today in the ED, was a bad day. or disaster. or madness. however way you want to call it, our shopfloor was full and overflowing. don't ask me why, but all sorts of patients came streaming in - from knee pain to workplace lacerations to high fevers. they came in fast and furious, and were hence admitted just as furiously.
it doesn't take a genius to figure out then, that when the emergency department is full, the wards will be full. so the back log became progressively worse and patients piled up outside the main area and they were made to wait for many hours before their beds were ready.
and it didn't help that just last week an article was published in the papers about a new fangled bed management system that has helped cut down waiting time for beds. we all know what the reality is, but the public of course believes in the magic two hours mentioned almost four times in the short article.
so what happened? relatives and patients began to yell at the poor nurses, who are the ones tasked with speaking to them about their beds and ward allocations. "why does it take one hour just to clean the bed?" one son yelled, completely unaware that his father was one of the lucky ones who got a bed within two hours of admission.
what does yours truly think is the problem?
expectations.
i recall a patient who fumed,"i am also in the service industry!" just because she was not getting the "service" she was expecting - an admission. we have become a society where we are spoilt for choice. if a particular retailer is unable to provide us with what we want, there's always another next door. hence the customer is always right, and whatever he asks, must be done.
medicine is not and should not be a service industry. it is already prevalent in the states, and even amongst the doctors in the private sector, but this should not be the case - and the public should awaken to this fact. you cannot walk into a hospital and decide how you should be treated. we are not a hotel in which you can order a room and room service to come with it.
but of course, with all the medical tourism and competition going around, "service" has now become very important and many times takes priority. we have now become afraid of complaints, much more than those big multinationals who have billions of dollars to lose. i remember a time when mcdonalds barely batted an eyelid when people got hurt trying to rush for some "limited edition" hello kitty dolls, or mattel getting bashed by psychologists for glorying the wrong body type in barbie. these companies know that people will always be hooked on big macs, and that little girls will always love brushing barbie's hair. -we- know that people will always fall sick and need our attention, but every complaint letter is dealt with the utmost respect and fear, even though that we could have had the patient's best intentions in mind.
we are now mindful of everything we do, everything we say. thou shalt not greet the patient with an unsmiling face (even though it's now 4pm and you haven't eaten/peed/pooped in the last 8 hours). thou shalt not make the patient wait for more than two hours for bloods/beds/specialist reviews (even though all these are way beyond your control, especially as a lowly MO).
the hospital is now a hotel, that's what it is.
This little story has been making the rounds during lunchtime:
Doctor told 74-year-old patient to attend talk, stop medication
Letter from Frances Ong Hock Lin
ON THE morning of Aug 30, my 74-year-old mother-in-law went to the Accident and Emergency Department of the Singapore General Hospital because she was having an asthma attack.
A doctor attended to her. He also told her to attend a talk that he was giving every Monday evening at a shopping complex in town. At the same time, he convinced her there was no need to take medication as the body could heal itself.
My mother-in-law returned home and proclaimed that she was fit enough to work and that she would not take any more medication. She claimed that a doctor had told her so and that she believed him.
My mother-in-law has just undergone a heart bypass because six of her blood vessels were blocked. Her doctor from the National University Hospital had prescribed medication for her which she is now planning to stop taking.
Her cardiologist at the NUH could not certify that she was fit enough for work yet she said that she believe that she was. A check on Facebook showed that the doctor who had attended to her at the SGH belonged to an organisation that I believe is into neuro-linguistic programming (NLP). I would like to ask the following questions:
- As a doctor practising Western medicine, is there a conflict of interest in promoting one's own interest in NLP?
- Is it ethical to convince a patient who has a medical condition to consider alternatives when she is most vulnerable?
- Do the SGH and the Singapore Medical Association have any policy regarding doctors using neuro-linguistic programming
I'm not suprised by the fact that such doctors exist, or that patients will believe and trust them - if you were a patient who had to take many medications every single day, wouldn't you want to be told by a doctor you don't have to? People want to believe in what they want to believe in, but unfortunately a little thing called reality tends to get in the way of that.
