Saturday, January 3, 2015

Death of a Child

"Ibu, jangan tinggalkan kakak"
 
Mother, please don't leave me.
 
Words like this coming from the lips of a 4 year old girl a few hours before she died made me believe that sometimes children just have the ability to know that they will go soon. Adults have their own ways of dealing with impending death, but since being in Paediatrics, I cannot help to wonder how children deal with it.
 
It was a Tuesday morning, and I saw a small boy being pushed into the isolation room, a room reserved for children suspected to have a contagious disease. I was in charge of the cubicle opposite the isolation room, and saw that my colleague in charge of the isolation cubicle was quite busy attending another patient. I offered to help take blood investigations for the newly admitted patient and set a line through the veins to hyrate the child.
 
When I asked permission from the mother to bring the child into the procedure room, I saw her eyes was swollen, fresh tears. It is common for a mother to shed tears when seeing her child in pain. But I failed to recognize that the emotional suffering she endured was far deeper than I thought.
 
Blood taking in Paediatrics remain a challenging procedure for young doctors, not only because the veins are small, but also because children tend to resist aggressively. Restraining a child to take blood is not an easy task. With a bit of a struggle, luck, and the mother holding tight to the child, I managed to gain access of the veins through the small needle. I withdrew just enough blood be sent to the laboratory. However, to my disappointment the needle that I used to squeeze the blood out almost fell off, and as expected, a small bulge formed under the skin as I tried to push fluids in. It meant that I had to insert a new needle. I asked the mother is it okay to insert a new one. I was worried because she obviously seemed sad. But that was when she bursted into tears and said:
 
"Buatlah apa-apa saja untuk selamatkan anak saya ni doktor, kakak dia dah meninggal pagi tadi"
 
Do whatever you can to save him, Doctor. His sister just died this morning.
 
For a moment, my mind went into a halt. She started to burst into tears and hugged her son tightly and went on to say
 
"Kakak dah tak ada"
 
Sister is no more with us.
 
I did not know what to say except to whisper 'Inna lillahi wa inna ilayhi raji'un' (surely we belong to Allah and to Him shall we return). I focused on gaining access to another vein. To my relief, I managed to secure a line, and after cleaning up after the procedure, only then I managed to gather my thoughts and asked the mother what really happened. In a breaking voice, the mother told me that her 4 year old girl died this morning on the way to the hospital. She has been having fever for the past few days, but just when her fever started to settle down, that is when rashes appear on her palms and soles of her feet, with multiple ulcers breaking out in her mouth. She went to another hospital and the doctor diagnosed her as having the 'Hand, foot and mouth disease", by itself is self-limiting and rarely life threatening, and told the mother to rest assured as it will go away on its own.
 
However, that night she deteriorated quickly and started vomiting out blood. At the same time, the mother realizes that the younger brother had also started developing rashes on his hands, and to her suspicion, he has ulcers in his mouth too. That was when the little girl said to her mother "please don't leave me". The mother quickly called the ambulance to bring both children to the hospital.
 
On the way to the hospital, she died.
 
The mother went on to tell me that her neighbour's daughter had came to her house to play a few days before. She also had the same symptoms as her children. A few of my colleagues were aware of the case. We knew that Hand, Foot and Mouth disease (HFMD) rarely cause deaths. Judging from the bloody vomit which might indicate bleeding in her digestive tract, and also the high number of children around the area admitted to our wards with dengue, our best guess was that it was HFMD superimposed on dengue fever. In other words, it was dengue that caused her death, and already having her immune system weakened by dengue, she also contracted HFMD from the neighbour's daughter at the same time, so when she presented to the hospital with typical signs and symptoms of HFMD, the doctor was easily misled to NOT think of dengue and sent her home with the reassurance that it was HFMD.
 
