Saturday, April 4, 2015

Keep Calm and Finish Housemanship

Today, as I was doing my job in the wards one of my colleague made a quick remark of me "well, you seem to enjoy working". I was putting notes on the computer, while playing Echosmith's Bright on low volume on the phone in my pocket. Head bobbing to the tune.

Yeah, I was happy.

I gave it a thought, just a year ago, I hated my job. I woke up feeling nauseous, trying to brush my teeth was a challenge as to not induce vomiting. I had palpitations as I near the hospital entrance. I jumped at every notice the staff nurse gave "Doctor blood pressure patient bed 3 low", "Doctor, temperature patient bed 6 spike", "Doctor, doctor, doctorrrr mana discharge note???". It was overwhelmingly crazy, I admit it was a tough environment.

Today, I admit I am still not one of those passionate and dedicated houseman who would stay back at the hospital to learn something new. I finish my work fast, to get back on time to go for my NGO meetings, to reply emails, to get in touch with investors, to prepare for my next talk. But at least I no longer hate my job. It instead felt fulfilling. Morning drives used to be full of wary imaginations of how the ward would be full, how the rounds would be horrible. Now I drive to work with my brain thinking about...nothing. What will be will be.

I guess as you expose your brain long enough to any challenging environment, your brain will adapt to it sooner or later. The secret is to keep pushing on. The moment where you feel that you are losing out and about to give up, that was when you push the hardest.

For those new houseman out there just starting out, if you feel that you are living through hell, I understand, I was once just like you. But if you keep pushing on you will see enough patients and learn and identify patterns of diseases, patterns that allows you to predict the next course of treatment you should initiate. Patterns that are, in a sense...remarkably beautiful as you discover and bow down to Allah's promise that there is a cure for every illness in this world except for death.

So keep marching on until the sun comes out, and one day, you will be able to say to the staff nurse, with confident, in a most calm and collected manner..."rilex, run 1 pint normal saline dulu, slow sikit ah"

Thursday, April 2, 2015

The Best Job in The World

Last week Hospitals Beyond Boundaries​ produced its first paycheck to its first employee, a local Cambodian Medical Officer in Phnom Penh. We have come a long way from being an NGO founded by 2 medical students, to a group of 13 young professionals that works on voluntary basis, and now an international organization that creates employment for local communities in low-income nations. It feels great to realize that we are creating something that could change the core of people's lives. In the Malaysian landscape where financial security is becoming more and more a rarity, a place where even being a doctor does not give you job security, we, the youth are defiant on permanently being job seekers. We are slowly becoming job creators. Crafting what could probably be...the best job in the world

Wednesday, February 11, 2015

The Rise of the Gen-Y Doctors: Stop Scaring Us Off!

Since I have been working in the hospital for the past one year, I can’t help to notice the burgeoning number of medical students exhibiting these non-purposeful movements inside the wards. There could be up to 50 medical students in the ward at one time, from various universities, private and public alike. While to some of my colleagues, these students are a nuisance and just slow down our work, I actually don’t mind having them around, because not too long ago I was like them too. I understand how it feels to be there to get your cases for teachings, to fill in log-books, to be eager to learn or do something, do some real doctoring. But I can’t help to think “wow, all these people will become doctors? There are 2 to 3-fold more of them in the ward compared to patients!”

The glut of new medical school graduates is obviously not breaking news. I brought up this issue back when I was the President of the MMA Medical Student Society in 2011. Although I am still worried about the glut of new doctors coming in, I do not agree that scaring these doctors-to-be into quitting medicine and find something else to do is the way to go. I don’t think it helps those whose parents has invested a lot in sending their children to medical school, using all their savings, and having high hopes for their children to be the first doctor in the family.

We should stop scaring future doctors that there will be no more jobs for them in the future. If we limit ourselves to the thinking of medicine involves only being in the mainstream specialties like being a cardiologist, neurologist, surgeon, paediatrician and the likes, yes there will be not enough places for all of us. But the new generation of doctors must see medicine as a much wider field, much of it unexplored, and any of our innate talents can be incorporated to advance this discipline of saving lives. Let's face it. Everyone is a genius in their own fields of interest. Even though you are erupting enthusiastic about doing hard-core clinical medicine, there must be certain departments in the hospital that brings you down to the level that made you think twice about being a full-fledged doctor. Forcing someone to be an outstanding doctor in a department that he or she is not interested in is like forcing Stephen Hawking to paint and Picasso to explain about the beginnings of the universe.

