Compliance

(I merged the stories of two non-compliant patients into one for convenience of story-telling. )

Mrs Chan is a 75-year-old lady, with a history of diabetes mellitus for eight years and developed nephropathy recently. Oral hypoglycemic drug failed to control her condition and the HbA1c level raised to 8.5% in the latest check up. The level stayed well above 8 throughout the years despite several increment in insulin dose. She claimed to be compliant to the injection.

In one follow-up the physician have a spot check of blood glucose by H'stix and it turned out to be 33.1 mmol/L. This necessitate an urgent admission since she was at the edge of developing hyperosmolar nonketotic coma. Normally she would have been put on sliding scale of insulin, however, the physician deliberately ordered regular insulin injection this time, in the same dose as prescribed for her home injection.

You know what, when the same dose of insulin was injected by the nurse but not Mrs Chan herself, her glucose level returned drastically to 6.9 mmol/L within six hours. If she had really injected the same dose of insulin for the past three months, her HbA1c should be around 6-7% only. (NEJM 310 (6):341–6.)

Everyone is innocent until proven otherwise. Is it due to drawing the wrong dose into the syringe, or due to her poor injection technique? She was referred to the diabetic nursing specialist for inspection of skills, and she was able to demonstrate a nice injection successfully.

The doctor further probed if she was really skipping the insulin, and she strongly denied it. She also refuted his argument by showing a "homework" of home H'stix blood glucose monitoring - all the values were well below 7 mmol/L.

The painstaking doctor consulted the chemical pathologist, if there is any condition that HbA1c can be falsely high. The reply was, "If the patient is not suffering from any haemolytic anaemia recently or having any haemoglobinopathy like sickle cell disease, there shouldn't be any errors."

She is a mother of two. I bet she must have taught her children to be honest. I also bet when we were young, we must have lied to our parents and teachers to conceal our fault or laziness, etc. Yes, we know that she is actually lying. But what can we do? I agree that this is a kind of rejuvenation, are you convinced?

Ethic

A Senior Medical Officer asked us not to post personal comment on the case notes, at most elaborate in blogs. Therefore, I write down this incidence here.

Today I came across a case note of a 35-year-old woman. A doctor from another specialty had attended a consultion ("consult") of her. You know what had the doctor put down? Here it is, quoted verbatim:

Height = 1.51 m, Weight = 94 kg
Very very very very very OBESE!!!

So immoral, so naive, and so pathetic.

I had delibrately counted the number of "very" in the case note, it was really five, I remembered it clearly, no cheat.

Brotherhood

Rocky is a 22-year-old young man with good past health, admitted to the orthopedic ward for a fractured right thumb during a football match two weeks ago. The pre-operative blood test incidentally revealed a normocytic normochromic anaemia with haemoglobin of 6.7 g/dL and creatinine of 450 umol/L. Kidneys on both sides were only 9.4 cm, which were small in his age. Urine analysis shown minimal proteinuria and therefore glomerular pathology was excluded. Congenital agenesis and post-renal cause were unlikely given his asymptomatic clinical features.

He was taken to the nephrologists and a Tenckhoff catheter was inserted last week for peritoneal dialysis (PD), in view of rapidly deteriorating renal function. His creatinine reached 1000 umol/L today and necessitated an urgent in-patient PD. The experts are now putting Medullary Cystic Disease (By the age of onset, probably type 2?) higher up in their list differential diagnosis. Further management includes renal biopsy and definitive treatment should be renal transplant.

There are four boys in Rocky's family and he is the third one. All three boys, with two known to be more determined, agreed to donate one of their kidneys to Rocky after knowing his situation. Words are cheap and life is not that simple. The brothers have to go through a chain of exhausting investigations before proceding to transplantation. Hopefully, we can find a kidney from them for Rocky.

But think back. If the kidney biopsy of Rocky comes back and Type 2 Medullary Cystic Disease is confirmed, the pre-transplantation tests for the brothers would become a chain of screening tests - the disease is autosomal dominant - all of them may carry the diseased allele. In the worse scenario, loads of dialysate and four kidneys, instead of one, will be needed.

It would be a disaster for this family.

On Government Service

It should spend no more than 3 minutes to print two pages in our hospital.