The mother had stopped weeping by the time she finished telling me what happened. I accompanied her back to the isolation room. What she had told me shook me to the core. A lost of a child is tragic, but a soul of a sinless child is promised heaven, a soul that He calls al-nafs al mutmaina: the reassured soul, which is mentioned in the Quran:
 
"O reassured soul, return to your Lord, well-pleased and pleasing. And enter among My [righteous] servants. And enter My Paradise" - Quran, 89:27-30

Nobody can promise you that they can still be here tomorrow. Nobody knows what tomorrow will bring. We keep on thinking that everything will be the same tomorrow as it is today. But the fact of life is that life can arbitrarily cut you off your air. When you have a few hours to live, what would you do? For an adult, mostly would choose to spend their time with their loved ones. The last phone call, the last dinner, the last "I love you mak, I love you ayah". But for a child...maybe all they can say is
 
"Ibu, jangan tinggalkan kakak"
 

Tuesday, December 23, 2014

Finger Fashionista

In orthopaedics, we usually get called down to do a finger refashioning at the emergency department. Just like manicure, finger refashioning makes the fingers look better, except that instead of cutting the nails short, we cut the whole finger short. Our intentions were good though, these fingers were already cut in the first place. We make them look nicer and less prone to infection. A typical mechanism of injury would be that of fingers stuck in factory machines. These fingers look horrible before being refashioned, depending on which machines they were stuck in. Sometimes they are crushed by stamp print machines, shredded by paper shredder machines, lacerated by grass cutter machines, rolled flat by paper roller machines, but the worst one I have seen are the ones stuck in sugarcane machines. They are crushed and shredded at the same time.

Usual patients are the migrant workers, because they are the ones working in factories to operate machines. It is sad to think that these people came here to Malaysia in search of a better future for their family but ended up losing a few fingers. So one day, I had a call to do a finger refashioning for a factory worker who got his fingers cut at a wood cutting factory . The poor guy was a Burmese, must be in his 30s. He was accompanied by a young man in neat corporate uniform, his supervisor. I learned from the supervisor that he just came from Myanmar and did not speak a word of Malay, and just a little bit of English. When saw him, he was in pain and had his right hand covered by a piece of cloth that was already half-soaked with blood. Slowly, I removed the piece of cloth and from the supervisor's story, what I saw was expected: the index finger was nearly total amputated. It was just dangling there, the only thing holding it in place is a layer of skin. The bone was totally crushed. But what bothers me is that the thumb was crushed as well. Of all the fingers of our hands, the thumb is the most that affect hand function. The level of amputation determines the extent of the functional deficit. I knew I had to take extra precaution to preserve the thumb length.

So I asked the supervisor to wait outside while I do what needed to be done. To tell the truth, I liked being called to do finger refashioning. When I am in the sterile scrubs, in the silent procedure room with just the medical assistant and the patient, I feel at ease as the frantic noise of the ED department outside drowns out. I get to escape from the hectic wards for a while. I feel a sense of calm and focus as I start to wield the blade. In experienced hands, finger refashioning should take just about 30 minutes. I took a tad bit longer, but in moments of intense focus, you barely notice the time pass. The fingers were still oozing blood. In a nutshell, I gave anaesthetics to make the fingers feel numb and insensitive to pain, stopped the bleeding, crushed the bones to make it shorter than the surrounding skin, trimmed the ragged edge of the remaining skin and soft tissue to make it look smoother, at the same time creating a skin flap to close the gaping hole, and sew the opposing skin together. Convinced that the bleeding was secured, I covered it with topical antibiotic gel, and then with a white cotton gauze.

I was satisfied with my finger work I did that day. I explained that he needs to take antibiotics as to prevent infection to the injured finger, and has to come to the local health clinic to get it cleaned up daily, and come again to our clinic to get the stitch removed and reassess the wound. I tried my best to explain to him in the simplest form of language. At the end of my explanation, I looked at him. He was looking at me with a blank stare. I looked at him, he looked at me. I was looking at him, he looked at me.

Okay that's it, this guy does not understand a word I said.

Exhausted of all effort to communicate near the end of my work shift, I showed him the 'thumbs up' sign, and said "Okeh?". Although in pain, but perhaps still numbed by the local anaesthetic I gave him, he looked at his thumb, now made shorter, covered with white gauze, lifted it up, trying his best to show me a 'thumbs up', and said:

"Bagus!" (Good!)

With his other hand, he gave pat on my shoulders.

Well, that was unexpected.

I called the supervisor in. I explained the same thing to him, hoping that he will have a way to communicate my instruction to this employee of his. I also mentioned to the supervisor that I had already explained to him, but I don't think he understood, and gave a quick remark that he understands the word "bagus" though. 

But the supervisor said "Uh, I don't think he understands the word, I think he was just imitating my boss".

"What do you mean?" I asked curiously.

"You see, at the factory, at the end of the day our boss will give a thumbs up to those who worked well, before they end their shift, and will give them a pat at the shoulders. They then will happily go punch out their attendance card at the punching machine".

