A 68 year old man was seen in an emergency department of a hospital for chest discomfort. By the time he reached the hospital, he was asymptomatic with no evidence of any ischaemic changes on ECG. However, he was noted to have a glucometer reading of 20 mmol/L. He is a known diabetic on medications. Thus, he was admitted. Before admission, a branulla/venofix was inserted to his left wrist.
He was admitted to the medical ward and discharged 3 days later. He presented to me yesterday ( 10 days later) with this:
According to the patient, the swelling started immediately after he was admitted but no one bothered to rectify the problem. In fact, before he was discharged, he spiked a fever but he was discharged the same day after removing the branulla. NO antibiotics were given.
He is now having florid cellulitis with pus collection/discharge and ultrasound showed an abscess collection. Despite 2 courses of antibiotics by GP, he did not get better.
The case above is just to illustrate how a simple procedure like this can lead to complications. Since I was a houseman I was trained to look at the branulla site during every round. When I did my housemanship, my consultant was a Haematology trainee and most of her patients were on chemotherapy ( 1 cubicle in the ward was allocated for chemo patients). I was taking care of her patients for almost 3 months as she refused to let me change ward! I had to beg her to let me go to another ward for the last month of my medical posting.
Since haematolgist are very particular about infection, I was trained to look out for any possible hospital acquired infection in all the patients. Since then, I have this habit of looking at the branulla in all my patients. In fact, the nurse in charge will get a earful if she fails to recognise phlebitis and I had always made sure my housemen are also trained to look at it as well.
Unfortunately, many of the younger doctors/nurses nowadays does not seem to be bothered with this. The above complication is what you get when you do not identify early phlebitis and remove the branulla immediately. If the branulla has been removed on the day of the swelling, he would not have developed this abscess. In fact, even antibiotics may not be necessary.
So, I hope the younger doctors will learn why they wanted to become a doctor in the first place: to comfort always, to treat sometimes and to do NO harm. It is your duty to make sure the patient walks out of the hospital better than how he came into the hospital. I use to tell my housemen and medical officers that if a patients walks into the hospital, he should not be going out on a wheelchair or 6ft underground!
For the case above, I am beginning to wonder whether he has MRSA infection as he did not respond to 2 courses of antibiotics by GP!
Pagalavan's Avatar 
Wondering how come the patient manage to escape so many barriers like HO, MO and specialist without been noticed and discharged?
It happens!
ive seen plenty of those housemen negligence when treating the patients.
they come to the patient, never greet and just tell what they wanna do to them, and flipping the case notes at the bedside n write it at their notebook, as if like the patient is like their guinea pig.
ive seen one patient – the housemen was trying to insert brandula to him. she was having trouble putting it.. it was painful isnt it? then the patient was feeling the pain n he tried to withdraw his hand towards himself.
guess what the housemen did? she shouted at him ‘ jangan gerak la kalau gerak macam mana i nak letak?’
another patient, another housemen insterted the brandula. it came off, n the patient was bleeding profusely.. the whole bed linen was full of blood.
I was a house officer under Dr Pagal when he was still in government service. He has always been very supportive in the training of young doctors, esp the ‘fresh’ house officers.
its always easy to point our fingers at house officers when things go wrong. to be fair to them, they are just a bunch of ‘innocent’ and inexperienced doctors. though i do agree that the quality of recent years have gone down the drain, there are still some good ones around.
what worries me more is the quality of medical officer/senior doctors/consultants remaining in the service to guide this young doctors… if we don’t retain good senior doctors in the service, then we will only have the blind leading the blind!
Last time when I was a HO, we used to be told, HO are the bottom of food chain, you are even more inferior to the SN. So anything that goes wrong, you are the first to be blamed. Nowadays, I beg to differ. HO seems to have moved up the food chain, whereas the specialists/consultants have descended down. Anything goes wrong, they will be sent to the audit to clarify mistake of their surbodinates.
I do agree that seniors are there to supervise their juniors. But stop blaming the senioirs solely when things go wrong. Have anyone actually wonder seniors doctors (ie.specialists and consultants( have many more commitments. They not only cover 1 ward, but many wards. Have to be oncall and rush down to the emergency dept to see urgent cases when called upon. Have to run clinics. Worst, have to attend various meetings, organised by the administrators for achievement of KPI, etc….
If everyone plays their roles well, ie. professor/lecturers in medic school taught the students well, and screened out those not-so-fit students to become doctors; the MMC bite the bullet and disallowed those from unrecognised university or suspicious university grads from working and endangering our patients; the KKM do more to retain seniors in the service (eg. salary, working environment, career advancement, stop those unnecessary works which look good on paper but channel the effort towards improvement of clinical works); MO instead of dissappearing, supervise their HO; specialist/consultants keep an eye on those working with them; I guess such problems can be minimised. Only then specialists/consultants will not be overworked, not covering many wards, not holding many non-clinical portfolios; then they can spend quality times with their juniors, doing what they know best….clinical works and teaching.
Dr. Paga has spoken on the glut on HO/MO, that will start to be apparent in 2015, but will it ever occur in the rank of specialists/consultants? I don’t think so, cause every month we hearing seniors leaving the service, not because of salary solely, not because of career advancement solely; but because of frustrations with the service. Right from the administrators to the attendants, everyone couldn’t be bothered with the improvements these seniors want to implement for the benefit of patients. So when you can’t change the system, either you join them or you leave. I think many chose the latter.
>> “So when you can’t change the system, either you join them or you leave. I think many chose the latter.” <<
And many do.
The major sickness afflicting all levels of our government related administration in Bolehland is the paternalistic arrogance that "if you don't like it, feel free to leave".
This arrogance stems from their unshakeable belief that the people they mistreat have no better options available to them. How wrong they are.
The best talents will always have options open to them. In fact, they should thank their arrogant administrators for dishing out the final straw that drives them to leave, and therefore avail themselves of much better opportunities.
We are now inhabitants of the global village. Any employer that does not know how to value its greatest talent pool will eventually be left with nothing but mediocrity.
Thanks for the comment leow. Yes, you are right: blind leading the blind.
May be having a Visual Infusion Phlebitis (VIP) score form in the ward to assist with the monitoring of cannula/branulla sites for both nurses and HO will be helpful! =)
houseman…consultants..or anyone
remember lesson 1: FIRST DO NO HARM
Lesson 2: see before you touch
lesson 3: Touch when you know what you should feel
lesson 4: Treat your patient as you would treat yourself
25 yrear old practising consultant to any sick patient
@anoy:Is it forbidden to ask the patient not to move during painful procedures,like ABG or IV catheter insertion?
Could it be that the patient is one of the first victims of the new “shift system”, and was “disowned”?
possible but it has happened before as well
But will happen more often with the new shift system i guess
just wondering…is canulla called a branulla? is venofix the brand name and is it similar to venflon?
yes
It is really common to have phlebitis nowadays.. Reason? It’s not just HO. Branula insertion can be bd or tds, because IV antibiotics such as IV cloxacillin are given directly through the branula. And not even flushed if there is no accompanying IV drip. If you start giving instructions to flush it with saline, they will give the saline first, then IV antibiotics thru the branula. And we have the happy occasions of “Doktor, venofix required”.
Vein care should be the responsibility of everyone.
Yes, vein care should be the responsibility of everyone but someone has to take the lead and makesure that things are done properly. That is missing!