Get Out of the Way

If you see and hear an ambulance with its siren on, please get out of the way. 

A siren means that there is an unstable patient that is being transported for emergency care, and it is every person's civic duty to clear the road to their best of ability to ensure that time is not wasted.

Today I had the stressful experience of transferring a pediatric patient who was having seizures, and at a point in the transfer his oxygenation dropped. 

Imagine being the health staff, trying your best to resuscitate a patient in a shaky ambulance as it tries to weave its way through the traffic, trying to keep your balance the same time as a hundred and one things run through your head. Imagine watching in trepidation as the oxygenation worsens and having to prepare to intubate in the ambulance as the patient deteriorates.

Then imagine the feeling of looking out of the ambulance and seeing a traffic jam, in addition to realizing how drivers are taking their own sweet time making a path for the ambulance to go through, to the extent that the driver having to make an announcement so the cars in front of him would actually move.

Imagine being the mother in the ambulance, seeing her child go through a situation like that.

Imagine the feeling of the doctor, or the nurse, or the medical assistant in that ambulance, knowing that every second counts - and that potentially this could have been a case of life and death.

Please have some civic consciousness.

An ambulance siren is a serious situation, one where every second could mean a difference between life or death.

Please get out of the way.

The First Exam

It's been years since I've taken an exam that matters.

I had been complacent in my career for years, not willing to attempt the next step towards progression - perhaps in some ways because I had enough turbulence in my personal life that I was not willing to rock the boat any further. I was content in the way things were in my daily life, with my friends and activities, and perhaps, I was reluctant to make the sacrifices to change the status quo.

The thought of change can be one of the biggest barriers to oneself, and yet it's something so essential. 

I always wanted to embrace life, to challenge myself, and yet I held back with the same efforts with my professional life.

The exam itself wasn't a turning point.

It was an attempt to move forward, a progression that I had waited many years to even attempt. A leap over that stumbling block inside my head, one that told me that I would not be able to cope, that there were others who were more qualified.

As I attempted the answers, I realized how uncertain I was, and how little I knew - and it did not seem right to me that I should be content with my state of hesitancy. It was not fair to me, and it was not fair to the patients that I see on a daily basis, and whatever the outcome, it was a reminder that I should continue to better myself.

I was surprised I made it through the exam, one out the twenty plus odd candidates out of the seventy who sat for the exam, many who I felt were more knowledgeable than I.

I did not make it through the interview, but it was okay.

The attempt at the exam was a start.

Now to keep the momentum going!

Happy International Doctors Day

Apparently today is International Doctors Day. 

When I decided to embark on this journey, I couldn't quite foresee how extensive it would be, and how much I would be changed by the conscious choice to embrace the Hippocratic Oath. 

The field of medicine is so vast, and I'm forever thankful to have been exposed to wonderful mentors and had the opportunity to rotate around a variety of departments until I found a field to call my own. 

There is so much I have had the opportunity to learn as a doctor - to speak gently, to break bad news, to be able to stand by my patients in their grief, and on the other side of the spectrum, to share their joy and thankfulness. 

Sometimes the learning curve isn't just about the science and the knowledge. 

I learnt to dream big from my specialists in infectious disease, who played a crucial role in getting RVD drugs introduced and subsidized in Malaysia. I gained confidence and overcame a fear of public speaking through my orthopaedic postings. I learnt the importance of teamwork through my emergency rotation, and how to appreciate the importance of primary care through my community posting. 

I'm thankful to have had the opportunities I've had in my short career so far, and it's changed me as a person for the better. To my fellow colleagues, wherever you are and wherever you are going, it may seem like an uphill battle at times, and it may seem like the world doesn't quite understand - but medicine truly is a calling. 

Keep fighting the good fight. 

Happy Doctors Day!

Life as a Klinik Kesihatan Doctor

Recently making the rounds on chat was a screen shot of a new surgeon who was complaining about training medical officers from Klinik Kesihatan (KK), or district general practitioner clinics. It was an unfortunate situation where she decided to share her thoughts on social media, but put it in a very rude manner – comparing medical officers in KK to cows and the difficulty in training them. 

