ACLS part 2

Since I wrote ACLS part 1 that I took the other day, perhaps I should write about the one that I retook. :)

I went to IMU that day, quite early to find out what time it will be hold and to attend my selective in the hospital that started on the same day. :)

It was a fruitful day, to be able to see my close friends after so long and to be independant (attend forensic apartment by myself) and to attend ACLS with confidence. :)

So this is the question that I got.

Patient came in with breathlessness, chest pain, suddenly went unconscious.

First thing CHECK responsiveness.
patient is not responding
Call for help.
Check pulse. (yay, I remembered!)
Pulse present.
So I said get my stuff to assist ABC by using oxygen mask. set up IV lines, get BP reading, and cardiac monitoring. BP was low. forgot how much..
The cardiac monitor shows 2nd degree type 2 heart block. (morbitz type 2)

I got it correct. :)
and so I said (to be safe) check for perfusion status. But if it's already type 2, the right thing is to start TCP right away. So anyway, perfusion status is poor, with all the symptoms going on and low BP, so I prepare for TCP.
while awaiting TCP, I'll start drug:
atropine 0.5mg every 3 to 5 min

then here's what I made wrong, forgot to check the effect. SO must check rhymtm again and pulse and BP.
it doesn't help
add in epinephrine 2-10microgram/min
or dopamine 2-10microgram/kg per min

check rhytm, the rhtyhm changed to ... shocking.. XD Ventricular tachycardia. (VT)
check pulse
no pulse
start CPR right away, prepare defib.
CPR for 5 cycles. no change, shock patient. 200 (for biphasic) and 360J for monophasic
and then resume CPR, check pulse and rhtyhm

pulse resume
rhymthm changed back to second degree heart block type 2

TCP was ready...
so leave to the professionals for that..
End of story..

that's what I got. :)
hope I pass this. :)

EDITED: passeddd! yay!

headache

It feels like the temple of my head is squeezing everybit into my mind.

It is aching pain.. 

Results from getting all tensed up for the ACLS I"m taking on Monday. 

Well, why tense up..? cause it's the second time I'm taking and I don't want to fail it again. 

I think I give lots of 'what if' situations when I'm studying the algorithm, and ends up with ' what if she (examiner) came up this... oh no.. what should I do?' questions. 

I know where I screwed up in last exam. When my friends were taking the exam, I can answer the questions that the lecturer asked them in my heart. I know where I should be going. but when it reaches me... 

I panicked, kept my mind focused on the second part of 'getting the bp set, oxygen mask, iv lines' cause I scared that I might forget. THAT leads me to forget the straight away thing after checking responsiveness and call for help is check pulse.. 

A total wrong right from the start and I lose all the confidence.  

she says no pulse. 

start cpr immediately.
get defib, give oxygen bag mask, set up iv lines, and cardiac monitoring. This is where it should come.
the cardiac monitor shows this:

the second part I get wrong, is I didn't figure out it's a PEA activity. 

the screen shows sinus tachycardia. 

the examiner looked at me saying "are you sure?" when I said 'shock' patient.. then I took a lot at the screen again.. I know I'm not wrong. It shows "sinus tachy." THEN after like 5 seconds of looking, the chart pop into my mind. only VT and VF is shockable. I was like.. 'OH HELL!!' and it's a 'pulseless' and so it's a PEA. should not shock the patient! this is non-shockable rhtyhm. 

continue cpr for 5 cycles and then add in atropine 1mg iv every 3-5 min. 

check rhtyme and pulse.

then she continued saying no use. no use for two times and I repeated my answer with atropine two times.. 

so what should I do? 

yes, investigate the causes..

I listed out the 5T and 6Hs. but took some time again listing cause I was panicking already.. 

I was all 'crap crap' 

then she asked me what's the most possible cause in this patient. 

pt is young asthmatic. 

I said "hypoxia"

what else? 

eh... 

what others in young asthmatic? 

so. then after I paused for awhile i decided to give it a shot since it's the only answer in my mind, so I said "tension pneumothorax"

correct..

so what should I do? 

needle decompression. 

landmarks?

second intercostal space, midclavicular line. 

and you'll hear a hiss sound after poking

then what do you do?

check rhtyhm and assess vital signs. 

take x ray

patient returned normal

pulse present.

yay.. then..? 

what did you do just now?

I think think back.. needle decompression... 

insert chest tube! 

take x ray. 

asssess vital signs. 

patient returned normal

monitor. 

post resuscitation care.


so the most important thing for me is not to panic..  and have confidence. oh well.. I got the most difficult twisted case.

I studied hard for this time.
I must pass this time.
I can be a leader when I want.

best wishes for me. 

Medic, I can't hold on?

Once one get into medical field, you'd surely be asked, 'how's medicine? Is it hard?"
Some people might nod, some people might say 'it's okay'.
I used both responses.
To different people.
At different time.

I used to say to people.
"No, I don't regret studying this." with a joking "not yet." added to the end of that sentence to make people think that I'm not egoism.
But now...

I have different thoughts.

Recently, this year,
I'm thinking more and more to myself, asking myself, do I regret this?

The answer, out of 99% is 'yes'.
Most of the time, I have this thought of 'giving up'.
But all the time, I rejected the 'pulling myself out' from this mess idea, because I still wished to think that I can do this.
I still wished to prove to myself that my future life is not as bad as what I thought...

