Yet Another Loss

When I first received the text from a specialist in my old hospital, my heart caught in my chest. Yesterday, the medical fraternity lost another doctor to the clutches of fatigue, in a scenario that is unfortunately all too common for us in this field. 

Dr Afifah was a medical officer in my old hospital, and her story strikes too close to home. I cannot imagine what her family and loved ones are going through, and can only pray that they find the strength to pull through these difficult times. 

We've all been there. 

We've all known someone who has fallen asleep for a microsecond at a point when we were too tired during our jobs; from the harmless swerve of the steering wheel, to the more sinister material or physical losses. 

 We've all made jokes about how tired we were, complained about how little sleep we've had, told our little anecdotes about how we've fallen asleep on patients - as if it's become something so absolutely normal in the course of our daily lives, almost like a badge of honour in our job as doctors. 

Perhaps we were luckier than our other colleagues who did not do as well. The concern among senior doctors is the prevalent belief that your skill is equivalent to the amount of hours worked. That by getting rid of the oncall system we'll produce less efficient doctors, that the health of our patients will be compromised. 

There are too many things to be taken into consideration, many sides to the tale, but as a medical fraternity, it is important to sit down objectively and figure out a system that will strike that balance between medical competency and the wellbeing of us doctors. 

Truth be told, that could have been me. 

It could have been any one of us.

Musing About the Government Health System

Sometimes I think we doctors continue working in the government because it keeps you grounded. 

You see patients who need you, not those who can afford your services. You see those from all walks of life, from the scared old lady who has no idea why she’s ended up in hospital, to the poor uncared-for gentleman whose children have abandoned him, to those individuals who feel entitled to certain services because of their class and rank. You really do see it all. 

You learn that patients are the same, regardless of who they are, or what they earn – all blood, muscle and tissue underneath our different skins. They’re the same uncertain individuals underneath that bluster, but it’s the way they deal with their illnesses that makes all the difference. 

There are times when working in the government sector is tough and disillusioning. There are times where you feel like you want to just see patients, but being a doctor is more than just patients, and as the administration work piles up, it is easy to become jaded with the system – until you remember your patients. It’s them that keep you there, like a life line that reminds you every day why you do what you do. 

Sometimes it feels like you haven’t done enough, or you cannot do enough, and there are days where you despair because humanity is much too harsh at times, and we have all had those moments where we’ve all become a bit too involved with our patients, only to realize we have to slowly pull ourselves back and find that balance between our professional selves and ourselves. 

You see your patients, day in, day out, and cross your fingers that you don’t burn out. It is the core challenge that lies with most clinicians these days.

The government system has its pros and cons, but what I would love most is a greater flexibility at work. A system of shared hours for those who wish to balance a personal and professional life, and a public/private clinic division – an incentive that I’m certain would help retain the number of specialists, and give them the opportunity to focus on their areas of interest.

It’s a pipe dream, but all dreams start from somewhere. In the meantime, I still look forward to work, and hope that every day I’m doing a little bit of good for the world.

The Common Cold

So I’ve succumbed to the flu – after two days of minor sniffles and cough, I found myself waking up with achy joints, nausea and the biggest headache I’ve had for awhile. I found myself unable to get out of bed due to lethargy, and ended up just calling in sick to work – the first time I’ve called in sick for a long time. 

My concerned grandmother kept popping in to see if I was okay, and although I passed it off as a minor ailment, she insisted I had a fever and told me not to bathe. 

What? Not bathe? 

“You have a fever, it’ll make it worse to bathe,” she said. 

Naturally, being scientific minded, I took a shower anyway, but it got me thinking about the perceptions that people have about the common cold. A majority of my patients come in for cough and cold, insisting on MCs (that’s another story altogether), with all sorts of ideas about their symptoms. 

Firstly, having a cough and runny nose are symptoms of nose and throat irritation, which can be caused by environmental allergens or an infection. Most commonly, it’s a combination of both. With most infections, it can be either bacterial or viral, and the confirmation of the diagnosis leads to the available treatment. 

