The last time when I wrote the Part 3 of this topic, some of the commentators were saying that I am only talking about the problems/mismanagement of the government sector and not much about the problems in the private sector. Well, I had written about the problems caused by General Practitioners and soon I will be writing about private hospitals in more detail. The issue that I am trying to bring up is not whether a proper diagnosis is made or not. Most of the time, if the attitude of the doctors, especially the frontliners are good, simple diagnosis like what I had mentioned before would not have been missed. It all boils down to attitude. If you become a doctor just to get a paid job and not with the interest of the patients at heart, then you might as well leave the job! In this part, probably my last part, I will expose few more simple but dangerous errors that was made by the frontline doctors.
A 36-year-old lady had abruptio placenta and an emergency LSCS was done in a government hospital. Unfortunately she lost the baby (IUD). She was discharged 3 days later. 3 days after discharge, she presented with fever, diarrhoea and lower abdominal pain. She was brought to the A&E department of the same hospital 2 days later. The doctor in the A&E department just asked her a few questions and discharged her with some medications ( treated as a simple AGE). The doctor did not even touch the patient!! The next day she went back to her GP who referred her to me. On arrival she was toxic looking, febrile with tender guarded lower abdomen. She was immediately referred to our O&G consultant who diagnosed her to have huge rectus sheath hematoma, infected. She recovered well with antibiotics and conservative management.
A 20-year-old Vietnamese lady was admitted to a general hospital with LIF pain of 2 days duration. She was admitted the night before to the Gynae ward but discharged the next morning! It seems only a medical officer saw the patient the next morning and discharged her with TCA 6 weeks while she was still in pain. She was immediately brought to our hospital. An ultrasound showed huge left Ovarian cyst which was already leaking. An urgent laparoscopic surgery was done.
A 30-year-old lady was referred by GP to a government hospital’s gynae clinic to rule out ectopic pregnancy. She had LIF pain with positive UPT. The patient waited at the clinic from morning to about 2pm before seeing a doctor. She was not sure who saw her but she was told that it is all fine and asked to come back in 6 weeks. She went back to her GP who referred her to my hospital. Ultrasound by our Consultant showed a left ectopic pregnancy which was already leaking. A similar case happened few months ago where the patient collapsed at home just the day after she was seen in gynae clinic to rule out ectopic. An urgent laporotomy done at the same hospital for ruptured ectopic pregnancy!
In my Part 2 and 3 , I had mentioned that one of the problems in government hospitals is the lack of proper supervision from good senior consultants. These situations seem to be getting worst day by day. This coupled with poor attitude of the junior doctors is only making the situation worst. If you look at the 3 cases above, even a good medical student knows that something is not right with these patients. Come on, a patient who just had LSCS 3 days ago comes to you with fever, diarrhoea and lower abdo pain? I am sure even a medical student should be able to think of the causes even before you put your hand on the patient. The 2nd and 3rd case above also demonstrates that some doctors are not taking their job seriously. They seem not to be interested in their patients and just wants to keep their load down or shall I say ” don’t want more workload and headache”!
As a doctor, we should always be very suspicious of anything that a patient complains. I use to tell my Monash students before that we should work like a police officer who is investigating a crime. A detail history and a good physical examination will give you a diagnosis almost 80% of the time. A high index of suspicion is needed to make any serious diagnosis. If not, you are of no difference compared to a medical assistant or nurse!!
Pagalavan's Avatar 
The scenarios you described have happened and definitely not only once. However mentioning only incidents in the govt hospitals and omitting the issues in the private sector provides an unbalanced portrayal of the Malaysian health system which is admittedly in a bloody mess.
As I said, I will come to private hospitals later. I have written about GPs mess and soon private hospitals mess will be written.
Sorry, was confused by ur mention at the end of paragraph of this being the ‘last part’.
I will talk about private hospitals in my “Malaysian Healthcare system for the dummies Part 4” series.
The problem is many of our doctors think they are above the law.
If ethics don’t push one to move away from complacency and be more meticulous, maybe the law will.
If only lawyers start to pursue doctors, like in the western countries, maybe you will see less mortality and morbidity in the hospitals.
Maybe, maybe not. A more legalistic environment, eg US, has not reduced mortality or morbidity in hospitals. It has increased costs without a corresponding improvement of results.
A major difference of medicine in comparison with other fields/sciences, is that it is still an inexact science dealing with the vagaries of the human body. Mortality and morbidity can, and will, happen even when all the ‘right’ things are done. In addition, there are usually several ways of managing a particular condition. Therefore it is not surprising that the justice system has failed to grasp the intricacies of medical events. Most of the time things are not as clear cut as described above.
I read with interest your blog post regarding the simple but dangerous errors that was made by the frontline doctors. Indeed, not only frontline doctors make mistakes, but occasionally the more senior ones too.
I still remember an incident which happened approximately 2 years ago when I was a HO in O&G. I was on call on that fateful day. This young 29 year old pregnant lady in her first trimester was admitted to the gynae ward in the late afternoon for lower abdominal pain and PV bleeding.
I was bleeped by the gynae ward nurse in the evening regarding this particular patient who appeared unwell which she thought looked rather unwell. I was also informed by the staff nurse that the ward MO (MO #1) and ward specialist (Specialist #1) have reviewed her before 5pm and an viable intrauterine pregnancy was confirmed by ultrasound which was performed by specialist#1.