What I am pleasantly surprised by are the skepticism displayed by Ms Ong (something rare to see in a newspaper forum), and the responses from SGH and SMC:
Suggestion to attend free talk was inappropriate: SGH
Letter from Mark Leong (Dr) Head, Department of Emergency Medicine Singapore General Hospital
I REFER to the letter by Ms Frances Ong Hock Lin. We are sorry for the anxiety experienced by Ms Ong and her family.
Patients seen at the Emergency Department are given advice based on their medical condition.
In light of the patient's pre-existing illnesses, our doctor had encouraged her to modify her lifestyle after rendering the appropriate treatment. Prior to discharge, he mentioned an opportunity for her to attend a free talk. This suggestion was inappropriate. The doctor has since left our employment.
We require our doctors to adhere strictly to the Ethical Code and Ethical Guidelines set out by the Singapore Medical Council. Professionalism and integrity must be upheld at all times. Every action should withstand professional scrutiny and not breach the trust of patients.
Adhere to guidelines: Council
Letter from Singapore Medical Council
THE Ethical Code and Ethical Guidelines (ECEG) sets out the fundamental tenets of professional conduct and behaviour expected of all doctors practising in Singapore.
Among other things, Section 4.1.6 of the ECEG states that "A doctor shall not in his professional capacity support the services provided by persons or organisations that do not provide legitimate medical or medical support services".
The Singapore Medical Council would like to advise all doctors that they are required to adhere to the guidelines set out in the ECEG or they may face disciplinary proceedings if they are complained against and found to be in breach.
They basically stopped short of calling the doctor a quack.
One thing that I think bears mentioning is the last sentence in SMC's reply: the SMC may only initiate action when a complaint has been filed - if no one actually files a formal complaint against this doctor, then despite the incident being mentioned and acknowledged in a newspaper, no binding action will result. So if we want to rid our profession (or if you want to rid our profession) of dubious practitioners, then sometimes we have to take the effort and act so the proper authorities can act too.
Not too long ago, a blog entry about KTPH A&E's lack of 24-hour senior support triggered a comment that basically asked its writer to be careful about the consequences of "whistle-blowing". Something about Singapore MD being shut down, maybe its contributors being hurled into outer space, or having their limbs ripped off, I can't remember.
First of all, at least one of S'pore MD's co-authors has faced a possible shut-down before. Not because s/he wrote something which was untrue, but because the truth proved too painful a pill for the powers-that-be to swallow ( and more importantly, because his/her blog just happened to be featured by a prominent overseas newspaper, causing a spike in international readership ).
Soon after, I came across a Time magazine article about WikiLeaks, which I happen to think is damn cool. Direct link to the website here. :)
So let's think about this a little bit: what is the main purpose of whistle-blowing?
Answer: to expose an injustice to the public, and hopefully, right a terrible wrong.
In the local context, exposés regarding medical issues usually stem from 2 sources - journalists and patients. And oftentimes, the latter blabs to the former, and it makes headlines.
It is widely known that members of the medical fraternity are expected to adhere to a "code", a code that I don't have to spell out for you. And while many would like to believe that such a code only exists in the medical circle, it in fact does not. Other examples: any profession that involves uniforms and the legal possession of firearms; law; finance; the Catholic church.
Wouldn't it make much more sense for doctors to be exempted from such a code? Why protect someone who's endangering the lives of his/her patients? Why protect organizations that know a serious problem exists, but do nothing to resolve it?
As you can see, the KTPH issue has been kept out of the press. Perhaps the powers-that-be issued an unofficial gag order, but rest assured that they're aware of the issue and are at least taking some action, according to a source I spoke to. It's a rather feeble attempt, but at least it's something.