We are aspiring to be a first-world country, but we are still having the third-world way of seeing things. We still look at the less-mainstream specialty as ‘second-class’: the pathologists, basic medical scientists, pharmacologists, haematologists, public health specialists, family medicine specialists, etc. When one of my friends aspires to become a haematologist, my colleagues automatically thought that he just wants to be lazy and sit around answering the phone from house officers who need MO code for their blood investigations. Truth is, haematology is a far more challenging field, and I had witnessed it myself when I met with Dr Noryati Abu Amin when I worked for the WHO. She is a dedicated and highly respected Malaysian haematologist that has served the World Health Organization HQ in Geneva for more than 10 years, creating guidelines and protocols for safe blood transfusion that is strictly followed around the world. She is currently the head of National Blood Bank Malaysia. You see, some good students with good memories are born to become protocol-memorizers. Some that are not that good memorizers but are greater on the innovation side are born to become protocol-developers.

In the first world countries, many ‘less-mainstream’ specialty doctors, the researchers especially, achieve great things in the field of medicine, winning the Nobel Prize in Medicine. In some first world countries, you need to have a degree in something else before you can enroll into a medical school. They are very supportive of inter-disciplinary application of knowledge. Every medical student knows David Netter. He took a degree in arts before doing medicine. As a result, he incorporated art into anatomy, and hence produced one of the main references for anatomy that all medical students around the world use. In Malaysia, when you are interested in something different from the mainstream, people label you as ‘not a real doctor’. When one of my MO was transferred department to join the CRC (Clinical Research Centre), the other specialist and MOs looked to him as ‘too weak for the department’, ‘not doing a true doctor’s job’, because he is more interested in doing research. For me, medicine has to incorporate 2 main values: service and academic. Service is important, but if everyone’s doing service, who is going to develop medicine further? As we move on to become a developed nation, our health care must evolve to become that of a developed country, where research comes hand in hand with service. Maybe we need more doctors to study Tropical Medicine and learn ways to stop the epidemic of dengue instead of adding more beds to the hospital, maybe we need more doctors to research the antimicrobial resistance in the hospitals, maybe we need another doctor to even take up politics and revive the old days where Malaysia moves forward at a fast rate, lead by a medical doctor. Smart people are smart enough not to do medicine if we scare them off. If we keep scaring them off, the only ones left to do medicine are the dumb ones who don’t care about their future.

When we see the medical field as a vast, largely unexplored area of knowledge, we will see its job opportunities in abundance. So medical students, or all those aspiring to be doctors, come, come from where ever you are. No matter where you graduate from: Indonesia, India, Czech, Russia, everyone has their own talent that can be incorporated into the field of medicine. Only if we open our minds and see medicine as a wider field. We are the Generation-Y doctors. Maybe a Nobel Prize is within the reach of our generation. In the words of the Irish singer Damien Rice in his song ‘Trusty and True’:

“Come, let yourself be wrong
Come, it's already begun
Come, come alone
Come with fear, come with love
Come however you are
Just come, come alone
Come with friends, come with foes
Come however you are
Just come, come alone
Come with me, then let go
Come however you are
Just come, come alone
Come so carefully closed
Come however you are
Just come…”

Sunday, February 1, 2015

Another Year

Scrolling through photos of Malaysian delegates at this year's WHO Executive Board Meeting, I only realized it has been a year since I was there. Time flies, life has been so much busier, life in the hospital is so much different. But I guess Allah has the best laid plans, everything has a reason. 

One instance is that I was involved in helping to draft a framework for WHO's Roll-back Malaria program in Geneva. I thought my ideas were good, but now I am back in my own country seeing how Malaria really looks like, I had to think twice. It's funny that we prescribe mosquito nets, and the mother tells me the mosquitoes are INSIDE the net, nets are too old and torn, some are even not used and are modified to become fishing nets! (the family originated from Indonesia, and they were back in their hometown at that time).

In terms of my country's own public health threat, the past few months has been exhausting with the non-stop cases of dengue coming in. I did not work on something about dengue when I was in the WHO, and wished I had. The dengue epidemic in Malaysia has totally went out of hand, and it is frustrating to have the same child coming in with recurrent dengue, which he had a few years ago. I could get angry assuming that the parents did not do enough to protect the child, but on further questioning, the parents in fact had done their best to make their house aedes-free. But the problem is, what's the use if you are the only one working to eradicate aedes. The neighbours are still ignorant, the community does not care when a container with stagnant water is outside of their house compound. The community is still malaise about dengue when nobody in their family has died of dengue. They still wish for a miracle vaccine and the government to provide these to solve the problem. They haven't seen a mother crying in regret, asking for forgiveness in front of her daughter's dead body that has died of dengue.

I did not experience this before, and never had a burning desire to solve this at a global level. I guess it is really helpful to be in contact with patients, knowing how they live, eat, sleep, how their socio-economic conditions are. As the words that is stuck at my supervisor's door at the WHO HQ: "Is it sufficient to treat patients and send them back to the conditions that makes them sick in the first place?". That is the thing that kept me going, what gets me through the long hours, sleepless nights, and all the unnecessary yelling and scolding. Another year to go. I'll be back

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"

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