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

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 wrongCome, it's already begunCome, come aloneCome with fear, come with loveCome however you areJust come, come aloneCome with friends, come with foesCome however you areJust come, come aloneCome with me, then let goCome however you areJust come, come aloneCome so carefully closedCome however you areJust come…”

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

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"

 

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.