Last but not least, I hope the powers-that-be will view Singapore MD is a valuable sounding board, and not as a threat. We are not gunning for people to lose their jobs here. We'd just like the administrators and the public to know what's happening at the frontlines, hopefully early enough so as to prevent a major catastrophe.
You will find the brief recorded history of the NDM-1 gene on Wikipedia - it is fairly accurate, and saves ploughing through several case reports and full length journal articles. However, it is likely that this gene - one of a superfamily of carbapenemase enzymes - has been around way before 2009. If you look through publications in Indian medical journals (one example here), or conference presentations, you will start to get the picture that carbapenem resistance in Enterobacteriaceae started to become a significant problem around the early to mid-2000's, with export to other countries occurring once a certain critical prevalence was reached. It is important to note that the NDM-1 gene is only one of a large number of carbapenemase genes found in Enterobacteriaceae such as Escherichia coli or Klebsiella pneumoniae, although only one other has so far demonstrated epidemic potential - K. pneumoniae carbapenemase (KPC) gene that was first discovered in the US (North Carolina) in 1996. Several variants of this gene are now found in Enterobacteriaceae causing intercontinental outbreaks, notably in Israel where a KPC-3 producing K. pneumoniae caused a nationwide outbreak in 2007 that is still ongoing despite a national effort to contain the problem. Both sets of genes (NDM-1 and KPC family) are found on plasmids, which are mobile genetic elements capable of transferring horizontally between related bacterial species. This is therefore a more efficient (for bacteria!) way of dissemination and is far harder to deal with in terms of infection control. The gene that causes methicillin resistance is (largely) fixed to the bacterial chromosome of Staphylococcus aureus, therefore one only has to try to control the epidemic/outbreak clones (sounds easier than it is to achieve!). When the gene itself is mobile and can hop across species, multiple epidemic clones can appear (and disappear) and it becomes almost impossible to stamp out by conventional methods of control such as case detection and isolation.
Despite the relative success of KPC-producing Enterobacteriaceae at causing outbreaks worldwide, I consider NDM-1 producing Enterobacteriaceae to be a far larger problem potentially. The reason is relatively straightforward if one cuts through the political claptrap: there are just far more people from the Indian subcontinent traveling for medical reasons (i.e. medical tourism) than Americans, and they also tend to be sicker, with longer exposures to their own healthcare facilities (where there is a possibility of picking up these bacteria). Just look around any of the private or public hospitals in Singapore (try the 'A' class wards) and you will see that there are not that many Americans at all. The human and social factors driving NDM-1 spread are just far greater than that for any of the other carbapenemase enzyme-bearing bacteria, including KPC-1. Whereas we have yet to isolate any KPC-producing bacteria in Singapore after almost 15 years post-discovery, two local cases of NDM-1 producing K. pneumoniae carriage (not infection) were recently reported from the Singapore General Hospital (doubtlessly identified by researchers from the hospital's microbiology laboratory rather than MOH, as ST would have us believe), both from individuals who had recently been in contact with healthcare facilities in the Indian subcontinent. As a disclaimer, this is not saying that all the patients from the Indian subcontinent will carry NDM-1 producing bacteria, but invariably, some will be positive, and in the course of their treatment in hospitals outside their country, opportunities will arise for the dissemination of these bacteria.
Why should we worry about carbapenemase-producing Enterobacteriaceae when we have had relatively high rates of carbapenem resistance in other Gram-negative bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii for years?
On a general level, carbapenem-resistant bacteria are a huge concern because these drugs (imipenem, meropenem, ertapenem and recently doripenem) literally represent the last line of safe and effective antibiotics for the treatment of severe Gram-negative infections, and there are no new drugs that are active against these bacteria over the next 5-10 year horizon. Many clinicians in Singapore have had experience with polymxyin B (intravenous) and colistin (inhaled and intravenous) - now the "gold standard" antibiotics for treatment of carbapenem- and multidrug-resistant non-fermenting Gram-negative bacteria (i.e. Pseudomonas spp., Acinetobacter spp., etc). This class of drugs has seen a revival worldwide in recent times, but there were good reasons for discontinuing their use in the 60's and 70's when the newer antibiotics such as later-generation cephalosporins were developed - they are far more toxic and considerably less effective than the beta-lactams in head-to-head studies. Bacterial susceptibility and clinical effectiveness are two separate matters, as most ICU and ID physicians can attest. Then there is tigecycline - a new antibiotic that is closely related to doxycycline. While most bacteria remain susceptible to this drug, inadequate plasma levels at conventional doses and lack of activity against P. aeruginosa limit its usability.
