Yesterday I saw an elderly couple in green zone.. Came because Blood pressure has been persistently high at home.. worried that the husband will get another stroke..
Ok, so BP was 150-160/80-90 in ED, otherwise no neurological deficits, patient fairly well..
Here comes limitation number 1: can't admit patient to the ward, BP not too sky high, no symptoms to suspect recent stroke..medical mo would kill me.. next follow up with medical in 3 months time..so I am left with the option of readjusting medication dosage..
So here's the conversation with the aunty(patient's wife)
Me: ok aunty, so I will increase the dose of A to xxx and add B.. after this I will give you a slip to monitor your BP in klinik kesihatan
Aunty: I dunno how to get to klinik kesihatan, I only know how to get here
Me: well aunty, the emergency department is for emergency cases, usually bp monitoring wil be done in KK unless they cant manage a very high bp
Aunty: well hospital is the nearest to my home and I need to pay more than rm10 to get here by taxi you know.. I don't know how to get to other klinik
Limitation number 2: ED don't see cases for monitoring and regular follow up because it is for people with emergency cases. If we do, those emergency cases will be neglected and patient's life will be in danger. But on the other hand, we can't refuse patient or send them away, especially so in this case where they had to travel by taxi to get to the hospital.
Me: okay aunty.. nvm.. I will write you the prescription slip for 2 weeks, then after that go to the nearest KK to get your prescription.
Limitation number 3: ED MO cant prescribe long term medication.. eg antihypertensive.. can't prescribe sleeping pills bacause it's a controlled drug.. can't prescribe A list medication eg: Clarinase, Arcoxia, Augmentin unless signed by Sspecialist..so even if I prescribe, the pharmacist will not dispense.
Despite all the explanation,
Aunty: I can't go to KK.. can't you just write the prescription for longer?you know.. I have to take a taxi and pay so much to come to see a doctor
Me: Your children will come back this CNY? Ask them to bring you there?
Aunty: My adopted child only come back once every 1-2 years
Felt bad so went to consult my ED pharmacist. Same answer, the most can give 2 weeks.
Went back to the aunty.
Me: aunty kenot la.. the most I can give is 2 weeks
Aunty: I usually get his prescription through pos laju.. you just add in the prescription and pos laju to me la.(aunty still don't understand my limitation)
Me: like that aunty.. I try call medical and see what they can do. Ok?
Consulted medical MO for ed referrals and he was nice enough to tell me he would come. But of course he needs to see the more urgent referrals which may mean waiting another 1-2 hours. Aunty comes in every 10-15 mins to see if the medical mo has arrived.
Limitation number 4: ED MO can only refer but we cannot control how fast the other party comes and we understand that they too need to attend to other urgent referrals or possibly patient who collapse in ward. But problem is patients don't understand and they wil end up shouting in frustration at the ED MO.
In the end, wrote a prescription for 2 weeks and gave a referral to medical outpatient clinic in hospital to TCA in 2 weeks.
Took me almost 30-45 mins to counsel.. another 1 hour or so to settle the case. Was helping out in green zone so can allow a bit of leway time.
Limitation number 5: In a normal ED shift in green zone where we constantly have 20 cards on our table to be seen, say we take 5 mins to see a patient, we will only finish seeing 20 patients in 1 hour and 40 mins ( bear in mind, patients are continuosly coming)..that doesn't add to the time we wait for blood result, x ray, procedures n stuff.. going from ed to xray, for the blood to reach the lab and for lab to process the blood and send results back to ED, one can just imagine how much time it would take and that is beyond our control.
Saw this uncle and aunty at the gate as I was walking out, waiting for taxi to go somewhere else to shop for CNY. Taxi driver wanted to charge Rm10 for a place that was 4 mins away and it was expensive for them(personally I think the taxi driver is asking too much also). I offered to pay their taxi fare but they refused. In the end they bargained till Rm8 and took the taxi.
We may not realise how difficult it is for some people just to get to a hospital to seek treatment and most of them are neglected old people. I felt bad. Probably on a busy day I would have resented people coming to ED with problems like this because it takes forever to settle and my work would pilling up. And I felt bad that I couldn't help more.
If only I could....