Coming from KK myself, when I initially read the screenshot that was circulating around I do understand her frustration. There are times when certain doctors enter KK with the expectation that life is going to be laidback and easygoing – and there are instances of senior doctors who have stayed too long within the system and have started abusing it. 

However, to generalize something is exactly that - a generalization and not a lot of people have an idea of what goes on in KK.

KKs are not just your cough and cold clinics, which is a misconception that many have. 

We follow up the stable patients for non-communicable diseases such as diabetes, hypertension and asthma, and try to optimize the patient performance within the shortcomings of time and resources. We monitor their target end organ damage through a yearly ECG and fundus examination and relevant blood investigations. 

The Mother and Child Care clinic looks at antenatal follow up and routine paediatric follow up up to 18 months. There were a lot of things I learnt once I started serving in KK and I consider myself lucky to have been placed in Muar, which has a fantastic, dedicated team of health staff. 

I see an average of 40-50 appointment patients a day, and a higher number of outpatients depending on the day and how many staff we have available. 

Blood tests take an average of a week or two prior to coming back, and having the luxury of (practically) instantaneous results from a hospital setting, this was very different. Follow up was on an appointment basis depending on how many medical officers and how many patients we had per clinic. Medical officers would have to juggle between administrative work and clinic duties, and if there was a meeting that clashed, sometimes it would be a race between trying to reschedule all our appointments or having the resident medical assistant look at them. 

On another perspective, I was stunned myself to realize my staff nurses knew every single mother who had given birth within our district and would go to their home for home visits up to 40 days post-partum. All the mother had to do was to inform their nearest district clinic that they had given birth, and you would get free home care. Coming from an urban area, I didn’t know a single friend who had used this service. 

And the returns! 

Returns were a new word to me, which basically encompasses data collection – a job usually done by the support staff, but as YMs (Yang Menjaga) or Medical Officers In Charge, we would have to keep an eye on these KPIs and make sure that we reach those yearly targets. We would have to answer to the state if we were lagging on these. Returns would include targets for our chronic patients, screening of the general population, school visits, mental health screens – and the list just keeps on going. 

This was just the tip of the iceberg of our Health Ministry, and it was a huge eye opener to see the machinations to keep the whole system running. 

I do miss the hospital setting sometimes. On occasion, I miss the rush of acute care and trying to puzzle out the mysteries of diagnosis. On the odd occasion where I get to practice my basic life support skills, I’m thankful for the training I had as a house officer in Hospital Sungai Buloh. 

However, being in Klinik Kesihatan has taught me more about the big picture. 

At the end of the day, whether working in an acute hospital setting or a district clinic, we all have our part to play and pointing fingers or making generalizations within our profession does not help anyone – much less the very patients we are supposed to treat. 

It is more important to be the best doctor you can, regardless of where you are – to be humble, and remember the principles of the Hippocratic Oath that we are meant to practice by. To be tolerant when needed and teach when you can. To remember what it was like to be fresh and new and ignorant, and to try and better ourselves. To treat our patients how we would like to be treated. 

The surgeon is question was reprimanded and I’d like to think that she’s learnt from her mistake and will continue on in a better capacity that previously. 

After all, we are all on a path of learning.

A Resilience of Spirit

I met an 88 year old patient in clinic who had come in for knee pain, which would worsen when he was doing activity. He was skinny, with really deformed hands, the kind you see with really bad rheumatoid arthritis.  I've seen a lot of older people who suffer from really bad pain in their joints, and this sometimes leaves them unable to go about their daily tasts in life.

As part of my consultation, I enquired about his ability to do daily tasks, especially with the way his fingers were so crooked, but he smiled and waved me off.

It didn't seem to bother him, so I counselled him regarding his knee pain and the likelihood that he most likely had osteoarthritis. I offered him some pain medication, but told him that we had support for physiotherapy and occupational therapy if the pain didn't subside, and that we could always step up the pain medication if normal Paracetamol didn't work. 

He said he would take some for now, but told me that you couldn't 'manjakan' or give in to the pain, or it would gain control over you. He told me that his attitude towards pain was no to coddle it, but accept it and go on with every day life as it is. He didn't mind having a little bit of pain, but it would not be his master.

This man is 88 and still rides around on his motorcycle, does his usual activities of daily living normally and refuses to walk with a cane, just because he believes that the mind is stronger than the physical failings of his body. 