On a more specific level, Enterobacteriaceae such as E. coli and K. pneumoniae are far more common than the nonfermenters (they can be found as commensals in the human gut), and far more virulent, having a lower threshold for causing infections. Can you imagine trying to do bowel surgery on an NDM-1 or KPC-producing K. pneumoniae carrier? Or a hypothetical scenario where a significant proportion of the population carried such bacteria in both hospitals and community? If we continue on our current trajectory, this scenario may well happen.
There has been a large number of bacteria bequeathed with the title of "superbug" - usually by the press - in recent times. These include - not in any order of importance - MRSA, VRE, penicillin-resistant Streptococcus pneumoniae, multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa, ESBL (extended-spectrum beta-lactamase)-producing Escherichia coli and Klebsiella pneumoniae, KPC (Klebsiella pneumoniae carbapenemase)-producing K. pneumoniae and E. coli, and lately, NDM-1 (New Delhi metallo-beta-lactamase)-producing K. pneumoniae. The term "superbug" connotes antibiotic resistance rather than hyper-virulence, a common public misconception. Some isolates of Acinetobacter baumannii are resistant to all known antibiotics, but this is a relatively weak opportunistic pathogen, largely incapable of causing infections in healthy individuals (although fulminant infections continue to occur in ICU patients, burns patients, or hospitalized patients with various tubes sticking in and out of them). On the other hand, the pneumococcus - while not particularly antibiotic resistant - can infect and kill individuals of all ages and health states (and therefore the critical importance of vaccination in childhood or when immunocompromised).
Generally, when a bacterium first develops resistance to an antibiotic, a fitness cost is imposed on the organism that comes from maintaining a new and additional "process" (that may well be alien to the bacterium - many of the antibiotic resistance genes found in bacteria capable of causing human disease are actually horizontally transferred to them from other bacterial species that may not be pathogenic). One inexact analogy would be the slowing down of your computer (especially if old) when you are running several applications at the same time. The bacterium then seems to be less capable of causing infections, a phenomenon observed with organisms like MRSA or multidrug-resistant tuberculosis when these first appeared. However, this fitness cost is not by any means static: after a period of time, the bacterium generally adapts to this and resumes "normal function" when causing infections.
As an example, when MRSA first appeared in the 1960's, physicians and scientists observed that infections only took place in the hospital setting among immunocompromised patients, and the organism disappeared after discharge from the hospital (this may take up to a year, however), replaced by other staphylococci from the community. For the longest time, this was held to be true until community-associated MRSA appeared in the late '80s and '90s. It took a long time for the scientific and medical community to actually believe that MRSA can cause infections in healthy individuals outside the hospital setting - something that most young doctors today may find hard to imagine, particularly with what we know about evolution. How did the organism evolve to do this? By replacing larger and "clunkier" methicillin resistance gene cassettes with more streamlined and smaller versions, and by assembling heterogeneous cell walls made with a variety of penicillin-binding proteins rather than homogeneous cell walls comprising mostly of the alien PBP-2' that confers methicillin resistance. Such changes enabled CA-MRSA to compete successfully with other staphylococci in the community setting, and to cause infections even in healthy individuals, resulting in outbreaks in almost all continents worldwide.
Next up: NDM-1 and why this is (IMHO) the most important antibiotic resistance phenomenon to have emerged after MRSA. Or you can look it up on Wikipedia.