I eventually went up to see her after setting some stuff in other wards. She was pale as a ghost and was clenching her lower abdomen in severe pain. I quickly went through her notes and noted the ‘viable intrauterine pregnancy’ with the impression of ‘threathened miscarriage’ documented and the ultrasound was performed by the said specialist.
At that time, her BP was stable but lowish and she was quite tachycardic. Her abdomen was tender and the subsequent VE revealed a closed OS, cervical tenderness and bulging POD. After examination, I immediately informed my MO on call (MO#2) who arrived within 5 mins. She performed the same examination and thought it could be a ruptured ectopic pregnancy. I showed her the medical notes and she noted the results of the earlier ultrasound.
However, to cut things short, the patient had another ultrasound by the oncall specialist (Specialist #2) ( who was mercifully doing her on call rounds in the labour room at that particular time) which confirmed a ruptured ectopic pregnancy. The patient’s Hb dropped to 4g/dL (Hb on admission was approximately 8g/dL). She was whisked off at once for an emergency minilaparotomy and she had approximately 8 pints (or more) of GXM blood transfused. Fortunately she survived.
The above case will forever be etched in my mind for numerous reasons. So many things could have gone wrong in many ways. I fret to think of what could have happen if I (or my on call MO#2) were to arrive late. Nevertheless, this incident became an issue in the monthly morbidity and mortality meeting. I would like to point out that the incident was blamed on the ward MO (MO#1) but not the ward specialist (Specialist#2) who actually performed the first ultrasound and confirmed the ‘intrauterine pregnancy’. Trust me, I bear no malice for any of the MOs or specialists involved in the above incident.
The above incident is just an example and probably has gone wayward. The point is that more senior doctors sometimes do make mistakes. And also, when they do make mistakes, the junior doctors are blamed for it. I have been blamed for certain mistakes (fortunately nothing life threatening) done by MOs and specialists from different departments.
Please note that I have also done my fair share of mistakes when I was a HO but most of the time, we, as junior doctors were left on our own to do things by ourselves. Nowadays, with the burgeoning amount of HOs in government hospitals, proper supervision from good senior consultants/specialists would certainly be difficult.
Yes, totally agreed. I know of some so called specialist who are not up to par. I know surgeons who can’t do simple surgeries and yet got no insight on their mistakes and what they have done to the patients. I will talk more about this when I start writing about private hospitals.
Yes, in government hospitals, all mistakes are dumped to the MO! Only when a lawyer’s letter comes, the specialist has to answer! If not it will be swept under the carpet.
http://pagalavan.com
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doc,
what does TCA and UPT means?
doc,
what does TCA and UPT meanss?
TCA: to come again
UPT: urine pregnancy test
another sad day in the medical profession.
http://chronicle.com/article/Corruption-in-Russian-Medical/128200/
in relation to this article n prev one, yes, now a days, pt op to go to governmentt polyclinics for treatment as they notice the treatment n follow up at GPs were inadequate plus the treatment are way expensive. at KK (klinik kesihatan) we received many pts coming in for continuation of care from GPs as they could not afford the treatment and that no proper f’up done other than just continuing their medicine. sometimes, pt came in without any knowlegde of their medicine, when we asked back the GP to write a proper letter to inform us the current treatment, the GPs letter seems to be illegible, and even doses of medicine not written up properly (as if like he is just too busy to write/ fed up, not sincere enough to refer that pt(..some dont even write a letter but only scribble something on a piece of rough paper) which then put us in difficult situation most of the time.
when u say govt clinics much better now a days, but except the fact that the clinics are always overcrowded..that is so much true. as for me, i just recently started working at KK and the load is just too much. we always try our best to treat patients accordingly but time has always been the issue as too many patients flooded the clinic. a single pt may come in with mulltiple problems, then obscured with other ordinary patients who just come in for URTI/ AGE but honestly they are perfectly well but acting as if they are extremely sick but the fact that they only wanting for MCs. too many cry wolfs gave us a lot of impression about false patients which may sometimes causes us to miss those really n truly sick patients. there are pts who simply force you to write a letter as they wanted to be referred to specialist even though for simple treatable diseases (even after a long explaination)
as a doctor, i not only want to treat my pt but i want to educate them. when i see asthma patients, the reasons behind their uncontrolled asthma was not really because of the choices of medicine, but because of compliancy and poor education regarding their illness and medications like reliever, preventer. i notice, if i spend extra time to explain to them, it improves compliancy hence improving their diseases. but where is the time to do so when you are basically fighting against time….(patients also now a days complaint a lot regarding long waiting hours…i mean, what can we do… if we just smart tag our patients, they think we are nuisance and not thorough enough, but if we spend more time to probe the problems, they say we are asking too much and other waiting patients are just too impatient to wait for their turns.
i dont mind sometimes working off hours for really needed patients (not for those who cry wolfs just came in for MCs) however, working straight long hours without rest will affect our energy, mood and quality of treatment. nevertheless, we need time to rest to clear our brains as seeing too many patients in short period can be really draining and exhausting. most of my colleague and myself find it difficult to think clearly by the time it reaches noon…i calculated, we would see patients average of 4.8 minutes per patients.. so…. we can calculate ourselves…what more can we do in less than 5 minutes, to get history, examination, investigation, referals if needed (plus if you have language barrier patients, then it will be a big challenge)
is there any way that we can do to improve this condition, to help both health practioners and patients…
Sorry to post something off topic. But this is an appeal to readers ( doctors etc) of this blog in the whole country to help look out for this missing boys
http://www.facebook.com/PleaseHelpUsToFindNayatiMoodliar