For the old-fashioned printing system in the library, we have to prepay for the printing quota by adding values into our student ID card. Then, we insert the card into a slot on the keyboard, key in our password, then we can print up to the prepaid amount, and have your sheets ready for collection at a printer less than 20 metres away from you.

For the newly implanted printing system in the computer labs, we can log into any computers with a well-known "password" written on the whiteboard. After ordering a print, a dialogue box will appear and ask you to input your desired password. Then, go to the multifunction printer and insert an octopus card. Key in the password you set a minute ago, and select which document to print, value will be deducted from the octopus card. That is, anyone who did not have student ID card can use the computer and printing system, provided that they have an octopus.

Yesterday, I went to the Central Library at Causeway Bay to print two pages. It was not my intention to test the public library service, but some necessary documents were found missing after I had crossed the harbour.

In order to use the computers there, "You have to fill in a form first. The next available session will be 20 minutes later." Okay. I spent my spare time with East and West by Chris Pattern. When the computer became available to me, I wonder if it was still using a 56K modem for Internet connection. To be fair, you may attribute the slowness to the vast number of library users. Fine.

Printing one B/W page costs me $1.5, which was the cost of printing 5 pages in the hospital. Well, everything is expensive on the Island, no only rent and electricity, but also ink and paper. I could still bear with it.

Things became more annoying when the nearest printer was two floors away. A dialogue box appeared on the screen "Printing Code: 00012345" I clicked "Okay". The first one disappeared and was replaced with another one "Please collect your print out with your printing code." Damn, why didn't you tell me these two pieces of information in a reverse order?

I was turned down by the staff at the information counter two stairs above while I tried to collect my printout without the code. "Oh, you have to print the document once again." Therefore, I enjoyed the speedy Internet service provided by the well furnished Central Library once more. This added oil to fire.

After the first lesson, I jot down the printing code immediately after ordering and hurried upstairs. What made things more complicated was "Well, you have to buy a printing card first. "the staff explained to me, "It costs $20. "

"I am printing two pages, i.e. $3 only, and now you ask me for $20? I only print once (and probably never in the foreseeable future after this incident) but I have to buy a card?" It was a dissatisfied voice.
"Well, you can return the card to the circulation counter at ground floor for remaining value."
I replied him with a frown.

"Input the printing code into this computer...Click "OK", Select the document, "OK"...yeh...you have another page to print right? Repeat the steps once again..."

"Is that okay?" I lost my patience.
"Before that, you need to take the receipt and..."
Annoyed enough, I stared at him with anger.
"...I will do that for you."

It took me nearly 40 minutes between entering the library and having two sheets in my hand. My document was, framed, with the printing code and time chop on top of it.

I was furious about the service provided by this lead public library in Hong Kong. The task was very simple - print two pages.

1. I have to fill in a form and wait for 20 minutes for a computer;
2. A 56K Internet service was provided;
   
3. Unclear instruction given by the system;
   
4. Miles away for a printer;
5. A card was needed for printing. Why not octopus?
   
6. Complex procedure to get my printout; and
   
7. Unauthorised modification of it!

Our university and hospital were rich. Yes. They were funded by taxpayers. I was curious. Isn't the public library funded by taxpayers too? May be I am just too demanding, but I will be one of the taxpayers in few years' time.

More stories

When I was putting my account summary, bills and letters into my newly bought shredder, pieces of "blue sheets" were found among the pile of confidential documents.

***

Judy was a 30-year-old unemployed lady, with known anorexia nervosa and BMI of 11, admitted for dizziness, abdominal pain, diarrhoea and vomiting. She was admitted 3 months ago for similar episode. After that, she had been referred to obstetrics and gynaecology for amenorrhoea and clinical psychology.

In the O & G clinic, the professor who saw her denied to take up her case - as her amenorrhoea was only secondary to anorexia nervosa, but not a primary gynaecological problem - they just cannot help.

For the clinical psychology part - Judy denied the psychologist. She claimed that she was sick, tired, having a headache, and many many whatsoever reasons, to keep the psychologist away since the third consultation. The perseverant psychologist tried to postpone the appointment for five times before giving up. Her incredible reasons were clearly documented by our staff.

May be she thinks that psychologists were not helpful? Anyway. This time she was admitted once again. Who to blame?

