CHERYL LEE YING XUAN

1) Executive summary/Abstract

Our group spent 3 weeks at Tan Tock Seng Hospital (TTSH) shadowing Dr Endean Tan, Head of the Acute Internal Medicine Service (AIMS) at Tan Tock Seng Hospital. During our attachment, we started writing a report about influenza A and how different wards handle influenza A patients (specifically a comparison between General Ward and AIMS). We provided some background information regarding Influenza A and how doctors decide whether to ward patients. We reviewed the possibilities of creating a future screening tool that could aid doctors in deciding if patients should be warded.

During our attachment, we attended many medical lectures conducted by Dr Endean Tan and other TTSH doctors. In particular, we learnt in depth about sepsis (a life-threatening illness) and gait analysis(study of human motion to identify gait abnormalities). Additionally, we sat in on the comprehensive case analysis of new and existing patients in the AIMS ward every morning. Hence, in our wiki, we included a section on how doctors format their case analysis to present to the senior consultant in the ward, detailing the doctors’ thought process regarding patient management.

There were many interesting aspects of this job. As we were shadowing a consultant, we had access to places in the hospital where the public is not allowed. Hence for the interesting aspects, we picked things we learnt that are not common public knowledge. Our attachment was cut off early due to the 2019-nCov virus (Wuhan virus). Despite that, I have learnt a lot of life lessons from Dr Endean - especially the importance of having passion for one’s job. I picked passion as my main takeaway as I greatly admired his passion for medicine.

3) Elaboration / record of the activities done

Firstly, we conducted a literature review to better understand background information of Influenza as well as the issue of unnecessary hospitalisation.

Secondly, we obtained data from TTSH regarding Influenza A patients admitted to TTSH. We then performed analysis on this data by categorising the patients into those that were hospitalised for a day and those who were hospitalised for more than a day. For patients that were hospitalised for one day, we assumed that these were unnecessary hospitalisations. We analysed their demographics, pre-morbids and identified symptoms that are prevalent among these groups of patients. For patients who had a longer period of hospitalisation, we analysed their demographics, pre-morbids and symptoms. We also compared the standards for hospitalisation and discharge between AIMS and the General Ward. We then compared similar cases for AIMS and General Ward and identified differences in the duration of treatment between the 2 groups.

Thirdly, we compared our findings for the 2 categories of patients (those who were hospitalised for a day and those who were hospitalised for more than a day). From this, we determined some indicators that showed the need of hospitalisation. Using these indicators, we designed a medical scoring tool that will aid doctors in deciding if a patient should be hospitalised.

The rationale for creating this scoring system is that currently there exists no standardised tool for this purpose - whether a patient should be hospitalised or discharged is based on the doctor’s judgment. This can result in unnecessary hospitalisations or excessively long hospitalisations. To make the decision-making process more objective, we decided to propose a medical scoring system. We assumed that patients which were only hospitalised for a day were unnecessarily hospitalised since their cases are likely to be less severe and could be treated in an out-patient setting. We chose to compare patients in AIMS and the General Ward with similar background and similar severity of influenza as we wanted to prove that there are significant differences between how they are managed.

5) 4 content knowledge / skills learnt

Sepsis - a life-threatening illness

Your body releases various chemicals into the bloodstream when there is an infection. A patient is septic when the chemicals are off-balance. This can harm a few organ systems and eventually progress to septic shock (a life-threatening condition in which blood pressure drops dramatically).

A scoring system such as the Q-SOFA score can be used to calculate the risk of sepsis. Early treatment for this includes antibiotics and large amounts of intravenous fluids. To be diagnosed with sepsis, you need show signs:

• A generalised or localised infection
• Change in mental status
• Systolic pressure ≤ 100mm Hg
• Respiratory rate ≥ 22 breaths a minute.

If the patient experiences septic shock, he/she will have unrecovered hypotension despite adequate fluid replacement, thus requiring medication to maintain blood pressure greater than or equal to 65 mm Hg.

Risk factors for sepsis include:

• Young or old age,
• people with compromised immune system,
• patients with chronic illnesses of invasive diseases and people with open wounds or injuries,
• patients who have previously received antibiotics or corticosteroids.

