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.

Over a Year as a Full-Fledged MO

Okay.

So, they are right.
It gets better.


There are days when it feels like absolute S*&# and you fear the slippery slide to insanity, and best believe those days sometimes come more often than not...

But overall,

it

     gets
         
          BETTER.


Believe in your dreams.
TRY to be patient and not morph into the malignant boss of your nightmares.
No matter how stressed you are.
Pray hard to Him and ask for His blessings in all that you do.

InshaaAllah, it will get better. It may take months, maybe even a year, but it will improve.

So, hang in there.


And when it does get better, remember your dreams (ahem, specialisation?) and GO FOR THEM.

As my favourite medical specialist has told us, do not settle- have an ambition and chase after it. Always strive to improve yourself and move forward; never be too comfortable with where you are.


Thanks, Boss. You will always be our superhero.


And hey, ignore the meanies who tell you you're stupid and make you feel worthless.
Take their advice when given, but ignore the insults.

ACCEPT that you may be so stupid sometimes, it's absurd. Do not have too much ego, okay?
Just accept that your lack of knowledge at that time was inexcusable. You are not super intelligent, even if this title required you to score the highest in all your school years- it means jacks@#& because you are in a field filled with so-called overachievers so again please just accept that.

LEARN. Consolidate. And most importantly, MOVE ON.


Yes it's particularly hard when it concerns certain... beings... but try, for your sake.



Belated Title: Advice to Past Me.
Proper Title: Advice to All Ailing New MOs.

P.S.: I am STILL a new MO. One year does not a senior MO make.

Joy to the Tears

There is no feeling in this world to equate to a post-call after an eventful call.

And there is no feeling quite like realizing, 'Damn, I have the best colleagues.'


There I was, trying to resuscitate an unstable patient in the Red Zone.
Green cases piling up in the background.
Some yellow cases too- being handled with my other shift partner.

Some friends left a Christmas party in the maternity ward momentarily, just to see how things are in the ETD.
Saw the "festivities" taking place in the ETD (*cough*disaster*cough*).

And immediately began clerking green cases. Helped me and encouraged me in decision-making regarding the resus case. Helped me try NIV and coax the patient to follow through- even though that failed quickly.

Helped look after the patient as I called boss for the nth time that night to aid in decision-making.

When the time came to intubate, they were there at the ready- one holding the BVM, another positioning the patient's head, another holding the pre-meds- in lieu of the SNs and MAs who were busy suturing, serving medication, and registering other patients in the background. Supporting me emotionally as my nerves were tattered and frayed from all that has happened.

When intubation was done, they helped set up the ventilator (I am next to clueless when it comes to ventilator settings), secure the placement, fill out and send the post-intubation CXR form.

Stayed there a while longer to ensure everything else was running smoothly, giving input when needed.


They could have spent that time in the ward singing Christmas carols, enjoying more of the delicious food arrayed, chatting about fun stuff or enjoying the reactions as presents were being exchanged, cheery Christmas music playing in the background, laughter a constant presence.
But they didn't.

They helped out someone in need instead, in a place less desirable: filled with beeping monitors, disgruntled relatives, patients groaning in pain and body fluids galore, air filled with infectious microbes- during their off-hours.

If I could award them with APCs, I would award one to each of them. Because my colleagues put the needs of their friends and patients in front of their own desires.


They are the best Christmas presents I have ever received. 

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.

Minefield, Field of Mine.

You would think that after being an MO, you would have more days to be free and thus type in your blog.

THINK AGAIN.

It's not the time that is the issue; rather, the fact that you are too scared to voice your opinion because somehow, with the so-called upgrade in your job title, comes even more fear of being reprimanded. You are even more accountable for what you say.

Hence the anonymity.

I have so many things to say that at times, I am almost bursting. It doesn't help that so many interesting issues are viral particularly in the healthcare sector. But, as always, I prefer to keep mum and let the more outspoken and confident people deal with what they would. Any word or action can and will be held against me at the most unexpected moments.

What a minefield, this field of mine.

*****

I have never pondered quitting so much as I do now.