Sometimes, I wished I had chosen a different thing.
I wished I had been more firm and more AWARE of what is happening around me.

But I was not.

And I doubted if I am out of it now.

Patients and doctors BS

HIV- a short form of human immunodeficiency virus that causes AIDS. HIV is a virus, while AIDS is a disease. Having AIDS doesn't mean that you're dying soon but it will lead you to death. HIV destroys your immune systems, specifically your CD4+ killer cells. Our normal CD4 level are about 500 to 1000 cells per µL or more but in these patients their level dropped down to lower than 500. When this happened, they are prone to infections. Their immunity became so poor that even a small flu can kill them.
HIV transmission are through three routes, 1. unprotected sexual intercourse, 2. blood transfusion/sharing needle, 3. vertical route (mother to child in pregnancy)
HIV positive patients are able to lead a normal life is they follow the precautions and medications prescribed by doctor. They needed to take medications twice a day with a period of 12 hours in between, which means if they take it at 8am, they will take another one at 8pm. They have their own medication time; it differs from one individual to another.
The time for medication must follow the specific time they had set out since the first time. It is crucial for them to follow the medication on time everyday.

They shouldn't miss even a minute in taking them. Even a delay of ten minutes will cause the virus to develop resistances towards that medication, causing the virus to replicate. When that happened, the medication will eventually become ineffective and that's when you have to go on to the second line of medication. Second line of medication usually consists of more side effects, a much more severe one that will damage your organs. There is no cure for HIV. And there is not much drugs/medicine available for anti-viral, especially HIV. But they are able to lead a normal life if they managed it well. Some are able to live through seven to ten years.

For today's lecture, we were taught of how to break this kind of bad news to the patients. The doctor said that eventually, we will have to deal with this kind of things, and one day, the MO will just ask you to tell the patients about this bad news. I can kind of imagine it myself, no experience, with the report on my hands, walking and facing the patients. You'll feel nervous. But at the same time, you really dont want to just crush the patients' and family's hope with that 'I'm sorry to tell you that blah blahblah.' We'll see lots of death later in our life. I heard from the doctor telling about how a patient jumped down from the hospital 7th floor after hearing his report. I heard about how a orang asli (who were used to living in the jungle) who jumped down from the second floor of the hospital because he did not know that he was in a building. I watched a real video about how the orang asli in my country refused treatments in a hospital because of his belief that he might die in the hospital and a past experience that a friend of him died in the hospital after going there. I heard about how a patient tell a doctor about a secret that other people might not know, that he/she did not even dare to tell other people about.

Apart from all the knowledge we must muster, we are told to have to learn how to deal with the patients' feelings etc. We must try to give them some spaces of hopes and supports. but sometimes, there are limit that we would reach. Yes, doctors are human too. Just like you and me. Sometimes, you just have to be mechanical/not to be too attached to the patient. Else, you'd lead a sad life.

Elective in General Hospital Sibu

this is me at A & E, got nothing to do, posing. XD hey, this is my first photo taken in labcoat. wohoo. though, the labcoat was borrowed from my friend's father's shop. a little too big for me. amniotic fluid, this color signified that the baby's in fetus distress. (If I'm not wrong)

cute, isn't it?

Alright, I'm finally finished with my report. Later in the afternoon, I'm going to meet my new mentor to pass it up. What's written in the report were was happened during the elective, but not everything was recorded in it. haha.

It was fun, truly. I get to know new friend, a crazy friend. Lol... other than that, I got to witness many cases, patients, procedures. We were even offered to do the IV drip. The time we stayed was from monday to friday, from 8 till 5. But because I don't have the transportation, I had to stay until 6/7 for the first week. Lots of Unimas students who's also on elective come into the A & E department only after 5. The nurses said that there were lots more of patients and busier after 5.
I also see that how the doctors there were mostly MO and HO. Due to the fact that they are on call overnight at that department, they don't really have the enthusiasm to teach us. (not all, Dr Jesse was the best we met.)

At the O &G department, we got to witness baby birth. Aw... the baby was so cute. Really, I saw countless of baby delivered over the week. Some mothers took lots of time but some fast. I saw one of them, who took like... one hour for the delivery. She was an obese chinese. And she really took a lot of effort and was constantly at the point of giving up during the process. Okay, this is the bad part. At first, the nurses were advising and encouraging her nicely to push, teaching her the correct technique. But the mother couldn't get the correct method, and results in the baby couldn't reach the birth canal after half an hour. In the end, the nurses were becoming more impatient. I can't blame them because what they said was true. The baby was stuck in there for too long, no oxygen, it's bad for the health of the baby. The mother just had to suffer for a few minute, but if it delays, the baby might suffer mental problem for the rest of her life. Yes, it's a she. In the end, she managed to do it. luckily, phew.

on a side note, I kind of understand why M'sia government hospital lacked doctors. Look at their working schedule. Their working time for a HO were from 7 in the morning until 11/12 at night for the first 10 days at the new department. and then, the on call time will depend on number of people available in that department. Most of the things were left for the HO to do, and during on call, if there's emergency especially at the medical ward, I heard that it's the HO that'll be wakened up first. The HO has to solve the problem by him/herself before you can call up the MO. Ma, I guess, I'll worry about these later in my life.