I laughed out loud, and the supervisor had no idea why. The Burmese guy was still smiling, I wonder if he understood what was the conversation about. So he was merely imitating his boss at the factory, guessing that "bagus" with a thumbs up is a sign of appreciation. Oh well at least I know it means I did good job.

I looked at my watch and realized it was way pass my working hours. So after being told 'bagus!' and given that pat on the shoulders, I happily go punch out my attendance card at the punching machine, similar to what factory workers do every working day. In some way or another, we are all the same. I am a cogwheel in a white coat in this machinery called the Malaysian health care system.


Friday, December 19, 2014

Superhero the Musical - The Story of the PPR Kids

"The art of theatre humanises the human race" - Samad, main character in 'Superhero'

After more than 2 hours watching the musical theatre "Superhero" at the National Museum's Auditorium, I still could not believe such a beautiful and lively performance come from the PPR kids of Kuala Lumpur. PPR, which stands for 'Projek Perumahan Rakyat' (People's Housing Project) is an effort by the government to relocate squatters to live in permanent homes with more "comfortable, relaxed and healthier environment". However, "comfortable, relaxed and healthier environment" is not easily achieved when their living space is cramped with limited number of rooms, air ventilation and space to move around. 

With increasing family size, it is easy to feel suffocated living in such small spaces, which why children and teenagers who live in these places often spend most of their time outside their houses and explore the world on their own. While it is a good thing to explore the world, it can also be a risky business for kids when they are out and about without the supervision of their parents. Especially in this city of Kuala Lumpur. Kids can either find good inspiration outdoors and do something good with their lives, or make friends with the wrong people and end up getting involved with unhealthy activities, skip school and worse of all, commit crimes.

On a couple of occasions, I gave talks to these PPR kids in programs that are organized by myHarapan (the Youth Trust Foundation). I was supposed to motivate them, but even before giving these talks, I knew I to had to crack my head on how to get these kids interested. I mean, come on, I talked to those people at myHarapan and they say it is hard enough for teachers to get attention of these kids in school. Why would they want to listen to some stranger coming to give so called 'motivation'? So I decided to scrape all my old scripts and decided to tell a different story. Unlike the speech I gave at MRSMs or high schools, I didn't focus on them to be successful just academically, but on being successful in doing anything that they are interested in. I know there are PPR kids who are academically brilliant, but for the majority of them who secretly have inborn talent, I encouraged them not to be afraid to do what they like, do their best in it, and make it productive. I told them the story of my good friend Jimmy, a chef with no academic qualifications, not even PMR or SPM, who ended up working as a sushi chef in Switzerland. My talk was about going all out in whatever you do. To my relief, I saw their gleaming eyes as they relate to my story, and I know I had their attention when one of them shouted "Mak saya jual laksa!", when I asked them if theu know anything about the food business. Best of all, I saw hope in their eyes.

"Hanya perlu percaya!" (Just need to believe), shouted one of the character during the play. It became a theme of the musical theatre, that if you believe, anyone can become a hero. What send tears down many of the audiences is that these characters, they are not fictional. These kids are playing out what happens to be their own lives living as a PPR kid. They share their story of happiness and sadness, the hard life of their parents to make ends meet, the difficulties they face at school and much more. This musical theatre is organized by myHarapan and Revolution Stage. Through this project, the PPR kids undergo basic theatre workshops. The workshop is divided into 3 stages, and this musical performance is the 3rd stage. I cannot emphasise enough that this effort my myHarapan and Revolution Stage really bring out the best in these kids. I had a chance to talk to some of the kids and the organizers after the show. One of them pointed out how they can see with their own eyes the change in these kids as they go through the workshop. At first they weren't very involved, didn't talk much and were very shy onstage. Now, the audience can see first hand how confident these kids are on stage. With them being so young, there is no doubt that this kind of confidence will take them far in life. The kids told how life has changed for them ever since joining this project. Previously spending time loitering around with friends, smoking and 'rempit'ing around, they now have a productive outlet for their energy and creativity.

It is hard not to believe in the theme "hanya perlu percaya" after the show ended, because you can see in front of you that these kids made it here to become so good in acting because they just believed. I admit I haven't seen that much theatrical plays in my life, but I can tell you that it was an awe-inspiring experience and I would not hesitate to recommend it to all of you loooking for a good way to spend your day. 

