Ethics at work

Ethical dilemmas

1. Smoking cessation post op – patient on triple therapy NRT, bupropion and champix. High risk of nausea with NRT and champix. Dr refused to change drug. I counselled patient and advise to reject champix if needed.
2. This is more tough – patient with brain injury with poor prognosis and unlikely chance to survive/return to baseline. Grew e.coli bacteremia in the blood on Tuesday. I recommended IV antibiotics. But doctor did not start despite code status DNR M3. Discrepancy between doctor and patient family wishes. What do I do? Should I honour the code, or let it go since I’m not the MRP.
   1. In the end, I discussed with doctor and started CTX 2g Daily x 7 days for GNB Bacteremia.

 

Jan 19 Reflections

Yesterday was a bad day. Maybe it was “blue monday”. I didn’t know it was such a thing. I was restless at work, cranky, irritable and extremely impatient. Coincidentally, I also broke NF Sunday (the day before). Coincidence? No idea.

In any case, today is a much better day. Even though I MO last night, I woke up today not too tired, and feeling much more refreshed. Maybe because I hit the hay a lot earlier. Work was extremely productive for me and I accomplished a lot for my patients.

1. Rash consult – contact rash. not drug induced.
2. Phenytoin assessment – patient actually thanked me saying “its always good to see you”. I only saw him once. I guess I made a good impression!
3. Tube site infection – made assessment and recommended septra + keflex
4. Whole bunch of infections
5. Pancytopenia assessment
6. Daptomycin elevated CK assessment.

In all a good productive day.

I also took the time to dress nicely!

After work, I got a call from a friend asking for advice about her presentation. Now, I’m usually all about helping people the best I can, and I enjoy it. But sometimes, I just can’t stand pessimistic, negative people. Even after giving good advice – just excuse after excuse. It almost seems like she just wants to take the easy way out and is scared of adversity. In this case, there’s really nothing anyone can say or do to make her feel better. The pessimism isn’t coming from reality – its coming from her intrinsic character.

Man, I now realize how negativity in a person can really translate to other people. And I realized – I was just like that once. I used to see the glass as half empty. I’d point out all the flaws in every plan. I would worry and complain – fishing for comfort, encouragement and sympathy. In the end, I’d lose out on a lot of opportunities, or exaggerate a problem to much bigger than it is. No wonder I started to feel like my friends were abandoning me. They just couldn’t take my negativity. I probably couldn’t either.

Really trying to be positive. I still catch myself sometimes, rationalizing the negatives. Even just a off handed phrase like “I doubt that’ll ever happen”. It’s important to be realistic. But there must be a way to be realistic and optimistic at the same time.

I’m trying to find that balance.

On the other hand, I’m grateful my patients like me. I’m grateful that old friends reached out to me. I’m grateful I can stand taller now with better posture. I’m grateful to have a job and be alive today.

 

There is a patient I’ve been looking after.

I first met him in OPAT when he came in for his outpatient antibiotics. At the time he was on Vancomycin for his MRSA wounds in his groin.That was a few months ago.

This time, I see him on my ward – internal medicine. Same problem. But he’s had his surgery already. however, his groin wounds still hasn’t healed.

He remembers me! he strikes up conversations with me and asks me to keep him updated with his medications and antibiotics. I find it strange he has a whole team of doctors looking after him, and he asks me to update him. He makes a point to greet me every time and in a way, I feel really honoured he would put that trust in me.

We have developed a pretty good relationship, and he’s very understanding of his conditions.

It’s Christmas and I’m covering the whole hospital. But as he asked me a question to go over his cultures and antibiotics plan on Christmas Eve ( last day before holidays), I promised I’d go visit him on Christmas. He wasn’t allowed to go home because they don’t want to risk him opening his wounds.

I did just that – I visited him on Christmas morning and we had a chat about his medications. That wasn’t my job as ‘weekened clinical”, but I couldn’t not say hi on Christmas.

It’s great to have developed such a good rapport with a patient. This is why I do what I do.

Metronidazole Cream

Metronidazole 0.75% cream can be use for malodorous wounds.

A doctor told me she used to crush up metronidazole tablets and sprinkled on the wounds. She asked if there was a compound we can make. First thing I thought of was – well we have Metrogel. However, I wasn’t sure what concentration was considered “effective” since I’ve never done it for this indication.

Turns out metronidazole 0.75% gel topical was used to treat malodorous wounds! Been studied with good effect.

True story.

Ondansetron and Metoclopramide

Little tidbit today.

Patient has a bowel obstruction and constipation. Was on ondansetron.

Ondansetron not recommended in patients with constipation, so recommended metoclopramide.

Just need to remember that metoclopramide is contraindicated in patients with bowel obstruction. Also patient was due for stent insertion to bypass the obstruction. Also not recommended as the pro-motility movement may dislodge the stent instead.