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.

Where you lead, I will follow

Re-watching Gilmore Girls.

This time around, I'm closer to Lorelai's age than I am to Rory's.

SO weird.




END OF POSTING WOOHOO!

SO MANY THOUGHTS

1.

DEY. Control your short forms lah dey.

Watpe tew?

Ittew nk gi shopink skrunk

lanje ley?

cntk bju tew.

rege rape?

Rape?

RAPE???@

WHAT THE HECK IS WRONG WITH YOU PEOPLE?!??!?!?!!!



2.

ME IN WARD B: *Running around* AKAK, SAYA SANGAT LAPA--

SN WARD A 1: Dr, tak makan lagi ke? Tu ada nasi lemak Kak S bawak, makan meh--
SN WARD A 2: Dr, jemput makan kek akak buat~
SN WARD B 1: Dr, meh akak ada buat kerepek sikit buat kudap2--
SN WARD B 2: Dr, nak rendang dengan lemang?
SN WARD C: Dr, nah rasa kuih akak buat hari tu!
SN WARD D: Dr, ward kami ada buat makan2 sikit, meh la datang!

ME: -- *CRIES TEARS OF JOY WHILE STUFFING SELF SILLY*



3.

*Stares at logbook*

*Stares at schedule of bosses on leave*

*Stares at unsigned pages*

*Stares at unapproved leave forms*

I cri everytiem. ;___;



4.

Me: I'm so bloody tired.

Also me: Let's watch this 'Shape of You' parody for the 293848945893475934th time since it's 1 am and I'm on-call tomorrow!



5.

People: Dude.

Me: Whut.

People: You're like, almost an MO.

Me: *Fifty feet underwater*
*Gurgling air bubbles*
SRUUUR WUURRRR

How to NOT Die When 'Informing Bosses'

One of the less fine moments in life as a house officer- or any profession, really- is the need to inform certain matters to your boss knowing, most probably, that you will be berated for the information.

Deteriorating or collapsed patients are not included- those require immediate attention and only irresponsible bosses will refuse to heed your call. I'm talking about things in the grey area of urgency, which- unfortunately- make up the bulk of our time. Additionally, these gray-area issues contribute to a major portion of our bosses' source of anger.

By bosses I mean MOs, obviously. You don't normally immediately inform your specialists of abnormalities, do you?

There is no getting around it, nevertheless.
Sure people tell you to be resilient, otherwise don't become doctor lor, but that  sentiment doesn't help much since you weren't born with the resilience of other people. Nor were you raised  the same way. Upbringing contributes to resilience too.

I am a rather sensitive person. Malays may call it the tissue heart syndrome, or 'hati tisu'. Getting a scolding will probably lower my mood for the entirety of the day- so getting scolded early in the day really affects my performance.

But I've learned some adaptive maneuvers, more or less. Mind you they're not miracle solutions, nor are they magic, but they seem to work on me a little.

Okay, a lot, since people think I barely get affected by scoldings some days it's ridiculous.
And at the end of the day, I'm still enjoying my time here which means I'm not too negatively affected.

I sincerely hope this helps others too.

• Preparing/Psyching
• During this time, you should really know your case; the patient's history and progress, and why what you are about to inform can significantly impact the patient's management and perhaps their life
• Convince YOURSELF that it is important 
• Tell yourself it is for the PATIENT- no one else is more important
• Before informing, make sure you have assessed the patient and done the basic steps of management accordingly. If you're not sure, try asking your seniors- yes, that includes your senior nurses who have seen the same management chain day in, day out for years. Bosses hate mere informants
• On the other hand, some bosses hate the idea of you giving your own prescription/management, so just tailor what you do based on what you know of this boss.
• Remember that your boss is not your God. And the moment of wrath, if it comes, will PASS soon enough (this is especially important with more malignant bosses)
• If the last point is not enough, believe that God is fair and those who are truly not well-meaning will get their due

• While informing
• Take deep breaths. Don't rush through it. Better to be a little slower and pace yourself rather than rushing irrelevant and potentially wrong information out of your troubled tongue
• Look ANYWHERE but your malignant boss's expression UNTIL YOU FINISH PRESENTING. Over the phone, this is made infinitely easier
• Remember to be unfailingly polite and humble no matter what. Not for the sake of the boss, but for your own and others in the vicinity
• Don't overthink your boss's reaction before it is received. Just keep your information- and the patient- in mind while you are informing
• If the boss starts asking questions in a scolding manner, just try your best to answer with what you know and bear in mind that any scolding you are about to receive is fine. It is totally fine. It is temporary.
• Remember your responsibility and your duty

• Aftermath 
• If you were scolded, with no positive criticism given- throw the wrathful aspects of the session into a mental wastebasket, and chuck it into the ocean- along with your anger and disappointment. No, seriously, it works, if only a little.
• Keep any positive scraps of the scolding session into your mental scrapbook of improvement (or, you know, jot the new knowledge down somewhere safe and more tangible, like a tiny notebook or your phone, where you can easily retrieve them)
• Remember, again, that you were just doing your duty and your intentions were right (see preparing/psyching, bullet number three
• Remind yourself that you are still learning- and as a house officer, that is your NUMBER ONE goal
• Look forward to your next pleasurable activity whenever you feel like stewing over the disappointing event, preferably one far away from the hospital walls
• Remember it's only a few months of your life until you're not directly under said malignant boss! 
• Remember moments when you were praised. If it's too wounded, your ego needs a boost to function. You're not entirely worthless, mmkay?

