Ascites, Paracentesis and withdrawal rate of fluid in abdomen and my feedback on 12 September 2021 to sghfeedback@sgh.com.sg


I was Warded in SGH from 29 August 21 to 7 September 21.
I have given the following feedback to the sghfeedback@sgh.com.sg on Sep 12, 2021:
On 29 August 21 my son saw that my abdomen was still bloated, taut n tight and he immediately took me very early in the morning to the A&E at SGH. The night before, on 28 August 21, when he saw that my abdomen was bloated up he checked with his GP doctor friend, who recommended that I take Duphalac to let my stool out and if that did not help to reduce my bloated abdomen to take me immediately to the A&E.

The A&E did some tests and admitted me to the Ward. I had what is called ascites, a common condition of liver cancer patients. There are many types of ascites (see https://youtu.be/_yoyVe6pPjQ). If this ascites is not detected and treated early it will lead to lots of complications for the internal organs of the body.

The complications are: high BP, difficulty in breathing, cough, pain, diarrhoea, coughing blood, etc (see https://www.healthline.com/health/high-blood-pressure-hypertension/effect-on-body).

When I connect the dots in these two websites, it becomes obvious to me that a high BP will exert undue pressure on the internal organs of my body. And in the process, it can cause tremendous damage to the normal functioning of the various organs. When ascites and high BP are combined at this stage and not taken care of expediently, dire consequences will occur.

I did not know before that ascites can endanger life!

Most patients don’t know that either because from my observations in the B2 Class Ward that I was in and from the gist of the conversations that I overheard, most of the sufferings of the patients in this room were somehow related to cancer and ascites. And it is so sad and tragic. Why? Because in 8-9 days of stay, I have witnessed at least 3 deaths. How do I know there is a death? Because of the circuit breaker for Covid-19, only one visitor is allowed to visit a patient but for terminal cases, more than 3 members of the family could keep vigil for 3- 4 days, then they cried out “Pa Pa” and a new patient would occupy the vacated bed very soon after the bed has been cleansed. Singapore is very short of hospital beds with its rising elderly population!!!

SGH expertise is superior to most advanced countries. SGH is very systematic and thorough. It goes step by step to find the root cause and why patients encounter such problems. It tries out with medication first and doesn’t rush in to do the invasive procedure. But when a patient comes in with ascites at an advanced stage, there is not enough time to save the patient’s life. That is what I observed. I could be wrong but this is my observation and assessment.

For cancer patients, please, please take the ascites very, very seriously. Go to A&E immediately when the abdomen is like a bursting balloon.

The 80/20 Pareto principle and my body tell me to try to fast track the paracentesis procedure, which is to drain the fluid out of my abdomen immediately.

When I was admitted to the Ward on 29 August 21, SGH has done one procedure after another in order to cure me with medicine and to avoid having to carry out the invasive paracentesis. They gave me medicine, ultrasound, x- ray to my chest area to see that there was no fluid there. Ultrasound again to determine the faeces and fluid in my intestine, CT Scan to make sure there was no clotting in any vein of my liver as I have given a wrong impression, due to my faulty memory, that the ascites had occurred quite suddenly. Subsequently when I looked at the photos taken of me, it was some 2 months of build-up of the ascites.

On 3 September 21, SGH did the paracentesis and CT Scan. While preparing me for the paracentesis that night itself, the nurse, when asked, told me that SGH did 50 paracentesis that day itself!!! My paracentesis procedure took only some 15 minutes and it was completed around 19.45pm. The paracentesis procedure was done efficiently and effectively. I was brought back to the Ward itself at about 20.00pm and the first thing the nurse did was to clamp the large drainage tube leading to the bag.

It did not make sense to me that the nurse has to stop the drainage. The very purpose of the paracentesis, to me, is to drain as quickly as possible the fluid from my abdomen. But I was told by the nurse that the standard practice is for the fluid to be withdrawn at the rate of 600ml/day and I have reached 600ml withdrawal already. The nurse said she has to get the doctor’s permission before she could increase the amount beyond 600ml. Since I know my own body, I asked whether I can talk to the duty doctor as soon as possible that night. The standard reply given was that she had informed the doctor, I kept chasing one nurse after another nurse until a doctor came at 22.00pm. I was told they could not increase the rate of fluid withdrawal too fast as the risk outweigh the benefit. The doctor decided after much consultation and at 22.30pm gave instructions to increase the rate from the standard 600ml to 1000ml on the night of the paracentesis procedure. But the increase has to be done at 100ml/hour and to clamp and unclamp the flow every hour, so the process took 4 hours until 2.30am the next morning. This is exhausting for the patient who finds it hard to sleep! I find that sleep is very important to me.

