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.

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.

In Defense Of The Humble Doctors

"Mak Cik cek kejap ye".

This is not the first time I heard a doctor calling herself 'mak cik' when dealing with a patient, but every time I hear it, it is none other than from a Family Medicine doctor. Family Medicine is a medical specialty provides health care for the individuals based on knowledge of the patient in the context of the family and the community, disease prevention and health promotion.

They are the doctors that we first meet at the local Klinik Kesihatan, before we are referred to the hospitals, if necessary. They are the "gatekeepers" as what the medical fraternity likes to call, the ones who holds the dam to prevent a flood of patients to tertiary hospitals. Through emphasis on disease prevention and health promotion, they not only treat individuals but also the whole community. Family Medicine is an arm of medicine that is indispensable, but sadly are the heroes that are unsung.

Since Family Medicine doctors are the first to see patients, they can deal with any diseases under the sun. Hence in their training, they are required to do rotations for a couple of months in each department at tertiary hospitals. That is when I get to work with one of them, in the Paediatrics department, during one fine Saturday morning rounds:

"Mak Cik cek kejap ye"

She said again when dealing with a child. For some may argue it sounds unprofessional, lacks formality and all.

But I think to a child, it doesn't matter.

There is nothing wrong with it, and I think what is wrong is when a doctor is arrogant enough to be irritated when someone calls them 'Encik' or 'Puan'. She took time to talk with the mother, asking about the family, how they are supporting the child, socially and financially, in a very friendly and humble manner, like really talking to a 'mak cik'.

Being a doctor is a demanding job, I admit. The hospital can consume us and make us think that the wards, clinic and operation theatres are the only thing there is to life. Last week I was scrolling through the Facebook feed a post by a friend of mine caught my attention. It is about one surgeon, allegedly from my hospital, a tertiary centre, arrogantly bashing a Family Medicine doctor, labelling them as dumb and resistant to teachings.

It is quite common, when you spend too much time in the same place, with the same people, to develop an inflated sense of importance, putting yourself in the centre and thinking the world revolves around you, ignoring the fact that the outside world is bigger than what you see. Everyone is good at something, but not everything. It is not wise to judge that a chimpanzee is better than a dolphin based on a race to climb trees.

Respect must be earned, not forced. For many people, the more title you get, the more Dato' Dr, Professor Dr, and all sorts, the more respect you will earn. But for me, I can respect a doctor who is not a little bit annoyed when someone calls them 'Pak Cik'. I would hate it if I spend too much time inside that 4-walls of the hospital and develop this very false sense of self importance for myself. A way that I have found effective is to spend more time on the ground with the community through volunteer work, and secondly through traveling the world. That is how I think Family Medicine and Public Health doctors do it. It is a way to see that the world is wide, and what we do is just a speck of dust in this huge universe.

During my last call there was a death of a baby, which we failed to resuscitate after being exhausted of all efforts, and also a birth in the O&G ward, a premature, which we successfully resuscitated. It happened so spontaneously that the mother did not even make it to the labor room.

Moments of intense pressure makes time move so fast, you barely notice the clock ticking, during evening calls you come in when the sun is setting, go back when it's near noon the next day and punch in when the sun is setting again. I do enjoy the work, it made time felt worthwhile, but the most important thing is that it doesn't end there. It further values and add meaning to the moment when I am free to do what means most to me: treating the community and traveling the world.

Volunteer work and traveling should humble you. I am nonchalant when talking about my NGO trying to build a hospital in Cambodia because I went to South Africa and saw a kid of 17 years old who opened a school, and giving scholarships to people older than him. What I do is just 10% of what a 17 year old kid did. If that doesn't humble you, I don't know what does. We don't see this when we stay for too long in the same place with the same kind of people. Hence I always promise myself to use my free time for my NGO and for travel. It fights off arrogance. It makes me perfectly fine when people don't address me as 'doctor'. Call me "Pak Cik", I wouldn't mind. Because in front of the Creator, I am just a slave

Welcome To Life, Baby

"Premature baby in room 4, os full!"

I heard someone shout as I was attending a case in the labor room nursery. From the footsteps, I fathom someone running nearer and nearer towards me.

"Doctor, you're from paediatrics, are you?"

"Uh yes"

"There's a premature in labor, os full! We've tried to call your medical officer but couldn't get to her"

My heart started to race. Like a reflex, I reached for my phone and tried to call my medical officer. I cannot be attending a premature baby by myself. I was not trained to. A baby born premature can be born with so many complications and the first few minutes after they are born are the critical period that could determine life and death of a baby.

"Sorry, the number you have dialed cannot be reached". My heart starts to beat faster and faster.

"They are calling you doctor!". I had no choice but to run towards the labor room.

"Is paediatrics here?, baby's coming out!", I heard the obstetrician shout.

"Yes, yes, here he is! Don't worry!"

