderly moves from her seat."

"But I offered my seat to her", Lady 50B retorted, raising her voice in her defence.

"You should not demand that she moves over. She an elderly. You could offer your seat, but not demand that she moves."

Lady 50B insisted that she offered her seat. Is her command of the Chinese language so poor that she doesn't know how to offer her seat to an elderly in a polite manner? Even then, is her body language so lousy that she doesn't know how to smile when making a request? Then Lady 50B sat down, ate her lunch and started talking to Lady 50A as if nothing had happened. Lady 50B decided to adopt the "ignore the nuisance" (aka me) strategy.

I turned to Lady 50A and repeated, "Next time you should inform that you are reserving the table for 3."

Lady 50A whined, "I was expecting to eat alone". I'm not convinced. If that were true, why didn't she tell her friend not to bully an elderly lady into giving up the seats? The only logical conclusion I could come to was that she did not see anything wrong with her friend's bullying and played along so as to have a nice face-to-face seating for her lunchtime chat with her friend. Anyway, after my final sentence, she became quieter and less participative in her conversation with Lady 50B.

I finished lunched quickly and left the table without further words. Fifty-somethings in Singapore often lament the lack of traditional values in the younger set. It is perhaps time for them to look into the mirror.

Great work colleagues

I had a relatively good workday today despite the hectic workload. Took the team near the nurses' counter. Started with 7 patients, then 2 admissions and 1 discharge during my shift. 2 more new admissions at the end of the shift.

I attribute my "good workday" to my great work colleagues. SN L was in-charge, SN O was taking the other team, SEN S (from the adjoining ward) was assigned to be my runner and SEN MY was the runner for SN O. SEN L from the morning shift handed over several outstanding items to be followed-up. I admitted one of the new patients. SN L, SN O and SEN S helped me with the admissions-related work, 1 discharge, some doctors' rounds and IV insertion. Thus, I managed to finished the work on time, taped the handover report and had dinner while the night shift staff were taking report.

SN L is amazing. She stays calm, polite and supportive despite her heavy workload. I hope that she will go far in her career. SN O has good skills, is a careful and observant nurse. In addition, she is supportive of others where possible. She was from the same course as mine, 2 batches before me. I really love working with these 2 professionals. SEN S is a stark contrast with SEN MY. She automatically answers call-bells regardless of whichever team the patient was from. In addition, she shows initiative in admitting a new patient and offers to assist me with my 4 nebulization (although I did not need her help with that today). To top it all, she did all her work in good spirit without complaining.

Online fortune cookie

Sometimes when I am bored or stressed and not keen on meditating, I crack an online fortune cookie. One of the more memorable ones goes,

"Always remember that people may not necessarily want to hurt you. They may be acting the best they can given that current situation in that point in time."

IELTS result

Received my IELTS result today. I'm glad that it's good enough for my migration plans and application for nursing overseas. However, in order to register as a nurse overseas, I would need my current employer's reference. This would be tricky as I have yet to be confirmed at my current job. In addition, I still need a lot of support from my colleagues given my limited nursing experience. As an ex-lecturer put it, once people know you have an opportunity to leave, they may react in surprising ways -- sometimes positive and frequently negative. She suggested thinking of a life-choices excuse to reduce negative reactions.

My IELTS overall band score is 8, in a range of lowest 0 to highest 9. The various components are: listening 8.5, reading 9, writing 7.5 and speaking 7.5. Except for a brief lapse in attention during the listening test, I found reading and listening tests easy. For the writing test, I found it slightly challenging as speed is not my forte and I am losing touch with the occasionally-used vocabulary. I had fun during the speaking test. However, I wasn't sure if my casual conversational style -- frequent use of partial phrases instead of full sentences -- would affect my results. Thus, I am quite pleased with my results. [Note: "Quite" here refers to "very", as in the British usage of the word.]

Another thing is that my IELTS results contrast with the evaluations of my English standard by an ex-nursing lecturer [Note: different person from the above ex-lecturer] who graded my nursing essays. She commented that I have a poor standard of English. Granted that in a bad emotional state, I wrote off-topic in my first essay submission to her. However, my subsequent essays were also judged to be poor to average by her. My self-justifying rationale is that my writing style is not what she likes. My writing is heavily influenced by the traditional English style of long descriptive sentences. E.g. Agatha Christie's mystery fiction. In addition, she prefers the use of simple generic vocabulary, whereas I was trained to use precise vocabulary, where available, over generic words. Thus, I gave up expecting good grades on essays submitted to her. My hypothesis was that like the evaluation of Art, the evaluation of English is very subjective unless one is professionally trained as evaluators in that field. Considering that the only preparation I did was to tune-in to BBC radio (British Broadcasting Corporation) regularly one week before the IELTS test, I consider the IELTS evaluation indicative of my usual standard of English. Perhaps this is just my self-serving bias.

3 months old

Back to work today after a 1+ week long break.

The ward manager (NO) was in-charge, doing double shift today. SEN L and I were taking teams, HCA K and SEN MY were runners for each team respectively. Was assigned the team with the single rooms (far from the nursing station), with 8 patients in relatively stable condition today. However, there was incessant interruptions to deal with issues from the patients in the other team and the adjoining ward.

I noticed a difference in the attitudes of SEN L and HCA K compared with 1 month ago.

• SEN MY still habitually refuses to do whatever she considers as not her work. As a result, HCA K gets annoyed with her. E.g. SEN MY expects others to cover her duties while she is taking her break, but she refused (or at least drags her feet) when it comes to covering for others while they are having their breaks.
• For the past few weeks before I went on leave, HCA K has been half-joking about SEN L being the NO's favourite, and that she has never been seen SEN L being scolded by the NO. Putting SEN L and HCA K together in a team results in some tension.
• In addition for the couple of weeks before I went on leave, SEN L had been mentioning about learning another skill to change her line. For some reason, SEN L was rather bo-chap today, even had to have me covering some of her work while she has already completed her taped report and taken her dinner (when I had not even had the time for either). Perhaps working in the front team with the NO on her back got to her nerves. I do not know.

What I have observed is that ward interpersonal dynamics are a challenge to manage.