An Interesting Chest X-Ray

A busy ICU

ok, first photo is of some of busy people in Surgical ICU. Note our hardworking nurses, Dr. Izzati & Dr. Nurul (surgical).

Anyway, the Chest Xray I've got here is of a 50 plus year old lady who has had a prosthetic metallic mitral valve replacement. She's basically come in with severe breathless. A&E saw this Chest Xray and thought she was in severe pulmonary oedema, gave her frusemide and intubated her & admitted to SICU.

On initial history taking from her relatives, she has been unwell for the past 5 months, easily irritated, not eating well, having chronic dry cough WITH on average once weekly haemoptysis. She has no previous history or contact of pulmonary TB. She normally takes warfarin for her metallic mitral valve replacement.

What's her INR or clotting profile ?

It was so high, it was beyond the scale readable to the machine !! & yes, she was having pulmonary haemorrhage visible in the endotracheal tube.

She was very unwell & went into Acute Respiratory Distress Syndrome (ARDS) and we managed her to improve her lungs or rather her ventilation after a couple of days. Magic, isn't it ?

At this point, it has to be Tuberculosis until proven otherwise. We sent 3 sputum samples and so far negative, and the PCR AFB is negative. We note that she has a hard enlargened left supraclavicular node.

Her ventilation requirements have improved and right now she is awake, and we are continuing to keep her on heparin infusion for her MVR.

What's our working diagnosis....

Could this be Wegner's granulomatosis, SLE, some other vasculitis, malignancy ?

We're still waiting for the autoimmune screen / profile to come back and she's not stable enough for a CT everything (thorax, abdomen, pelvis)

If the autoimmune screen and the CT comes back negative, what else could it be ?
Was it a warfarin overdose of the massive kind ?

Will let you know when we have the answers.

Ero Sennin

The Temburong One Week Duty

I’m back! Phew… just got back from Temburong duty last week and still recovering haha… not from the travelling but from catching up with my post-poned outpatient appointments in RIPAS. I thought I might write something about Temburong Hospital for the benefit of future doctors who will be posted there, unfortunately I could not dig out much information from the web, so had to do a bit of research. The information provided below is based on the 2007 Temburong hospital statistics and my observation during my one-week stay there. Enjoy…

Introduction:

The Pengiran Isteri Hajah Mariam Temburong (PIHM) Hospital is one of the smallest district general hospitals in Brunei Darussalam and supposedly houses no more than 50 beds with two main wards (Male + Children & Female), 1 isolation ward (converted into doctors on-call room and a multi-function area) and a newly furbished day-care renal dialysis ward. The hospital provides general medical services to a population of around 9,000 people in its district.

On average Temburong hospital sees around 123.5 patients per day in it’s Out patient Department (General & Specialists). The ratio of doctors to population in Temburong is approximately 1: 3000 with only 3 permanent doctors to serve the whole district.

Amongst the services that it is able to provide includes Outpatient & Inpatient services, Outpatient specialists clinics, Pharmacy & dispensary, X-ray, Accident & Emergency, Dental Care, Physiotherapy, Laboratory services and until recently a Day care Dialysis centre for 11 of it’s patients requiring Haemodialysis. 3 permanent medical officers have been dedicated to this hospital; one of them is a female doctor with experience in Obstetrics & Gynaecology. There are no local doctors posted permanently here as yet.

Doctors’ duties in Temburong

During a regular working day, the doctor who has been on-call for 24 hours the night before will be responsible to do a ward round in the morning before going Off Duty for the rest of the day. This leaves the other 2 doctors to run the general outpatient clinic, which regularly sees around 85 patients a day, and admits around 2-3 patients per day during their on-call period. Majority of the cases they see in clinic are mainly cases you would see in a typical General Practice, and for those requiring admission to hospital 70% are medically related, 13.3% Paediatrics, 11.8% Obstetrics & Gynaecology and only 4.7% Surgically related.

Since March 2008 the Department of Medical Services through RIPAS Hospital initiated a new move to support the medical services in Temburong. It offers a separate paediatric service every working day and sends one local medical officer from RIPAS hospital to spend 1 week working in PIHM Temburong Hospital. These extra doctors were incorporated into the on-call rota and will also be doing clinic sessions during their time in the hospital.

With the new initiative Temburong Hospital Medical Service can now operate with a 1 in 5 rota and relieves some of the burden in managing paediatric cases in the outpatient. However if a paediatrician is doing the on-call, there will be no next day paediatric cover, and if a RIPAS junior medical officer is on-call, there should be a senior person to be 2nd on call as well.