SGH system is excellent because every time they allow the fluid to flow out, the nurse has to take my temperature and BP before and after the outflow to see that they are within the permissible range. That’s a great counter-check to see that the outflow is not too rapid and there is no damage to the internal organs. The nurses are told not to drain the fluid too rapidly. But there must be a way of communication between the duty night doctor and the walk around teaching consultant doctor to allow for a system to be in place to increase the rate of withdrawal of the fluid immediately should the outflow be within the permissible range! Why? Because as I mentioned, it does not make sense to limit the outflow to 600ml/day. I had to do a great deal of chasing to get approval from any night duty doctor. The doctor after much checking and discussions(22.00pm to 22.30pm) could only increase the withdrawal of the fluid by 400ml, that is from 600ml to 1000ml. A total of about 2.5 hours (20.00pm to 22.30pm) of chasing to get an ok to increase the rate from 600ml to 1000ml.

My record or data showed that this extra fluid withdrawal of 400ml took 6.5 hours to drain. How come it took so long? because the paracentesis procedure was completed at around 19.45pm and I was back in the Ward at around 20.00pm. This extra 400ml fluid withdrawal took from 20.00pm to 2.30am (6.5 hours).

This 6.5 hours, to me, cannot be the correct system that was originally planned for! If this is the correct system then there will be no further changes or alternatives. The status quo will be maintained. The status quo would mean many patients may have to suffer severe consequences for its inflexibility. Perhaps, there is a need for the system to be changed. To me, there needs to be a review of this whole process if SGH wants to improve the system.

In the early morning of 4 September 21, I asked the walk around teaching consultant doctor could the drainage be increased further. He decided that the withdrawal of the fluid can be 1500ml that same day and the day after, on 5 September, to be 2500ml. When I asked when I could be discharged, he estimated it could be on 6 September 21.

On 5 September morning, I presented the data I collected to the teaching walk-around consultant that 2500ml(1000ml + 1500ml) of fluid was withdrawn from my abdomen but my weight loss was 6.7kg. [I have reasoned to myself that my weight loss should only be 2.5kg because 1000ml of water is equivalent to 1.0kg.Thus my weight loss should only be around 2.5kg or slightly more]. So where did the extra weight loss of 4.5kg (6.7kg – 2.5kg = 4.5kg) come from? When I told him the record showed that my weight loss was 6.7kg, he immediately connected the dots and took that as an opportunity to teach the young doctors following him!!! The young doctors have all the knowledge but they must connect the dots to come to a right conclusion. The extra weight loss of 4.5kg came from the diuretic medicine they gave me to pass the urine. Immediately instruction was given to stop the diuretic medicine.

On the day of 5 September, it took the morning shift some 30min to drain 800ml, afternoon shift some 2.5 hours to drain 800ml and the night shift some 3 – 4 hours to drain 800ml. As my abdomen is still quite bloated, I again reasoned that it could only mean that something has blocked the outflow of fluid from my body. Fortunately, on the morning of 6 September, a senior staff nurse noticed that the tiny drainage tube connecting from my paracentesis hole to the large tube connecting to the drainage bag was slightly twisted and she corrected it immediately. After that I was so tired by the whole process of the drainage that my record was a little fuzzy. But I did record that 400ml was withdrawn at 14.40pm, 400ml at 20.11pm, 400ml at 1.30am, 200ml at 4.30am, 100ml at 5.30am, 150ml at 8.20am, 150ml at 11.26am. Thus, I estimated, some further 1500ml of fluid was withdrawn. In total some 7000ml of fluid could have been withdrawn from my abdomen.

How did the tiny drainage tube from the paracentesis hole get slightly twisted? In the process of draining the fluid the nurses just clamped and unclamped the large tube leading out to the bag without bothering to check the tiny drainage tube leading out from the paracentesis hole of my body. This must be made as a standard practice for all nurses to check the tiny drainage tube leading out of the paracentesis hole. I wonder how many patients could have been discharged earlier if there was no twist and blockage in the withdrawal of their fluid. How many more hospital beds could have been utilised earlier.

On 7 September 21, I was discharged from the hospital, after 10 days’ stay. Before discharging me the doctor used a syringe to mechanically withdraw as much fluid out as he could. The doctor could only draw out just a little bit of fluid. It was a trying and distressing time for me in the hospital stay.

My basic principle and philosophy in life is that:
Any design can be improved,
Any work can be improved
Any process can be improved and
Any medical procedure can be improved.

All systems must never be rigid and fixed. It must not be such that people are so “kiasu” that they dare not make suggestions for improvement. Any suggestion from the ground up is frowned upon. Any initiative is punished. Such organizations become arrogant, bureaucratic and complacent (ABC). In today’s complex and volatile world, even the medical system has to constantly look out for improvement by allowing and rewarding good suggestions from the ground up.

As a patient in a ward, I have to establish rapport with the Expert and make suggestions whether this or that can be done. The Expert will never feel insulted or demeaned if the suggestion focuses on the key or critical issue that concerns the proposer (me as a patient) in that particular situation. I find that I always get a far better alternative as he is the EXPERT in his field. Otherwise there will be no improvement or no change or innovation.

In my feed-back form, I commended the walk around teaching doctor, the senior staff nurse who discovered the slight twist in the tiny drainage tube. I have recommended that this checking should be a standard practice for all nurses. This can help the hospital to discharge the patients earlier and free up more beds quickly.

