In the Haze

In a life filled with record-breaking moments, there is bound to be one that resonates with you more than most.

I rarely post about my patient encounters. I fear they may be unprofessional, a way of pandering to the masses; an accidental show of farcical empathy and intelligence; you name it. However, this is something I had to get off my chest. And let's face it, there is no real way I can be posturing with this particular story.

Be aware that this story might not be... savoury... to a lot of people. I am a Muslim, and that comes with certain obvious expectations. Malaysia has its own set of rules, too, regarding what I'm about to document here. So if you are not one of the above, you may be unable to fathom why I reacted how I did... 

But you can try.

In the wee hours of the night of a public holiday, a middle-aged lady was supporting her daughter as they walked into the emergency department, the daughter clearly in pain. The daughter had put on a green batik nightgown over which a kain batik was tied to her neck, massively covering most of her front. Mother, in a long-sleeved blue shirt and pyjama pants, called out, 'Help! My daughter is having severe back pain all of a sudden!'

I was in the midst of filling out a prescription form for another gentleman who came in with an unexpected allergic reaction. I eyed the duo as they swerved over to my assistant medical officer at the registration counter and were directed to the closest beds. The mother was told to lay her daughter down and register. They were non-locals and had to pay RM 100 instead of the rate we enjoy, a hundred times less.

Feeling the gentleman eye the duo with more curiosity than necessary, I hastily finished my explanations to him, discharged him and got up to see the lady.

Introductions. Then a quick look-over.

I am not blind. She was obviously having an abdominal distension suggestive of a gravid uterus.

I pulled down the kain batik, and pulled up her long nightgown. Sure enough, the linea nigra appeared into view along with a uterus of about 24 weeks' size.

'How old are you again?'

'18.'

'When did you turn 18, exactly?'

'Earlier this month, on the nth...'

'Are you married?' - typical Malaysian doctor questions. Don't ask if you ain't here.

'... Yes.'

'Doctor, the mother told us she's not married,' interrupted one of my nurses. 

It's not uncommon for a teenage girl to be married around these parts, especially for non-locals. But deep inside, I knew this was not the case.

'Do you know you're pregnant?'

A pause. 'Yes...'

'Does your mother know?'

Another pause, this time more pregnant.

'No.'

We'll see about that, I thought, as I reached over to the ultrasound machine. First things first, let's see how premature the baby is.

Probe on suprapubic area. No head.

I moved it upwards. A tangle of bodies.

No.

Two skulls.

NO.

Yet sure enough, as I moved the probe around, two fetuses were actively moving around, separated by a thin layer of membrane, head to head. They were around 20 to 22 weeks gestational age.

For many people, being pregnant with twins is a delight. But for healthcare practitioners, we know how complicated these pregnancies can be to the mother and both babies. And for a young doctor like me who isn't within the O&G department, even the seemingly simple act of scanning the patient becomes a massive chore. The case will need to be discussed with the specialist.

In the background, the patient is moaning in pain.

I have cussed internally and perhaps externally, but I have asked my nurses to bring the speculum and vaginal examination set over.

'Do you have any water or blood discharge from your vagina?'

'No, doctor, help me, it hurts so much!'

'Labour pains will get worse, girl,' my nurse told her, 'so be strong for your babies.'

For it was clear she was having contraction pains. 

These do not happen for no reason, so far into the pregnancy.

Examining her, I found her to be one centimeter dilated. I took the necessary investigations.

'Have you ever checked your pregnancy with any doctor before?' I inquired.

'No, this is the first time. Ow, it hurts!'

'Please be honest, miss, I'm trying to help you. Did you take any medication before this?'

'Yes.'

'What for?'

Silence.

'Did you... take medication to abort the pregnancy?'

'Yes...'

An external curse word escaped me, in a record-breaking moment.

'Where? Where did you get it from?'

'From a friend in town...'

'Where did she get it?'

'I don't know, she used it before too.'

'Did you bring it?'

'No...'

'Are you aware that you're not just murdering one, but two babies?'

'... What?'

'You are pregnant with twins!'

And I have never heard such words being uttered with such venom from a healthcare professional, as she stared back at me, flabbergasted.

The next few moments were more of a blur.

I rushed to the mother.

'Do you know that your daughter is pregnant?'

'Oh, oh what, really?' An unconvincing show of surprise, eyes widening too late, too long, barely any tension in her muscles- just not how most mothers react to an unexpected teenage daughter pregnancy announcement. The mother knows. Call it a hunch, but she knows.

'Why did you go to town today?'

'Just going out, you know...'

'Are you aware that she is trying to terminate her pregnancy?'

'Well, no, but she is in so much pain, please help her! Surely you can help her ease things a little...'