For a regular cough and cold, the prescription of symptomatic medications is sufficient – this means giving medications to relieve the irritating symptoms. It’s also important at this time to drink lots of plain water, as the irritation will worsen when the throat is dry. The use of honey is often also recommended to soothe a sore throat, or lozenges. 

Sometimes, parents are advised to give their children ice cream to relieve their throat – this is when your doctor finds the tonsils to be enlarged. In young children, this might result in coughing and vomiting as a result of the sore throat. 

Secondly, antibiotics are not something that is regularly prescribed to everyone. The use of antibiotics is prescribed for bacterial infections , and this is a diagnosis that is reached with a combination of the symptoms and the physical examination (on occasion, this is also confirmed with a blood test). Usually doctors prescribe antibiotics when they find a source of infection, such as exudates from the tonsils, or reduced lung noises, which may lead them to suspect a bacterial infection. Antibiotics do not work for viral illnesses, which is the major cause for most flu illnesses. 

Because the cough and cold are infections, some myths are not correct – you can shower when you’re having the flu (even if you have a fever). If you have a high fever, this might even help keep the temperature down! If you choose not to, this really is a personal preference. 

And because most treatments are designed to treat the symptoms, not the cause of the disease, anything that helps you personally with the illness is more than welcome. Most of the time, your body will heal itself, because that’s what our bodies are designed to do – fight infections and the like.

Start to A New Life

It's been a busy enough start to this chapter. 

Working in a government clinic, where things are done manually, where patients bring in books filled with doctors notes where I scratch my head to decipher the writing of the previous doctor to come to conclusion with the diagnosis - is a far cry from the ease of using a computerized system that I was used to in my previous hospital. 

I see about 50 patients on my own, and half the time I'm desperately trying to remember the official clinical guidelines off my head so I can make a decision based on good clinical practice as opposed to just starting something based on experience. 

I realize the burden of healthcare and how it stretches across the board, to these well-meaning kampung folk who come in and listen to your spiel, and hope that your clinical skills are enough not to miss the things that shouldn't be missed, and that your conversation with that little old lady about her diabetic medications should be remembered. 

 I'm tired at the end of the day, but it seems worth it. 

Times like this I'm glad I do what I do.

Now I just have to keep the momentum and keep learning the things that I do not know.

Reporting for Duty

This week marks my official transfer as a doctor in Selangor to a medical officer in Johor. 

I reported to the Johor State Department of Health on Monday and discussed with the officer in-charge regarding my posting, requesting Muar as I had family in the area. 

For those who are unaware of the intricacies of the government service, young doctors completing their housemanship in Klang Valley (which include Selangor and KL) are required to do a minimum of one year service in the district Those who are married are given priority to be as nearby to their partners as possible, depending on the availabilities of openings per state, which is very much a transient thing. 

For a majority of us who have grown up in Klang Valley, the uprooting process is something unsettling, especially since the process is sometimes fraught with administrative challenges. During your final posting as a houseman, you are given a form to fill in where you fill in your top three state preferences to be transferred to. If all goes well, you usually get an answer about a month before you finish your housemanship with a reporting date of approximately a month after you finish. 

You can call the officer in Putrajaya to check the status of your application as well (which I would advise, considering forms can get lost or delayed, in which case you have to deal directly with your human resource officers at your respective hospitals). If you are unhappy with your placement, you are allowed to appeal in hopes that the ministry will consider your appeal, should there be circumstances that merit your appeal. 

The downside of the whole process is the fact that when you’re given the reporting date of the state you are leaving for, you do not actually find out the actual hospital or clinic you have been assigned to until the actual date itself – such is the fate of us government servants. It is inefficient in the least, and doesn’t relieve any of the stress of relocating in the first place, without being able to organize accommodation or ask for advice regarding the areas you are being sent to prior to going. 

In addition, I was informed that because it was nearing the end of the year – and the government allocation per state and district for health services was rapidly dwindling, there was a possibility I would not be able to claim my relocation allowance. Sigh. 