'What the heck', I thought. Don't worry? This is just my 3rd day in paediatrics, I am still tagging and the only newborn resuscitation I know was my crash-course study before my final exams in medical school. The O&G houseman are still trying to call my Medical officer, but to no avail

"Oh, heck" I thought and wore the gloves anyway.

"Paeds, standby, baby's coming out!"

I saw the head emerging as the mother continues to push. Swiftly, after a few seconds the obstetrician delivered the baby out. But something was wrong. The baby was not crying. Hastily, they showed the newborn to the mother, exposing the genitalia.

"Ma'am tell us if it's a boy or a girl? Now!"

Either the mother was too exhausted or she couldn't comprehend the obstetrician's question, she went silent.

"MA'AM IS THIS A BOY OR A GIRL?"

The mother still looked confused.

"Oh whatever, it's a boy!" said the obstetrician. "Baby's not crying, let paediatrics take over!"

"Oh boy" I whispered under my breath. They still couldn't contact my superior. They handed me the baby, and I rushed the baby towards the open hood warmer where all the neonatal resuscitation equipment are.

It is true that in the moment of intense pressure, memories of knowledge you never thought you had in your brain came to emerge out of nowhere. Utilizing everything I know from medical school, after a a minute or two, the baby started to cry. Loudly. His skin turned from bluish to pink. I have never felt so relieved to hear a cry so loud.

It was an intense moment. 3rd day in paediatrics. What a start. Later I learned that the mother was actually unmarried, it was a case of unplanned pregnancy, and hence left the baby fatherless. Sadly, the mother is actualy a Malay Muslim. The nurses told me that I should recite the azan to the newborn baby. So I did,

"Allahu Akbar, Allahu Akbar
(Allah is the greatest, Allah is the greatest)

Allahu Akbar, Allahu Akbar
(Allah is the greatest, Allah is the greatest)

Ashadu An La Illaha Illallah
(I witness that there is no god but Allah)

Ashadu An La Illaha Illallah
(I witness that there is no god but Allah)

Ashadu Anna Muhammad-ar-Rasool-ul-Allah
(I witness that Muhammad is prophet of Allah)

Ashadu Anna Muhammad-ar-Rasool-ul-Allah
(I witness that Muhammad is the prophet of Allah)

Hayya 'Alas Salat
(Come towards the prayers)

Hayya 'Alas Salat
(Come towards the prayers)

Hayya 'Alal Falah
(Come towards the success)

Hayya 'Alal Falah
(Come towards the success)

Allahu Akbar, Allahu Akbar
(Allah is the greatest, Allah is the greatest)

La Illaha Illaallah
(There is no god but Allah)

The baby that was just now crying was silent as I recited the azan. His eyes are wide open, as if listening intently to the words.

With the words of Allah, we welcome you to life

The Time In-Betweens

I used to look forward for things to end. Like in high school I look forward for SPM to end so I can study medicine. In pre-clinical medical school I wish for pre-clinicals to end so I can practice clinical medicine. In clinical medicine I wish to graduate fast so I can become a doctor. However, once I have started working I realize that my eagerness for things to end has slowly fade away. A big part of it has to do with the daily routine of rushing here and there and the next thing you know the day comes to an end. A smaller part of it has to do with the fear of growing old. Time flies really fast when you are working 'in the zone'.

Now I just wish for time to pass by slowly. I no longer look forward for things to end. Housemanship may be considered a tough period of a doctor's life but I don't wish to rush though it. I wish to live in the present, enjoying life as it happens to me. There is so much things to do when we're still young. If I keep a mindset of wanting everything to end: finish Housemanship to become Medical Officer fast. Finish 2 years of Medical Officership to go into Master's program fast. Finish Master's fast to become specialist fast. Do subspecialization fast. The list will never end and the next thing I know I will find myself sitting in a clinic with a distended tummy.

Recently I've learned that creative endeavours, like writing in this blog does not necessarily happen when you have tons of time. It happens during the short periods between busyness. When you know you are going to be busy, you will try to find the time in-betweens. Like here I am, 5 a.m. and writing. I am still struggling to find the time in-betweens to do non-medical stuff, but I am trying. Creative endeavours are important, but it is important to make it in-between your daily job before it can flourish as an independent endeavour. As far as motivational speakers ask you to just jump and follow your passion to fully focus on what you're truly passionate about, it may take some time.

I am talking about a job in general, not focusing on the medical career. This is partly due many Malays that I see quitting their daily job to open an online shop or painting or playing in a band and stuff. Then realise it couldn't sustain them financially, and went back to their former job. A daily job gives you the security of a sense of belonging, a medium to keep in touch with people, and of course the financial security for you to keep a focused mind while you are doing your creative work. So keep your job, do things in-between, and when you're art has flourished, when people start buying your stuff like banana fritters and you become confident it can sustain you financially, then you make the jump.