Various Factors that can be controlled in Haemodialysis:

1. Blood Flow Rate

An increase in Blood Flow Rate leads to:

• Increase in concentration gradient
• Increase in waste extracted per unit time
• Stronger effect of ultrafiltration, preventing clotting
• Increases efficiency, it does not shorten duration

An interesting point to note: Patients with intradialytic hypertension needs their blood flow rate to be lowered

2. Dialysate flow rate

An increase in dialysate flow rate leads to:

• Increase in concentration gradient
• Increase efficiency

Cost is the key limiting factor as dialysate are expensive since they consist of specific concentration of minerals

3. Ultrafiltration Rate

• Calculated using the formula current weight – dry weight
• Dry weight of a human being cannot be obtained with the same methods as other organisms
• Lean body mass is estimated with the Boer’s formula
• Boer's formula:

LBM (men) = 0.407 * weight + 0.267 * height * 100 - 19.2. LBM (women) = 0.252 * weight + 0.473 * height * 100 - 48.3

• Since calculations would not be fully accurate, the doctors will have to make changes to the ultrafiltration rate after each dialysis.
• A high ultrafiltration rate above the normal can be resolved with replacement fluid (it is not a crucial problem)

4. Duration

• Conventional renal replacement treatment: 4-4.5 hours
• First treatment should only be 2 hours (Patients experience a high solute removal which might cause a dialysis disequilibrium syndrome)

5. Heparin

• A liquid used to coat tubing to prevent blood clots
• Look out for negative markers such as the presence of intracranial and intraocular bleeds

Case Presentation

When meeting a new patient, a doctor should classify the breadth (medical, function and social issues) and depth (justifications for the differentials and for the decisions made) of case.

The doctor should then write the Comprehensive Case Analysis (CCA). This is written in the SOAP format (subjective, objective, active issues and passive issues). Active issues refer to issues that are receiving or have received treatment, have new evaluation and management. Active issues are anchored to presenting complaints with corresponding plans. Passive issues refer to issues that have no new evaluations and are receiving ongoing treatment. Passive issues are presented after active issues with single-line entry and no plan.

Before going on ward rounds, the doctor would refresh himself/herself on the patient’s case through reading the detailed version of the CCA. The doctor would also review overnight events and results and check the parameters. Afterwards, the doctor spoke to the patient and conducted a focused physical evaluation. The information obtained should be documented in the SOAP format and list the daily active medical problems concisely, justifying them if appropriate.

During the ward round, cases would be presented in the following format:

1. New Cases:

• Demographics & premorbid status
• Past medical history
• Present complaints
• Detailed history of current illness
• Vitals & physical findings
• Investigations
• Active issues & management
• Analysis & discussion
• Functional issues
• Social issues

2. Existing cases

• Demographics & brief history
• Present status & investigations
• Medical issues & management
• Functional issues
• Social issues

Skills: How to break bad news to patients

This is an art in the field of medicine. As doctors will inevitably come across situations where they have to break bad news to their patients, healthcare professionals need to master the art of empathy so that they can convey medical diagnoses, especially the unpleasant ones, to patients in a more sensitive manner.

The importance of empathy in the field of healthcare is demonstrated as medical students are graded in this area. In NUS, students have a framework to show empathy. This is ironic as empathy should come from the bottom of one's heart, instead of it having to be taught. This might highlight the underlying social problem that there is a lack of empathy in the current generation.

The steps are as follows:

• Name diagnosis in simple terms (Instead of malignancy, use cancer)
• Understand the patient’s perspective (Use words that describe emotions)
• Respect
• Support
• Listen

For example, "It is unfortunate to inform you that you are diagnosed with cancer. I understand that you are experiencing a lot of sadness/grief. I would feel so if I were in your shoes. However, do not worry. My team and I will be here for you!"

I feel that this is an important skill to learn as while the medical knowledge learnt will not always be applicable in my current life, the ability to empathise is valuable since we live in a society and need to interact with others.

7) 1 takeaway for life

My main takeaway from this attachment is that passion is what drives you. Just like what Jon Bon Jovi once mentioned, "Nothing is as important as passion. No matter what you want to do with your life, be passionate."

In the path of being a specialist, one needs almost 12 years of education including 5 years of medical school. While studying might seem like a grueling task, it is a good preparation for the real work as a doctor. A doctor needs to be on call on certain days of the week, hence, they can work up to 24 hours non stop.

When I first started my attachment, I could not understand why my mentor could be so enthusiastic everyday despite sleeping for about 3-4 hours a day and reporting to work at 6am even though he only needs to report at 8am. In addition, he had the time to pursue other hobbies such as programming and sailing.

However, during the attachment, I slowly realised that passion is what stops them from burning out and losing their edge. Passion is what prevents them from losing sight of their initial purpose and cause. Passion is what keeps them going and what spurs them to do better.

If there was one thing to learn from Dr Endean and the rest of the healthcare staff, it would be to be passionate in everything you choose to do. Only then will you persevere, do your best and remain happy every day!