After completing a week’s duty in Temburong hospital, several observations has been made and are as follows:

1) The majority of the cases seen in the outpatient are very much cases you will see in a general practice.
E.g. Cough & Cold, Headache, General Obstetrics & Gynaecology, Management of Diabetes & Hypertension.

2) Despite Paediatric Cover, there will be a day in the week when the Paediatric On Call will be off the next day, leaving you and the other doctor to deal with Paediatric Cases. (NB Paediatric admissions accounts for 13.3% of total admissions, the majority are medically related adult admissions).

3) Hesitation in management of Paediatric & Medical Emergencies for the surgeons and expecting a paediatrician/medic to handle an Adult trauma case is sometimes a concern.

4) Certain important drugs are not available and some were found to be out of date
E.g. Intravenous Phenytoin for management of prolonged seizure (not available during one of the RIPAS doctors week of duty)

5) There were actually only 27 beds available & functioning (instead of 50 beds)


6) The person On-Call is supposed to do the next day Ward Round alone. The problem arises because the M.O. is sometimes quite junior and inexperience in certain specialty cases like Gynaecology and Paediatrics, but most importantly there is an issue of Continuity of Care.

7) No CME Activity listed or planned for the month

However there are some positive feedbacks about this hospital service

1) There is 24 hour Lab Service & X-ray Service
2) All round pharmacy service
3) The On-Call Room is decent & Clean
4) Good food provided by the hospital (apparently this is not a common phenomenon, if you are nice to the nurses and attendants you might get it I guess)
5) Dr Elangovan, the Senior medical officer is very helpful
6) Small Hospital, therefore very friendly environment
7) Hospital Drivers are helpful in transporting us to wherever needed (very useful when you need to get some food for dinner when you are on-call)
8) Helicopter transportation is prompt and almost 24hrs weather permitting


Taking into consideration that it is a small and fairly remote hospital, it is quite impressive that this hospital is still able to provide a fairly good all round medical service.

Suprisingly although the doctors’ population ratio is huge (5x of Singapore) the in-patient activity only accounts for 2.85% of its total activity, the majority of which is medically related. Below are several issues that have been highlighted and followed by suggested recommendations.

Suggested Recommendations:

1) To incorporate Local General Practitioners into the Temburong Hospital Initiative. This would definitely be beneficial for the population of Temburong. Not only it fulfils the objective of exposing our local doctors to Temburong, but also the added benefit that the majority of illness treated are very familiar to their expertise.

2) Incorporate a period of 1-2 month compulsory placement to Temburong Hospital for all Basic Specialty Trainee (GPs, Surgeon’s and Medics) during their A&E placement, perhaps the last 2 months of their rotation in A&E. However a permanent senior A&E staff (specialist preferably) should be placed in Temburong to ensure training continues for the trainees.

3) To give a Special Allowances for any Health Staff working in remote areas, especially in Temburong district in this case. This is to act as an incentive and appreciate the hardship our staffs have to go through to work at remote places where many facilities are limited, and to recognize that some of them have to leave their family behind to work at these places. Not only will this promote good morale but may even attract health professionals to work in the rural community. The allowances should be awarded to temporary, visiting and permanent staffs at the particular hospital/health centre. The ministry of health can help ratify the rates, so that it is appropriate and always-in line with the standard of living.

4) Provide a simple guideline handbook to management of common Paediatric, Medical & Surgical outpatient & Emergencies.

5) The morning ward rounds should be led by the Temburong doctors every day, to ensure good continuity of care and provide a potential teaching session for the junior MOs. It also promotes the sense of teamwork amongst the Temburong doctors. A timetable should be set to do ward rounds and all MOs should make an effort to come to the ward rounds.

6) Regular update of important emergency drugs.

7) The more experienced visiting MOs can do teaching sessions during their week stay for the Temburong health professionals. This not only gives the opportunity for the permanent staff to score CME points, but also encourages a teaching & learning environment for every health professional.



Conclusion:

In general approximately 97% of the activities in Temburong Hospital are outpatient based and only 2.85% are inpatient work, of which the majority of the cases are medically related followed by O&G and paediatrics.

This raises two important issues, firstly is the proportion big enough to justify having a hospital in Temburong. If it is, then should we allocate more money to ensure that it has adequate expertise, facilities, drugs and equipments. Perhaps we can start by placing a A&E specialist there. I could suggest Dr I.... from RIPAS for a start. Alternatively if it’s not, then we should concentrate on making it a better equipped health centre, with the current facilities that it already has.