I find myself comparing him to the countless MC seeker that I see for a bit of cough and cold, or the patients who let their pains and aches get the better of them, and I admire the resilience of spirit this one old man has in order in facing his daily challenges.

God bless you old man. 

I'll remember you when I start feeling the aches.

News Should Be More Than Words on A Page

I often find it frustrating to read the news, especially when I feel that there is a lean towards sensationalist journalism than actual investigative reporting. It is disheartening enough to realize the news is full of doom and gloom, from the subject of rape to the decapitation of young children, and most reporting seems to be a mere glossary of the events come by. 

It was particularly jarring to read the headlines of the papers today, which proclaimed ‘Naked Doctor Found Dead in Hospital Alor Gajah’. 

Now, there is news, and there is news, and there is a way to report news. 

The language of the reporting, which was plastered in both Malay and English newspapers is particularly disrespectful. We are not so far removed from death that we ignore the fact it is an actual process that has happened to an actual human being, and thus still deserves some measure of respect. And to a government doctor, a profession that traditionally implies a certain generalization of character which has chosen to serve other humans in need. 

Was it absolutely essential to emphasize how this poor individual was found naked, in the toilet? 

Was it essential to conjure up that image of this person, immortalized in death in the news, in a less than dignified state? 

Do these reporters even realize that this was an individual, whose family was probably in shock over the news, and to hear the death of their son announced in such a way while they were still grieving, is a slap in the face? 

This was an individual who had chosen the sacrifice of time in the field of healing, one who had been on night duty attending to these patients the night that he passed away instead of being with his loved ones as so many of us had the privilege of that very same night. 

The basic tenet of humanity, to even allow this individual a passing of life with some respect seems to have been lost in the dredges of what is considered news, and what editors expect will sell newspapers. 

I think it is time that we remember that the news reports real-life stories, of real people, not just words on a page with no link to those that they are writing about. 

I support the protest made by Dr Jim Loi, President of MPCAM (Medical Practitioner’s Coalition Association of Malaysia) requesting a public apology for the distasteful article that had been published and is now doing rounds on the Internet. 

**Edit: It was later reported that the doctor involved was suffering from a chronic illness of sorts and there was no suspicious circumstance regarding his death.

Hudud: Concerns of A Medical Officer

I have doubts about the implementation of hudud in Malaysia, especially regarding the law of amputation. I'm not entirely clear how these punishments were carried out back in the day, but with the recent discussion regarding the proposal of doctors directly being involved with the amputation has brought the issue to the forefront for a lot of doctors.

As doctors, we practice by the Hippocratic Oath, part of which is the concept of do no harm, even when instructed to. The thought of being the executioners per se, of a law in place is something that needs to be thought about and discussed between authorities and health practitioners. I find it a difficult concept to struggle with, the concept of being out an executioner instead of a healer - and it was with some relief to read about the MMA's president's disagreement regarding the appointment of doctors to carry out the amputation. However, it is still something that needs a lot of discussion regarding the actual implementation of the process.

While I believe the idea of hudud is fair and just, I have my doubts of the practicality of the implementation of this system. If a system is still corrupted enough where bribery happens and people in power are protected, I don't believe we are capable enough of implementing such a law.

Actual hudud works on the concept that the individuals carrying out the law are fair and just Godfearing individuals - of good moral and religious standing. With elements of corruption, what is the possibility of the system being twisted to other means - and the effect on the life of another is severe enough. Everyone wants to be Godfearing, but what if the ones who are supposed to uphold the law are the ones who do not fear God?

We are a long way from there and discussions like this and this gives me heart that everyone is trying hard to look at the different avenues of the issues involved.

For the moment, I don't think we're there yet - there are bigger things to tackle. If corruption still runs rampant within the country and even normal laws are being flouted, where justice is selective within certain classes of society, we are not yet at a point where implementation is going to be just.

Healing

Isn't the body a beautiful thing?

I am watching my wound, the way I have spent a portion of my time every day, and I have watched it heal. Watched how every day it seems to be a little bit different, how the tissues have knitted together to close the gap, to close the edges.

In a few days it will heal, leaving nothing but a trace of the wound it once was.