Dah.

Tomorrow is a new day!

One Fine Night in a Hospimart

I was wasting money in my favourite shopping place in this district (obviously Hospimart) when a lady came up to me.

"Dr baru habis kerja ye?" asked the middle-aged lady. She was wearing baju kurung, and being there so late at night I wondered if she was the relative of one of my patients. I barely recognise them, but I tried my best to be friendly nonetheless.

"Ha'ah mak cik. Biasalah, satu hari kerja, lapar malam-malam ni", I replied, grinning.

"Tak pe Dr, kerja macam Dr ni banyak pahala..." She told me. I just smiled and nodded, and said I hoped so.

Then she told me, "Sebenarnya anak mak cik dulu pun macam Dr juga. Dia jadi doktor pelatih. Tapi dia tak tahan dengan bebanan kerja... Jadi dia pun dah berhenti. Tak sanggup kerja lagi sebagai doktor. Puas mak cik pujuk dia, dia memang tak mahu dah. Rasa macam luruh hati mak cik... Berharap sangat nak ada doktor dalam keluarga. Nak buat macamana?"

I was taken aback.

"Bagus lah Dr tak putus semangat. Orang yang kuat sahaja boleh tahan kerja macam ni. Apa nak buat, anak mak cik tak boleh nak tahan..." She was getting tearful, and I was reaching my capacity too. How troubled the mother was. Her voice was breaking.

I put a hand on her shoulder and patted her, looking her in the eye.

"Mak cik, saya pasti semua yang berlaku ada hikmahnya. Rezeki anak mak cik di tempat lain. Mungkin dia yang akan boleh jaga mak cik nanti, walaupun dia bukan Dr.

"Saya sendiri, atuk sendiri sakit, ibu bapa sendiri sakit, jarang sangat dapat nak melawat. Sebab selalu jaga orang lain punya atuk, orang lain punya ibu bapa..." I felt my own tears threatening to fall, but I plowed on.

"Saya tahu mak cik sedih. Tetapi percayalah, mak cik langsung tak rugi kalau mak cik percaya pada perancangan Tuhan. Mestu ada hikmahnya, saya percaya. Mungkin tak nampak sekarang, tapi lambat laun mesti mak cik perasan." 

The lady nodded,wiping her tears. "Saya tahu, tapi kadang-kadang masih rasa menyesal."

I nodded sympathetically. We exchanged a few parting words, and I took my leave, my head abuzz with emotions and thoughts.



It's almost natural, it seems, for parents to want at least one of their offspring to become a doctor- except to parents who actually are/were doctors. At least it seems that way in this country. And it transcends racial boundaries.

I do not understand the fascination, not entirely, but then again I already am a doctor. I am well aware of our capabilities and our large limitations; I was, in fact, a product of such thoughts. My parents really wanted me to become a doctor. I was 'brainwashed' since my infancy, to the point that I actually thought I was here of my own volition.

But that's obviously not true.
No toddler would want to do this for the rest of her life.



And yet there is something so tangible, so rewarding, at the end of the day. The moment you leave the hospital, one of those rare moments where you are actively reaching beyond the walls of your wards or the hurtful words of your seniors, your own thoughts of inadequacy. These are the moments when you feel, 'Yes, I can do this for a lifetime. I can keep on doing this, just give me some breaks in between.'

And life as a house officer, I believe, is way more rewarding than medical student life.

Don't get me wrong, student years are very fun and there is no beating that 'no responsibilities' feeling. But now I get to own my hard-earned money. The hours can be crazy long, but we do get some rest in between. And in the end, I contribute. Despite my lack of experience, and sometimes my mistakes; despite the scoldings of being mere 'clerks' and the feeling of just having to follow orders. Despite these, I have contributed to the society in some way. I have helped save some lives.

I have, most importantly, played a part in alleviating other people's pain and suffering, and brought smiles to their faces.



Perhaps this can be the most rewarding job in the world. But for it to be that way, I must always look above and beyond my hospital walls.



And I pray, so that those parents- whose hopes seem shattered beyond repair when their children refuse to become a doctor- will find the truth and see the advantages of a child not working in the healthcare service. Most other jobs are rewarding, too, as long as one's intentions are right.



Anyway, it has not been the easiest past few weeks. And the story I just told happened in one of my previous postings. I feel like I lost so many insightful moments when I do not write them down somehow.

But at least this one will stick for a while :)

My Current Mission

I AM ON A MISSION

TO FINISH MY LOGBOOK.

And also to really truly decide if this is THE posting for me, because I have never enjoyed a posting as much as this one.

Seriously.
I'm thinking of taking MRCOG, this is how serious I am - and I haven't even REALLY truly conducted a delivery all on my lonesome, nor have I done a cesarean section!

Even during the most busy days I find myself enjoying it and that is just insane.

Also on a mission to

- Lose weight
- Be healthier
- Get married
- Be more patient
- Earn more money
- Be more disciplined
- Have more books

etc, etc.

Woo O&G!

My frequency of posting entries here is dropping at an alarming rate.

ALARMING!

I'm going to say one thing for now:

I am mostly enjoying this new posting. Heh heh.

Okay byeee