However I think the general picture is quite clear from the figures mentioned earlier (derived from Temburong Hospital Statistics 2007) Temburong hospital would benefit from having more generalist clinician around to support the population’s demand of healthcare provisions.

The one-week experience of working in Temburong Hospital has highlighted several issues on how we can better improve the quality of medical services to a small population district general hospital like Temburong. It has also given us the 1st hand experience of working in a hospital environment where facilities, manpower, and expertise are sometimes of limited supply.

The objective to expose our local doctors to our people is most probably a very good step forward not just enriching the doctor’s experience as an individual but also in identifying & highlighting issues for improving our medical services in the future as a whole. After all it is our own people that we are looking after and it is our Health Service that we want to better. My last comment would be, the choice of doctors sent could be better.. ahem.


Btw .. Don't forget to:

1) Be at the RIPAS Jetty by 7.00am for a boat to go to Temburong
2) See the Temburong CEO (Pg Sabtu) on your last day there and ask for the overnight form to claim for your allowances working there

More future Budding Specialists

Congratulations to our latest graduates Membership of the Royal College of Surgeons, Dr Amalinda Suyoi and Dr Amy Thien who recently sailed through (hehe... nda kan?)the final part of the gruelling 3 part MRCS exams at Edinburgh, UK. Both Miss Amalinda (graduated from Nottingham) and Miss Amy (graduated from Southampton) are currently working in the Department of General Surgery, RIPAS Hospital and will be pursuing Higher Specialty Training abroad in their respective field of interest.

Miss Amalinda Suyoi
MRCS (Edinburgh)

Miss Amy Thien
MRCS (Edinburgh)

Also who recently passed their membership exams are Dr Anas Naomi Hj Harun, Dr Yong Chee Kuang (I may get the spelling wrong) & Dr Dk Hjh Norzieda who have successfully completed their PACES of the Membership of the Royal College of Physician Exams last year. Dr Naomi & Norzieda are pursuing a career as Neurology Specialist and Dr Chee Kuang will be training to become an Endocrine Specialists in Singapore soon.

Dr Chee Kuang
MRCP (United Kingdom)

Dr Dk Hjh Norzieda
MRCP (United Kingdom)

So congratulations again to these guys for achieving their exams.. I was just thinking as I'm writing this article, the question why do we need to get our membership exams? Is it absolutely necessary? What is our motivation to achieve this exam? After all it is very very tough... and expensive! Doing the final part of MRCS exam can cost you easily $5,000 bnd! and usually it takes 2 to 3 try to pass.. Is there an alternative around it?

Hmmm....it's quite controversial issue since membership exams only apply to UK recognised Health Care System. What about Malaysia, USA, Australia... does having membership exam offer an advantage there?

In Brunei we have a scheme of service for the doctors and we follow a certain set of criterion advised by the Post Graduate Training Advisory Body. And most of these criterion has been set quite a while ago during our predecessor time. So within the guidelines already set we will see that MRCS, MRCP, MRCGP, MRCOG etc. exams play an important aspect in deciding that a doctor will be entitled to

1) Senior Medical Officer Post & Pay!

2) Ticket to Higher Specialty Training sponsored by the Government

It was one established method of deciding that a doctor has undergone sufficient amount of basic specialty training and are now ready for Higher Specialty Training with more responsibility.

But as training in medicine evolves, newer method of training & assessment has been developed and perhaps the days where Membership Exams will be over and replaced with SEAMLESS training like in Singapore where trainees are chosen right from the start of their post graduate period and undergo a 5 to 6 year period of training straight into a specialty.

In Malaysia the system is slightly different, where you can become a specialist after completing 4 years Masters programme in a particular specialty. What about USA, Germany, Australia, India, Pakistan.. ? I'm not sure how the training is like there but certainly the requirements for training will also be different.

As we get many doctors local and also our expatriate friends coming to work in Brunei, it's necessary that we are able to recognize these qualifications that they come back with and allocate them a post that they deserve and of course the correct pay. Something like a Specialist Accreditation Body like the one they have in Singapore is good start, comprising of local and invited oversea specialist with no conflict of interest, that can recognize and filter the right person for the right job.

Next topic we will discuss the pay of doctors in Brunei, the exact figures according to the current scheme of service according to your qualifications. If you are interested to find out the payscale of the doctors in Brunei from Medical Officer level up to specialist, please tune in next week, after I return from my 1 week duty in Temburong. We will also try to update on the latest with our ON-CALL Allowances...