The show is still happening until this weekend, 21st December 2014. Details is as in the poster below. Do come, and remember that the ticket sales will also go to this project's funds to enable them to do bigger projects and involve more PPR kids. With your help, more and more of these kids will become 'Superheroes' and lead them to better lives ahead 








Wednesday, December 10, 2014

Idiot's Guide to Surviving Housemanship

What's with all this ruckus about houseman complaining about their housemanship training in the press, and MOs and specialists complaining about houseman in return? I admit housemanship can be challenging, especially for those who just started. I also admit that during my first posting even I harbor the thoughts of quitting. But I didn't, and I have never regretted the decision to stay on while some of my colleagues resigned. Almost half-way though my housemanship journey, I think I'd like to share a few things I've learned for the past one year. I call it the ' Idiot's Guide to Surviving Housemanship', inspired by the 'Idiot's Guide to' series:

1. Don't take negative comments and scoldings personally.
You see, we live in an age where houseman are in excess. Every time a specialist or an MO scolds you, chances are, you are not the first one and unlikely to be the last one. Imagine, nowadays there can be up to 30 to 40 houseman in a certain department at a particular time. Without extension, every houseman will rotate in each department every 4 months. A specialist or an MO on average have to deal with on average 120 houseman per year. So there is a very high chance that whatever mistake you did has already been done by another houseman before, and the scolding is nothing directed solely for you. They just want you to improve, just like others who made it before you. So don't take things personal, they might have repeated the same comment and scolding for the 100th time. So don't go missing in action (MIA) everytime you get a bad scolding. It's nothing personal.

2. MOs and specialist are not out there 'to get you'.
Sometimes when we get real bad scoldings, we tend to think the MO or specialist has this certain mission to wipe us off this earth. We have this feeling that every time they feel our presence, they are there to get us, and when we are not around, they think of ways to make our life miserable. The truth is, specialists and MOs are human with their own personal life too. When we couldn't sleep at night thinking about how this particular MO will mess around with us during tomorrow's ward round, he or she might just be thinking about their next holiday destination, about their Master's application, or about their wedding plans. They don't have time to think about how to mess around with you. There are just better things to think about before bedtime. So don't waste your time at home worrying about tomorrow, instead be happy and spend time with your family and friends, like what your MO is doing.

3. Forget that you were ever on the Dean's list, a 4-flat student or a batch leader during your medical school days
While your achievements are good for motivation, as a houseman, you have to forget about all those because you start your journey just like everybody else, no more, no less. Because no matter how good you were, housemanship is a process of learning, and sooner or later you will tend to make mistakes. What matters is whether you learn from it or not. Many straight-A, 4-flat students just could not take housemanship and quit because they are not used to or have never tasted failure before. They are more vulnerable when faced with harsh scoldings, because they used to be so perfect in medical school. The less smarter ones are the resilient and tough ones because they have faced so many failures and scoldings during medical school that they feel like it is just another day in the life of a medical profession. So no matter how good or bad you were in medical school, forget about all that and start anew. An MD and MBBS is just a starting point. Now you are as dumb as everyone else and everyone else is as smart as you

4. Time is gold, steal it
Don't be an idiot and hold your pee when things get too busy. Volunteer to send the bloods to the laboratory, and on the way back, stop by the loo. Contrary to public belief, doctors are not THAT busy all the time. There are always time when patients are less, workload is low, long interval in between patients. Learn to take a nap wherever you are, just make sure your phone is on full-blast volume. Learn to sleep anywhere EXCEPT where there is no line reception. The most important thing is to make yourself reachable. You're considered MIA when your colleagues and staff nurses couldn't reach you. I know many would not agree on taking a nap during working hours, but personally I think that if I really have no work to do, it is better to take a refreshing power nap than being physically and mentally exhausted, endangering the lives of patients.

5. Your colleague will exaggerate everything
Sometimes when you did a mistake, and then the next thing you have your colleague texting you asking "Hey what happened today, I heard this specialist was furious at you for bla bla bla". Unless you heard from the specialist yourself, usually the story is exaggerated as it goes through the grapevine from one person to another. Things are not always as bad as people tell you. This is another case of 'nothing is personal'. Others might have done a worse mistake than you, and what matters is not giving up, going MIA, but instead take it as a lesson learned.