I have also commented that the M&E department should be responsible to see that the shower does not suddenly give out cold or hot water arbitrarily. Obviously, the standard excuse reply is that SGH is an old building and the hot water showers are expected to be not working properly. This certainly is not acceptable as SGH will still be in use for many years. Funds must be given to fix the faulty shower mixer taps and the M&E department be held totally responsible for this malfunction in letting out hot and cold water arbitrarily. In another shower room, the water flow amount is too little, therefore inadequate for bathing! I complained and the M&E dept came to adjust but the problem still remains. I wonder how many patients and staff have been scalded and shocked whenever they bathe!!! The cost for correcting this problem is so negligible. Do this at Ward 48 as a mock-up so as to hold the head of the M&E totally responsible and see that the problems are definitely corrected. No excuses!!!

Fortunately, as a Christian, I go to my God and trust that He is in charge of my life but I must not give only lip-service to my God. What this means to me is that I must do my part, which includes the following:

  1. Befriend my “new” normal. This means to find out as much as I can about the ascites and paracentesis procedures from the Internet and friends.
  2. Place it under the blessing. That is to look for the positive rather than the negative which is to whine and groan. Look at the sky rather than the mud. In these ways with the help of God I was able to go through the suffering relatively more easily. Whenever I feel down, fearful or anxious, I go to Him to ask, learn and lean for strength, support and comfort. I find that God can be trusted, faithful and never wanting. Of course, as a human being I often fail but I can go to Him again and again for spiritual strength, support and comfort.
  3. Talk to my closest friend knowing that he cannot do much. But it helps to vocalise my concern.
  4. Be very alert to the still small voice, a phrase, a quote, an example, etc that uplifts the spirit and acts on it.
  5. Quickly accept my “new” crisis and move on living my life with joy moment by moment and by being of service to others by sharing my experience. Each individual has to find the manner he/she can be of service or comfort to our fellow travellers.

On 8 September 21, when I was at home, my paracentesis hole was dry in the morning but unfortunately, in the afternoon, leaks were observed. My son rang the Ward nurse and his GP doctor friend and they all advised that I go to the A&E to stitch up the paracentesis hole so as not to cause any infection. I do not mind stitching the hole up but I didn’t want to go and wait for 6 – 7 hours at A&E just for a stitch. Besides that, I will be adding an unnecessary urgent load on the A&E dept. I decided, based on my own observation, that I am well and the leaks will clear up soon. I took that chance. To me, the Ward nurse just kicked the “ball” to another dept. but patients take the comment seriously. This can easily be solved by a simple note from the discharging doctor to any surgical clinic or polyclinic that they are allowed to perform the stitching. I know as a fact that any surgical clinic will do it if I am their patient. My son was still checking where I can get a stitch done without such a long wait. Meanwhile, I take the risky choice, to have the hole cleansed with chlorhexidine and bind up with sterile gauze and micropore surgical tape by him.

On 9 September 21 there were still leaks but I felt totally fine. The hole has become smaller!
On 10 September 21, I went for my second Covid-19 injection. There was no more leak.
On 11 September 21 my son had to travel overseas for a Business trip for a week. In order to ensure that there will be no infection for me on the paracentesis hole, he has arranged for a private registered nurse to clean the paracentesis hole for the whole week that he will be away. The nurse cleansed the hole and found that it was beginning to close up.
On 12 September 21, the private registered nurse came to clean the paracentesis hole and found that the hole healed well.

This set me wondering whether a system can be initiated with the goal of not loading the A&E dept. Some Ward nurses just kick the “ball” to the A&E Dept, while others tell the patient to see a GP first. I think practically all patients follow what the Ward nurse tells them.

I wonder whether in the discharge form, can something similar to the Covid-19 be stated like:

Side Effects How to Manage
Fever, chills Paracetamol 1 to 2 tablets every 6 hours as needed
Cleaning of wounds Any qualified nurse
Stitching of wounds Any surgical clinic or polyclinic doctor

If severe reactions occur, then go to the nearest A&E immediately.

I am available for Zoom discussion if you like to ask me anything.

Incidentally, I have been journaling my experience from a patient’s perspective in my “Battling Liver Cancer for 21 Years”. I hope in sharing my experience it may be of comfort and help to other patients. My book is not for sale but I can provide copies to anybody free of charge.

I am blessed and thankful to God, doctors, medical staff, friends and family for their help, support and prayers.
With warmest regards
Liow Guan Haw @ Lau Guan Ho
Written on 12 September 2021

I clarified further that, the main objective for giving my feedback on 12/9/21 to SGH is Not to complain but to state what my experience and observation were during my 10 days’ stay at the hospital.

My view on my feedback is that:

  1. SGH investigations ought NOT be to find out WHO is right or wrong
  2. but WHAT is the right thing to do so that SGH can improve its systems further.

With warm regards,
Liow Guan Haw @ Lau Guan Ho
Written on 22 September 2021

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