'She is pregnant with twins, you know.'

The mother stared at me, almost deadpan.

'And you are more worried about her pain than the fact that she tried to kill her own babies?'

'I, uh-'

'You are a MOTHER! How can you be so evil? How can you allow her to take the lives of her own babies? You're also a muslim! You know that it's murder!'

The mother's expressions were hazy behind my watery eyes. I realized I was screaming. Gesticulating. Frustrated.

'Doctor, it's okay, you have the full right to scold me. Just scold me, I don't mind, please... It's my fault,' she told me. And in my whirl of emotions I can't even tell if she was being genuine or simply trying to expedite the process.

I was losing my cool.

In fact I lost it, for I have never had violent anger outbursts in front of my own patients.

I stormed off.

And in the treatment room, I cried for the innocent little souls I saw on the screen- the two skulls next to each other, moving around. Hearts beating, limbs active, strong, surviving.

For how long?

I was not equipped for this. Being alone on-call, my staff unable to console me or advise me.

I wept.

I wept for the babies, and the naive young mother, and her mother.

I wept for my inadequacy and loss of professionalism.

I wept for the people who tried and failed to conceive for long years.

I wept for long minutes, an ugly mess of tears and mucus and loud sobs.

I dried my tears momentarily and called up my specialist for advice.

And wept some more over the phone despite all attempts to the contrary, much to my chagrin (and the specialist's).

She told me there is nothing she can do, and it is not really an urgent case.

I remember her telling me that there is no need to cry, because it does not help things.

I apologized profusely.

But since when has crying ever helped? It's out of our control and I hated myself for it.

'Did the specialist scold you badly?' One of my nurses asked quietly.

'No, it's not that, it's...' I couldn't begin to explain.

'The mother knows, you know.' The nurse told me, and said more of the circumstances surrounding the pregnancy. The guy refuses to be responsible. It was of little import to me.

I did what was necessary and what was ordered by the specialist- the police report, the plans to have her admitted overnight- and refused to see the patient.

What was I supposed to do, hold her hands and tell her everything is going to be fine?

I was a mess and so was she; neither of us needed to see each other.

The rest of the night was a tumultuous blur of emotions, for as I mourned the possible loss of lives, I mourned my reaction to it, too. I wondered if it would ever be possible for me to process such a case with less emotional outburst. I mourned my lack of knowledge.

I prayed to God for all of us.

I hurt myself.

And to stop from going further I began writing into my phone, writing all those feelings, pouring them out from my heart in an event lost to so many years.

I was glad of the reprieve I got after the case; no one sought the hospital in the hours that passed afterwards, probably sound asleep in their homes. Quitting was an idea that appeared in my mind often, painting violent streaks into my thoughts.

I walked around the hospital grounds in the haze, omitting my N95 mask entirely. The thoughts within were enough to suffocate me.

There is news that came with the dawn- the patient has stopped having contractions altogether in the ward. There is a huge chance that the abortion attempt failed.

I wonder what the coming days will bring to the mother, her mother, and the two unborn babies.

But most of all, I wonder what they will bring to me.

EDIT: The ward staff told me over electronic media, on my off day, that the babies were delivered the day after. Of course they came out alive, and it was quite some time before they passed.
I want to say that I wish the mother and grandmother are happy with what they've done.
But that would be lying.
They didn't just kill the babies, but a part of me, too. And that would never change.

Dignified and Truly Professional

"Dr, Klinik XX nak hantar satu patient. NCC*, non-local post-SVD** 3 hours ago at home. Patient unconscious--"

"--S^#T!" I responded in the most dignified manner possible.


There are several cases that warrant the most dignified response possible when you're located in a remote setting over an hour from a specialist hospital:

- Maternity cases with a high chance of morbidity and mortality
- Paeds cases (especially under 5 years old) with a high chance of morbidity and mortality

Those two are the most important to remember; the rest are nowhere near as frightful.

Because at the end of the day,

even when the patient was roused from a deep and seemingly unrousable slumber by you;
even if the blood pressure picked up and heart rate dropped rather dramatically after your fluid resuscitation;
even if the patient managed to arrive at the referral hospital with almost-perfect blood results, normalized vital signs, fully conscious and cheerful;

if the patient dies at the referring hospital
- leaving you flabbergasted as to what the heck happened there after all that??,

YOU
ARE
GUILTY
OF

...

SOMETHING.
Trust me.

Cry two nights in a row and then, puffy-eyed, go to the mortality meeting and explain how you have done everything within your means to help the patient; fingers will still point toward you for something completely out of your immediate control.