While I do understand the need for us junior officers to go out to the district and learn the ropes of the health industry ground up, I do wish it was done in a more orderly fashion – one where we would have the ability to plan in advance. 

Relocating is never easy, even as a single person as myself, without the extra baggage of family to worry about – and without the promise even to be able to allocate accommodation for us officers at our placements, it does cause additional stress to the individual, and the government loses out on work hours from we officers who are forced to take leave to organize our move the week we actually report for duty. 

Thankfully, there were openings in Muar for medical officers and I made the two hour drive down to then report to the District Health Office. Just remember that you'll basically be filling in the same forms that you filled as a houseman - if your human resource officer didn't inform you what to bring (as I wasn't informed) - make sure you have a copy of your transfer letter, your reporting letter, your full registration, your KWSP form, your salary number, a copy of the front sheet of your bank statement and details for your statement of assets. Delaying these documents will delay the process of transferring your salary from your previous workplace to your latest one. Bring along passport sized photographs as well (I'm uncertain if this was a standard number for every state but I had to bring in four pieces).

Considering the hassle I had prior to actually reporting for duty, I was pleasantly surprised during when I reported to Muar – all the officers I met were so friendly, and were very helpful in advising me regarding the administrative duties I had to fill up. The first officer I met made the effort of introducing me to every single officer in the District Health Office (I have to admit I could barely remember their names by the end of it all). Unnecessary maybe, but it was a nice effort on her part. The staff members I met at my assigned clinic were also lovely, and most of them took the effort to welcome me to my service in the district of Muar. 

It was a very different experience from being part of a big city hospital and I think I am looking forward to what the experience will be like. I start my official duties soon, and I choose to take this opportunity to learn what I can. 

For those who have undergone the process, I salute you.

For those who will be undergoing your transfer soon, take heart and be positive.

A Period of Change

I know I’ve been delaying, but change has always been something that scares me a little bit. 

I’ve moved around many places, learnt to assert my independence through dealing with the needs of daily life, and survived through it all – but every single time it comes around to having to leave again, I have a mental freak out. 

This time it involves me leaving home to move to Johor for my district posting as a medical officer. 

Johor. A mere three states down South, between three to five hours away depending on which area of the state. I can’t imagine what I would feel like if I had to move somewhere further, like some of my colleagues who have been transferred to Sabah or Sarawak. 

It’s not the location. It’s the thought of change. 

I had the same feeling when I first had to leave Australia to move back home to Malaysia – a sense of trepidation, mixed with excitement. The thought of starting that new chapter, of meeting new people, and doing something new. 

Ironically enough I’ve always loved trying out new things, and I’ve always liked meeting new people – all issues that suggest a natural propensity for embracing change. However I’ve always seen that as a short term issues, of hellos and goodbyes – nothing like the act of moving from one place to another. 

There’s so much to miss and I’ve enjoyed and appreciated my time as a houseman in Sungai Buloh Hospital. 

It was one of the busiest periods of my life, from being oncall to transiting to the shift system; from the early hours at work to leaving late when needed. From the initial fear of procedures and diagnosis to a more comprehensive understanding of treating patients and dealing with the stressors that came with the job and the people involved. 

I learnt not just how to treat the disease, but how to treat patients as a whole, and a certain work ethic that came from watching my bosses deal with patients. I learnt from my colleagues, juniors and seniors alike, and learnt about the type of doctor I wanted to be. I learnt from my patients, those lessons that taught me humility and patience and the value of dignity. 

My specialists were fantastic and despite the hard work, I loved it. I would not have been the same without the training I’ve received and I can only hope this will be something that I am able to carry with me throughout my life.

On my transfer letter, my head of department even made the effort to write me a personal note on my transfer letter that left me warm and fuzzy and near tears at how one of the most senior doctors in the service made the damn effort to leave a personal note on a letter. Cost him nothing, and meant everything to me.

Change is here. It is inevitable. 

And despite my fears, I will face this head on, and learn what I can along the way.

May Allah bless my path.

 

Only Hope

There are times in my career that you realize what some things are all about. 