How beautiful our body is, and it's ability to heal itself. Despite being a doctor and being able to witness instances of healing, it is something that happens so gradually that it is sometimes imperceptible, but our body is constantly working to achieve that state of wholeness again.

The things we take for granted?

It's like magic.

The O&G Battle: The Push for Female-Only O&G Staff in the Labour Room

There has been a huge movement recently in the Malaysian community towards pushing for more female practitioners in O&G, especially with regards to boundaries for Muslims. The original petition here.

While I agree that every patient (not just in the specialty of obstetrics and gynaecology) has a choice regarding their doctors, I do not agree with the hardline stance that male doctors be banned from the labour room, fully qualified or otherwise. I wonder if the individuals behind this petition truly understand the way that our hospitals work, and I write this in hopes that the public is more understanding behind the policies that we hold.

That said, this is written purely on a personal basis and reflects no official stance from any party whatsoever.

1.      Government Practice

The government sector, whilst there has been improvements in previous years, is often limited in the choices of our staff. Staff are rostered on based on a shift and oncall system, and whilst you have more doctors during the day, you may have limited doctors at night.

Please bear in mind that doctors are rostered on based on area as well (dependent on the size of hospital) – for instance, a doctor covering the labour room may also have to do the emergency caesarean section, in which case, the labour room might not have a doctor during this time.

Please also bear in mind that not all labour rooms have the privacy of the more modern facilities.

Also please bear in mind that all male doctors are not allowed to attend female patients on their own – they need to be chaperoned by a female member of staff. It is in your right to request this.

2.      Aurat and Modesty

It is your luck as the patient if the doctors rostered on during the time of your delivery are male or female, and please understand that we doctors stand by a code of ethics: of professionalism, and justice, and benovelence.

In Islam, it is permissible to be examined by a doctor of the opposite sex. It is also the responsibility of the doctor to put the patient at ease by explaining the examination and what the purpose of the examination is. It is a very personal thing for women in labour to expose their private parts, but do remember it is also considered within the boundaries of aurat for females to expose these parts to other females – so please do not use the excuse of aurat for this issue.

Similarly with modesty, when a woman is in labour, she is at her most vulnerable – but it is crucial for staff to be able to monitor the progress. At times like this, naturally there is an element of embarrassment to have strangers examine the vaginal opening – but this is a necessary process to monitor the progress of the baby’s descent, and modesty has to be put aside for what is necessary.

What we do in the labour room is out of necessity, and not for fun. All staff are meant to carry themselves in a professional manner, and if they do not, as a patient, you have every right to complain.

3.      The Push for Only Female O&G Doctors

Whilst there are many more doctors currently in service, it is not necessarily the case within specialties. In Malaysia, where there is a preference for women to play a more passive role at times, it is difficult for some to go out into the field and face these very real challenges – the need to stay overnight at the hospital, leaving their families at home, and the physical challenges of operating.

That said, I have also similarly heard many hypocritical statements where the very same individuals who only want female obstetricians prefer male surgeons. Please bear in mind that the job of an O&G doctor also involves the operating theatre.

4.      Denying the Education of Male Medical Trainees in the Labour Room

Please understand that junior doctors and house officers need to be trained to deal with all emergencies, including birth. Many of us are sent out to districts with no specialists or consultants, and these doctors are the first point of contact for certain communities.

Although it might not seem obvious in such large hospitals, please bear in mind that we doctors are sent out to all locations and we must have to undergo certain experiences, including labour, to prepare us for these future challenges.

5.      Your rights as a patient.

As a patient, you have the right to choose your doctors and those who examine you. However, this is dependent on the resources of the centre you are at. Your centre also has a right to choose how they conduct the training of their junior doctors.

In a private centre, you will have more flexibility, as is the case for most full paying places. There tends to be more resources available, and subsequently, your choice of doctor.

You can try to negotiate to limit the number of people allowed in the room. This is a reasonable request for the most part, and reduces the number of strangers that might go in and out.

You may also try to request having your husband in the room during the labour.

However, at the forefront, please remember that health staff often try to do the best we can within the confines of our limitations, and pray that during your labour, you will be attended by the doctor with the most experience to conduct a safe delivery, regardless of gender.