How would you think the patient will die because of a diagnosis you cannot arrive to, simply for the fact that it hasn't developed yet at your center nor do you have the facilities to diagnose it?
Doesn't matter, you were the cause for not having prophetic powers.


Conclusion:
1) Mortality meetings exist solely to shift the blame and not, as they are touted, to improve patient care, avoid further mishaps or 'banana trees fruiting twice'.
2) Don't become a doctor. It sucks.***




*NCC - non-clinic case
**SVD - spontaneous vaginal delivery
*** Okay it has its perks. But seriously don't do it unless you have a ten-metre-thick face and a heart encased with 5-ft steel, resilient to the most pointed misfortunes, insults and humiliation directed to you. Or just go non-clinical, heard the grass there is so green it's fluorescent.

Never Enough

It has been a long while.

It's funny, because I now have more time than I had the past 2 years as I have already finished my housemanship and am 'floating' in our ETD. In this department, floaters are not really accountable for much nor do they have the usual workload of a HO. Floaters work 8 to 5 with lunch breaks. And I have floated for over a month.

In other words, I have been very unimaginably lazy.

I also have gone for a rather lavish vacation overseas in some countries far colder than Malaysia, and I just have to say if it weren't for my parents I wouldn't have been able to afford even half the trip with what I earned the past two years unless I spent money the way I did as a student. Also, that half my heart is still where my vacation was. I am incomplete.

Speaking of incomplete.

I have received my new placement and I am glad to say, it is in Borneo.

GLAD?!

I am glad to say, I have not appealed to stay in Semenanjung.

But I did ask for a 2-week delay to report for duty, as I was informed quite late of my hospital (which will stay anonymous) and being quite the lone ranger, I need a lot of time to pack up my 2 years' worth of accumulated sentimental garbage.
And furniture.
Bet you ten sumpit-ed crocodiles they don't have IKEA where I'll be posted.

Which means I have to majorly save for my move back to Semenanjung if I were to move within 5 years, which is probably the case.

To those 2 of you who read my blog, thanks for following my rather truncated journey through HOship and here's an update:

I'm still alive.
HOship was the bomb.

Procedures, procedures

I have a 100% success rate with chest tube insertion and a 66% fail rate in intubation...

Of course, those involve really tiny sample sizes so they are very inaccurate.

I have the rest of my life to improve my sample sizes?

You wish the view was this nice all the time. Sauce

P.S.: Turning your failure rates into statistics may seem smart, but it's actually rather demotivating and may lead to sudden bouts of screaming out loud. So, sensitive junior doctors out there, don't do it.

The Road to MO-ship

Almost there. Sauce

Or should I say, 'well-beaten yet overgrown dirt path'?

I cannot find good resources on how people filled out the forms required for MO-ship.

Where I'm concerned, the process I'm currently undergoing (because I still have yet to receive my MMC number and would say I'm not really qualified to say anything of it) is rather easy so far. As I have documented earlier during my early HO days, my hospital's administration staff are highly helpful and efficient. I just ask and they will provide.

Just makes our jobs a lot easier; I can't begin to imagine how much of a headache the staff in charge of us feels, now that there are over 100 HOs in the hospital (I kid you not)! But she's always very pleasant and eager to help.

Anyways, once I have more details I will update this space.

For now, all I can say is:

1) Send your logbook from your 5th posting EARLY. Try at least 2 weeks before ending, so your admin staff's work is easier.

2) Prepare RM150 for the full registration fee (which could be reimbursed later LOL) and this will have to be done by wang pos, mostly.

3) Think (and pray) hard about what you want to do later and where.

4) Don't get hung up on a specific place/department to practice for now, unless you're married or have strong cables (yaknowwhat'msayin') OR have passed the first part of the paper, if applicable (i.e. MRCS, MRCP and the ilk).

5) Don't panic and freak out.
Which is exactly what I'm doing.

And perhaps,what I should be doing better,
6) PREPARE MONEY FOR THE UPCOMING UPROOTING TO UNCHARTED TERRITORY.
Movers and house rental deposits? Not cheap y'all, not cheap.

7) Get credit cards
Seriously, don't panic and freak out. Just keep revising man. It's all on you in a few months, man. All that responsibility and life-altering decisions.
All you.
So, you know, don't freak out or anything. It's chill.

Emergency Medicine

I'm loving this way more than I thought I would.

There are some seriously bad days, but 99.9% of the MOs are very nice (and even the 0.1% is nice in his/her own way).

NO AM ROUNDS WOOHOO!

Short attention span is fine.

Clerking is short.

ADRENALINE RUSH IS REAL.

YOU give the diagnosis.


I dunno man, it feels pretty real up here.

No ragrets.


Except, I do feel stupid a lot here haha!