A patient in my ward deteriorated today. It wasn't something new - patients in the medical ward deteriorate all the time. Sometimes it's a progression of the disease. Sometimes, despite everything we do, it's their time to leave the world. 

He remained a medical conundurum of sorts, an elderly man who had been perfectly well on his anti-TB medications, save for some kidney complications. He suddenly started coughing up blood and ended up being electively intubated, ventilated on a machine to help him breath. I still remember him struggling as we intubated him, insisting that he could not breathe. I still remember taking his wife aside and telling her to be strong, and that hopefully he would survive this ordeal. 

Sometimes we sit there doing our best for patients, pulling out all stops in hopes that we will find that answer to the disease, to support the patient as their immune systems battle whatever underlying problems they have, and we forget that sometimes you need to put everything aside and start again. 

New diagnoses, new avenues of investigations. 

As we spoke to the family, I am reminded that a large part of our jobs include those beyond the patient - their families and loved ones, and despite us doing all we can, we must always prepare the family when a patient deteriorates. Telling family members is sometimes the most difficult part, and the most profound. Trying to express to them that perhaps it would be kinder to let the disease take it's course, and be prepared for the worst to happen. I don't hold back from participating in that grief, I know that their sadness is precipitated from the news that I tell them, that it is because of the possibility of their loved one dying that I've had to break these news. 

I know this is where I should be. 

I hope he survives this weekend and that when I come to work on Monday he will still be there. I hope that we have done something to help make him better.

I can only hope. But if it comes to that, I hope we have prepared his family to deal with the aftermath of that loss.

Eye in the Storm

I miss silent nights. 

What I would give to sit and enjoy the silence in the cold crisp night, with a tinge of a chill in the air and the stars above lighting up the sky, wrapped up in a snug blanket with a steaming mug of hot chocolate. 

Magical. 

These days I live in chaos, in the bustling, busy world of the emergency department and it is a rare moment to be able to sit back and enjoy a moment of silence. The constant stimulation wears away at my nerves, frays the edges of my patience and I sometimes feel stretched to the core trying to maintain the humanity that I try so hard to with my patients. 

Then again, there are always those moments of laughter - feel good moments that make you realize that things aren't too bad after all. 

One busy night in resuscitation, one of our patients woke up from a comatose state - and ensued a good fifteen minutes of hilarity as the cheerful, demented Chinese uncle proceeded to strike up random conversations with the staff while simultaneously trying to get out of the bed sans clothes. I had a good, honest laugh watching the nurses trying to coax the senile patient back into his bed. 

I still miss silent nights, especially during nights at work where all hell is breaking loose. 

But then again, sometimes you just have to find your eye in the storm.

When the Situation is Reversed

It’s strange how the things you take for granted, the things you do on a daily basis seem different when it happens to those who are close to you. 

Bear was admitted for appendicitis – one of the more straightforward operative procedures that happens within surgery. Asides from the drama that had actually led up to his diagnosis and admission, I was surprised at how worried I actually was with the actual process of his surgery. 

I remember the text he sent. "Appendicitis, in ED. Going to HKL, ambulance."

He was working the night shift that night, and my first impression was that he would be sending a patient to HKL. How my heart stopped for a second when I realized that we didn't send patients to HKL for appendicitis, that he was the patient.

I didn’t want him to be alone when he went in, and I didn’t want him to be alone when he came out of the operating theatre. I didn’t expect to find myself keeping vigil by his bedside for several nights. I didn't expect my reaction seeing him so sick and lethargic, sleeping continuously to keep the pain at bay.

It’s funny how your practicality and everything that you know changes when a loved one is actually going under the knife. As a doctor, I often counsel patient’s families regarding operative procedures, and I am often in a position where I reassure family members regarding operation outcomes. It was also ironic that Bear, a doctor himself, hated surgery – and was forced to undergo it himself. 

God had placed us in a place so we could further understand the things that our patients went through, and I am thankful for that. 

I am thankful that Bear is now discharged and recovering well. 

Alhamdulillah.