My mom would read this and worry if I would quit medicine and go painting someday. But nah, this is just a general advice for people who are considering to make the jump in career too soon. I am just finding time in-between my shift duty to write more. I admire Atul Gawande, a surgeon in the USA whom wrote 3 books in between his surgeries, which all I read with much respect towards his thoughts.

Life of a Houseman

I could not even begin to describe how my life has changed tremendously for the last one month. My current and previous work is nothing like one another. I used to work 40 hours a week, from 9 to 5 in Geneva. Even if I go to the gym in the WHO building, it still counts as working hours. Even my 30 minutes nap after lunch in the 'Quiet Room'! Little could I imagine back then that I would now be working more than 85 hours a week, waking up at 4.30 AM everyday, drive 20 kilometres to work, arrive around 5.30 to 6 AM, and work non-stop till 8 PM. That's more than 12 hours a day.

Life back when I was a medical student was even much easier. We go to lectures and teachings. No class? Go to sleep. It is true that working as a doctor and studying medicine is a whole different thing. Medical school is all about medicine. Full stop. Working as a doctor, half of the time involves non-medical stuff like dealing with patient's family, implant company agents, police officers, wardens in the nearby Sungai Buloh prison, lawyers, private investigators, SOCSO agents, and once I have to even deal with SYABAS, a water supplier for one of their employees who they believe is faking or exaggerating his illness. It's a crazy world, this doctoring world.

I was overwhelmed in the beginning, thinking 'what the heck, is this really what I want to do all my life?'. During the start of my work, when I was tagging, the job seems so daunting that I wake up with anxiety and nausea everyday. As taggers, we have to know all 28 cases in the ward, expected to present them at any time during ward rounds, without looking or refering to any notes. The task was gargantuan, and we have to stay until 10 PM everyday, which is the earliest (usually we won't be able to go back until 11 or 12 PM because of more work), and come to work at 6 the next day. That left like 3 to 4 hours of sleep everyday. I did that for 19 days, until I finally got off-tag. It was really a tough time for me.

But I always believe that we can get used to anything if we expose our brain long enough to the new challenges. Our brain rebels when there is too much new information coming in all at the same time. It needs time to digest things. It has been a month and my brain has started to accept this new working environment. I no longer wake up feeling anxious and nauseous. I begin to take more responsibilities, managing clinics, scrubbing in to operating theatres, attaching to the emergency department. Work is still stressful especially in the morning before ward rounds, but the stress goes downtrend as the day goes to an end. At the end of the day, nothing beats the feeling of driving back home feeling good you had a patient's sugar or blood level controlled just by putting a sign on the drug prescription, you sutured close a gaping wound nicely and stopped the bleeding, you nicely trimmed some fingers that went into a cutting machine, and inserted a steel rod into the legs to temporarily help with fractures. It is a truly satisfying feeling.

I no longer have doubts if this is what I will be doing all my life. It can be fun, but we can't see it while we are in the middle of the hectic working hours. It is time like this current moment, where I have a half-day off and working night shift tomorrow, that I can take a step back, think about what I did for the past one month, remember all the things I went through, that I feel it is worth being a doctor. For me, if a work is too much it becomes stressful. But if a work is too little it becomes depressing. I remember times where I had a whole day to write just a single report, but it becomes so depressing because I kinda have a mental block when there is too much time and I don't know what to write. I start writing 2 hours before the deadline in the end and feel depressed again feeling that I could have done a better job. Working in the hospital, you never have free time to be depressed about work. It's stressful, but it's a positive stress. All the work is done in the ward, when you go back you pass over your patients to the night shift doctor, and you go home not needing to worry to much because you believe your patient is in the safe hands of your colleague.

So in the end...yeah, being a houseman doctor isn't so bad. The only thing I still resent is the inability to confirm and convince to your non-medical friends when you will be free. I have always been asked for appointments and meet-ups for either HBB or just catching up. It is so hard to confirm a date where you'll be free because we work on weekends and our day-off can fall on any day and changes every week. It sucks, but otherwise, life's OK ;)

Mountains Beyond Mountains

My favourite paragraph from Tracy Kidder’s Mountains Beyond Mountains. To be honest, I never expect to be working at the ‘HIV Central’ of Malaysia. I always thought that I will be posted to Kuala Lumpur General Hospital. But God has better plans for me. I could not even believe I am saying this, but after 10 month being away from clinical work, I am longing to start again. I enjoyed working at the WHO HQ in Geneva, global public health is still my passion and it will always be, but the field is so vast, and I feel that I need to carve out my own niche, and infectious diseases, the biggest threat to public health, is one of the things I am most interested in. If I look at the public health figures I look up to most, they are physicians first, leaders in public health later: Mahathir Mohammad, John Snow, Paul Farmer, Rudolf Virchow, to name a few. I truly believe that by diagnosing diseases of a person, it will shape your mind and way of thinking to diagnose diseases of society in unfathomable ways. In Rudolf Virchow's words, "Politics is nothing but medicine on a larger scale". So come tomorrow, "ID says treat. Love, ID".