***

Winnie was a 18-year-old HKCEE candidate admitted for an increasing goitre for 3 months. It was associated with mild dysphagia of solid food, change of voice, palpitation and unintended weight loss of 4 kg over the last month. Her aunt had a history of thyroid disease and was treated with anti-thyroid drugs. Yes, this is Graves' disease.

After the evening round, a group of youngsters in school uniform was surrounding Winnie, brought her with lots of jokes and gifts - two Teddy bears at least. Being young in wards is so endearing and invidious. What a strong contrary to those who lying on the opposite beds, they were grey-haired ladies, without any visitors or gifts, but a heparin block.

This makes me think of babies that most of us love. Even they were helpless, crying loudly, pee-or-poo here or there, their parents look after them with love and care without any reserve. Only when the parents becomes old and babies grown up, those in their prime time could not hear the cry from Dada and Mama, and grumbles when they wet their diapers.

***

Timmy was a 28-year-old computer technician, with known ulcerative colitis for 5 years, clinically admitted for colonoscopy. This was the fifth colonoscopy follow up after the diagnosis. His Barium enema study made me remember him, and also the classical striking full-house radiological features of the disease as described in Lecture Notes on General Surgery. He also made me remember ulcerative colitis was slightly male predominance.

While Molly, a 23-year-old university student, who was suffering from Crohn's disease for 2 years, and presented with similar vague abdominal pain and chronic diarrhoea as Timmy, made me remember that it was slightly female predominance. From them, I remember the age of onset for inflammatory bowel diseases, of course.

Do learn medicine from wards, and correlate it to books. Once you have got the "index" patient, stick to s/he, then you will remember the disease - except microscopic appearance and molecular pathogenesis.

***

Mr. Ng was a 30-year-old fireman, admitted from A&E for neck injury in Dragon dancing a year ago. He was struck by his partner who jumped from poles behind him, causing immediate loss of motor and sensory function of bilateral lower limbs. Neurological functions of upper limbs were weaken but not lost. No other injuries were reported.

He was conscious throughout, with Glasgow Coma Scale of 15/15, and was mildly dyspnoeic. Physical examination for upper limbs reveals a power of 5/5 for shoulder movements, 3/5 for elbow and wrist, but 0/5 for finger bilaterally, with impaired sensation at fingertips. Tone and reflexes were normal. For lower limb the tone was increased, with hyperreflexia and total loss of power and sensation. Plantar reflex was upward. Clonus could be elicited.

Magnetic Resonance Imaging shows a fractured fifth cervical (C5) spine, and combine with his physical findings, he was diagnosed to have spinal cord injury at C5 with paraplegia. This means that he had to be bed-ridden. For an immobilised patient on bed it is not uneasy to develop bed sores. Yes he did, especially since his sphincter function was lost, his excreta made his perineum a fertile soil for bacterial growth.

The story went on when he was transferred to the Intensive Care Unit (ICU) one month after the accident for further management of pneumonia-caused respiratory failure, including creation of tracheostomy for hanging him onto a mechanical ventilator, insertion of Ryle's (nasogastric) tube and Foley (urinary) catheters for his in and out respectively.

After stabilisation in the ICU, he was transferred to the rehabitation ward half a year after his injury. He had a long way to go. He was unable to return to his fire-fighting job, and it seemed that the Fire Services Department could arrange him with some soft duty. He had two elder brothers who were married and busy with their own families.

Mr. Ng also had a girlfriend who had been dating for 5 years and planned to get married in few years' time. Two months after the injury, he knew well that a total recovery was impossible for him. Therefore, he asked his girlfriend to leave him, to find a healthy man who could look after her and bring her a good life.

The girl rejected.

She insisted to visit him daily, to wipe her love's body day by day, weeks by weeks. She was totally devoted to him. In this disaster, I can see both of them were loving each other. Mr. Ng wanted her to have a better future, but not to be dragged by him. The girl knows that he needed her in this critical moment, so denies to leave him and flood him with lots of support. Here comes the excerpt of a famous vow of love:-

"...to have and to hold from this day forward,
for better, for worse, for richer, for poorer,
in sickness and in health,
to love and to cherish, so long as we both shall live."

This is not my first time to describe the uphold of this vow. Do you still remember Mr. Lam's story in my previous note Progress? Yes. I believe, there is something only love can do.