6. Everybody has their own problems to remember
One of the worst thing that could happen to a houseman is a public scolding, in front of your colleagues, patients, staff nurses, MA, Radicare people, lol. But that, too, shall pass with time. Don't get too depressed and go MIA, because everybody gets their own dose of scoldings and no one has the time to remember yours. Don't believe me? Try telling one of your colleagues: "Man, I still feel really bad for the stupid thing I dad in the OT last month". Chances are, they will reply with "Uh, which stupid thing again?". "You know, when I threw the fibreoptic scope into the yellow bin and the surgeon was so furious I had to go down to Radicare and literally scourge through the piles of waste to retrieve it?". "Oh, that one!". Point is, no matter how stupid your mistake is, in a month you will have to trigger others to remember it. So just learn from mistakes, and don't worry about what others think. In the medical profession, everybody has their own problems to think of, they won't remember yours.

7. You don't get extended because your boss hates you
In the extreme case of being extended, don't feel so down too. You don't get extended because your superior hates you. If they really do hate you, they would have let you pass as soon as possible because they want you out of the department and never want to see your face again. An extension really means that they feel that there is something inadequate in you, and you might need more time to learn it.
So fellow houseman, these are my 50 cents. Just remember, there are thousands of us, each and everyone with our own struggles, and we are all in this together. You are not alone. So cheer up, stop complaining too much, to the press especially, and may us all be great doctors for the better health care of our nation.

Sunday, November 30, 2014

Chichen Itza

My favorite destinations when traveling in a foreign country are either beautiful nature or archeological sites. Both will make you rethink about your existence in this world, make you feel small, but at the same time calling you to do things bigger than yourself. In Mexico, I took a 2-hour journey from Cancun to the state of Yucatan to visit one of the most famous archeological sites in the world, dubbed one of the new 7 wonders of the world: Chichen Itza.

Remember all the havoc back in 2012, propagated by Hollywood that the world is going to end? It stems from here, Chichen Itza, built by the Mayans, where their numbered calendar ends at the year 2012. But according to our guide, the Mayans never said the world was going to end in 2012. For them, 2012 marks the end of an era.
The Chichen Itza was most probably built around 7th century AD, during the golden age of Mayan culture. At the height of their civilization, the Mayans must have thought that their civilization would last until 2012, which then a new era will arrive. But it is a mystery to both them and us, how, having created the most unique written language, sophisticated art, architecture, mathematical and astronomical systems, the civilization disappear without a trace.

As an example of the Mayan's extraordinary mathematical, astronomical and architectural feat, the four faces of the temple of Kukulkan have stairways with 91 steps each, which makes 364 steps total. Combined with a base platform on top of the pyramid that unites all four stairways, it comes to 365, the exact number of days in a solar year. Then At about 3 pm on March 20th and September 22nd the sunlight casts a series of shadows against the western balustrade of the main stairway, which creates an optical illusion of a 37-meter-long snake that follows the sun "slithering" down to its own head carved at the base of the staircase.

When the Spanish conquerors came to discover this ancient site, and came in contact with the surviving Mayan people around the area who seem so humble and shows no evidence of sophisticated mathematical, astronomical or architectural knowledge, the first thing that came to their mind was that the Romans or Egyptians must have been here. For them, it is impossible for these people who seem to know nothing to build such a magnificent architectural masterpiece.

Our tour guide went on to explain that the enemy of the Mayans are Mayans themselves. The Mayans divide themselves into different settlements, and there was no effort to unite them all. Fighting off each other might be the reason how they perished. He also mentioned that the decay in society might also be the cause, political tremors, greed, lust for power, etc, which today's society are also guilty of. Sometimes we are so proud of our achievements, but look at how our society is decaying? Chichen Itza serves as an evidence of how no achievements lasts in this world, even the most advanced civilization of an era. Everything is beautifully summed up in the Holy Quran, Surah As-Sajdah, Verse 26:

Has it not become clear to them how many generations We destroyed before them, [as] they walk among their dwellings? Indeed in that are signs; then do they not hear?

The people of the great Mayan civilization may have perished, but what lives on is their knowledge, passed down to generations until it is still used today. Perhaps knowledge is something which we humans are bound to discover and carry on from one generation to another. It is from our Creator, and never belongs to someone or a particular civilization. That is why I love traveling to places like this. It reminds us that no matter how smart we think we are, every single knowledge never belongs to us. So never be too proud, but keep on advancing knowledge. In the words of a Sufi poet, never let success go too much into your head, but don't let failure go too much into your heart.