During my housemanship this was not something I lingered on. I believe I do not have the option to quit, and that I should grit my teeth and bear any form of torture until I am free of this probationary period, when things would become better.

Little did I know things will never become better in this minefield. It just gets seemingly worse.

I am still getting my measly HO salary, but money's not the main issue.
My on-calls are almost always not worth the stress and hours.

You think the brunt of scolding ends at housemanship? Think again. It's not a pleasant experience being scolded, much less when you are being devalued for having less knowledge than a medical student- in front of your juniors and patients.

This is worse for MOs who are not serving within a department with its own boss- the jacks of all trades but masters of none. The KK and district and OPD MOs.

There is too much anxiety and second-guessing. It's getting worse by the day, and quitting seems to be my everyday mantra. It's weird because we are thought to be living relatively peaceful lives.

So guess who just found out that clinical life is not meant for her.
At least, not in this country.
Not in this very toxic environment.

I never thought I was stupid, particularly, but I'm rethinking that thought entirely.
I think too many of my brain cells died and created large dams of negativity held in by strong anxiety walls, surrounded by forests of fear. There is no path for the river of knowledge in my brain anymore.

Everything dead-ends.
Never have I been so unhappy.

Is this the real life?
(DON'T continue singing. Oops, you continued...)

I want to better myself by armoring myself with knowledge and experience but knowledge is a word that sounds too much like no-ledge and it is slipping off of me, repelled by me, and I am scared that I am not getting the blessing nor fruit from all this stress.

I do not know what to tell my parents. Their whole lives led up to this moment of seeing me as a doctor in the family. And now barely 3 years later I say I want to quit?

So, that's what I'm doing right now.
Grinning and bearing, until it gets more bearable, because people say it will.

What Irks

You know being an MO is not all that bad.

Says the MO who has never had to go to a mortality meeting.


And once again I am going to talk about how much I detest the bullying culture that is rife in our  healthcare system.

There I was, in a workplace that is mine but not really, and all the MOs think it's alright to shout every single order to their HOs.
One of the nicer ones even told me, 'It's fine. Use them as your outlet. I do it all the time.'

Um, what?

Of course one can't really go all 'Oh but that is very wrong!' and go on a diatribe on positive workplace environment when one is just briefly visiting, so all one can say is, 'Oh, I'm not really much of a screamer-type. I think.'


It makes me think of my hospital back as a HO, and I thought... Damn, that was a good place for HOs to be, all things considered. Even in one of the most well-known malignant departments throughout Malaysia, we had it good. Most of my MOs do not shout nor humiliate unnecessarily, and some became very good friends of mine.


It starts from the top, as always. If it is very important to the specialists and HOD especially that no bullying should occur, then bullying would be very rare indeed in such a department. If a person is allowed to berate and humiliate their juniors publicly in front of their boss without being reprimanded for doing so, then chances are such behaviour will continue and become the culture and norm.

Which is unacceptable, for me.

Yes, patients' lives are at stake. And you defend your actions by saying you only have the patients' best interests at heart and want your juniors to 'learn'.
Yet all you are teaching them is how it is okay to lose your cool and displace your frustration to those who can't speak up against you. And why is it even necessary to publicly humiliate a junior for the way he/she talks? It's not a life-threatening issue, is it?


I hear one say 'Oh I was nice when I first started. But these kids keep on making the same mistakes and month after month I became 'malignant','

May I just ask, Is it because month after month these HOs change, perhaps, to newer batches?

It's not like we've all never done a lot of the mistakes they did.
I am all for being upfront and scolding where it is due. But do not do so with impunity. Do so with care, and the full intention of correcting and helping, rather than just venting out your anger.

Yes, there will be days when our bosses i.e. specialists and super senior MOs (another race not to be trifled with) scold us, for what seems to be the HOs' faults in the first place.
They will scold us regardless, and talk behind our backs- just as we do behind theirs.
STILL does not make it okay to scold our juniors and nurses unnecessarily and especially publicly.

Instead, reflect on what happened. Maybe you needed that humbling kick in the butt to remind yourself of your place in this world.


I hope I won't evolve into a 'malignant' boss. God forbid.

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.