Of Humerus Fracture & Swiss Cheese Model

Yesterday as I left the clinic I was suddenly overcame with a feeling of trepidation. I felt as if I had done something wrong somewhere but it's a vague sensation with some poor memory recollection of what actually had transpired in the first place. Later that day in the ED group there's an alert of a patient being wrongly discharged with a soft tissue injury following a fall where in fact she sustained a fracture of her right humerus bone. The doctor who was seeing her did not noticed the fracture from the x-ray. Turned out the doctor was ME.

I was utterly devastated. I was only informed of the error when I entered my night shift last night. I knew that the x-ray was somehow familiar but for the life of me I couldn't recall which patient I was seeing and whether I had assessed the patient properly before deciding that it wasn't a fracture and discharge her home with just painkillers. The x-ray in question is this:

There's an EP (Emergency Physician = specialist) who is in charge of reviewing each and every x-rays done to all patients who are discharged home without referral to any primary team (Ortho, Surgical, etc.) and he was the one who saw my mistake. To my (and everyone) horrid, I was alone in managing the case and I did not consult any registrar or EP regarding the x-rays and just took the matter on my own. The EP and his team managed to call back the patient after multiple calls made (God bless her, she was at school the whole day! KILL ME!), a U-slab was plastered on and patient was discharged with a referral to Orthopaedics clinic as outpatient.


Upon further asking colleagues around, it was determined that the patient I saw was in fact a patient who was halfway been seen by another colleague who covered for me when I went for Friday prayer. She had assessed the patient but at the time when I came back and did the pass-over the x-ray in question was not done yet. Add to the fact that I saw the patient near the end of my shift, there's a lot of cases that I still needed to see - the pressure and stress to finish it without extending my shift hours for too long had added to the error. It was my TERRIBLE MISTAKE for not reassessing the patient MYSELF and subsequently missed the fracture, leading to a wrong diagnosis and wrong management for the patient.

In Medicine, there is a thing we called Swiss cheese model of incident causation. Whenever an error is made, there should be a committee or someone in charge who will evaluate the whole situation in finding out everything about the said error, from the cause of it, the risk factors that can lead to the error, people or systems that are involved in facing the errors, and finally to the consequences the error caused. This whole thing is called a risk-stratification. I now will continue with my shameful but necessary reflection using this model. Sob.


Imagine a stack of multiple Swiss cheeses like this:

1. Each layer of the Swiss cheese represents level in the organization involved who faces the potential error. Error here is the end result or the actual damage that happened. The arrows in the diagram above are the hazards, or simply put, a potential error.
2. An error is made when every layer of the organization failed to stop the hazards from going through the emmental holes or the flaw in the system / organization (see the longest arrow above).
3. Understanding what the flaws that exist in each layer help us to stop the hazards from going through, thus preventing it to be an error. A prevented error is also called a near-miss incident.
4. Notice that in each layer some holes / flaws are bigger than the other. However, the smallest flaw can still permit a hazard to pass through unresolved. That hazard then can pass on to the next layer with a potentially larger flaw.
5. In my case, the layers of cheese can be made up into three layers:
• Green zone, where I first saw the patient
• Registrar / EP on call, who are assigned to supervise the doctors in Green zone
• EP in charge of reviewing all x-rays of patients discharged home of the day
6. In this model there is also what we called latent failures and active failures.
• latent failures are the system or environment that passively contribute into causing hazards. In my case: congested patients in Green zone, too few doctors to attend the case, among the few.
• active failures are the one who directly causing the hazard. In this case, it's ME. I failed to assess patient myself, I failed, to correlate the symptoms with the imaging, I failed to notice the error, I failed to discuss with my bosses, among the few. In the future I would see myself ALL PASS-OVER cases that were handed to me. I will even retake the history and repeat the assessment MYSELF. Also, all imaging of high-risk patients I will discuss with my bosses, no matter how much I know it's gonna cost me more time and my patience.
7. In the second layer, I would say the flaw was that I found it cumbersome to reach my bosses when it was too hectic. They are available to be reached for case discussion, but they can also be terribly busy at most times. I'm painfully aware it's MY FAULT anyway for not approaching them and in the future, I would discuss with them all cases that I find.. high risk.
8. The third layer is when the hazard stopped. My EP noticed the mistake, made the patient to come back to the hospital to get the appropriate treatment, the mistake had been alerted and I had found it discerning but it is for my benefit anyway (sob!) so that I can reflect on it properly.
9. I would say it is not a complete error, because the hazard was identified and correction was done promptly. An actual error (I'm trembling now) would be that there is a neurosensory loss and the arm of the patient was affected badly due to my incompetence. I would say I felt the steely haunting stare of Miss Rifa behind my neck, cursing me on my stupidity and wishing she had never passed my Ortho rotation viva assessment back then.

After my last night shift ended today on which I worked the whole early morning with such a gloomy mood, thinking that I am never gonna be good enough, that I should just quit being a doctor and cursing myself for even thinking of taking paper, or that I would never see patients in the clinic anymore - now that I wrote this down, properly reflecting on what I had done wrong and planning on how to avoid making the same mistake, I feel a bit better. Well, I still know I am stupid, but now with a renewed spirit to become less of an idiot.

Okay, that's it for now. Pray for no more error from me in the future. Ameen.

PS: What's the fracture and what are the nerve and artery that rarely but may be damaged?

The Thinly-veiled Curtains

I can't remember the last time I felt subdued coming back from work. If I'm to guess, the last time I encountered something that made me feel raw from the end of my hair to my very toes was when I came upon the undiluted rage as a grief coming from the relatives of the deceased patient. Sure, death comes and it goes. I saw more deaths since then. But over time they no longer shake me. I do fear of my own death but its crippling fear and sadness that blacken the grief just seem to mellow down.

In other words, death becomes impersonal to me. It simply became one of the simple yet unchanged outcomes of the patients coming in to the hospital. It does not change when I came to the ED. There's just so many things that need to be done, so many patients to look after, that Death bustles in and out in between the multidirectional torrents of people here like the easy flow of air. 

When you are too busy at work, deaths become harder to affect you. Sometimes it feels like there is a layer of veil that cover your eyes from the presence of the demise. That's what it always feel to me. I skirted here and there, fast on my feet maneuvering along the lengths of this thick curtain just to avoid getting tripped in the seams of Death. Anything but to deal with the grief that comes after the Death leaves. I make do with the necessary paperwork and occasionally I provide some explanations to the family, but never to witness the aftermath that follows. Deaths are impersonal, I reminded myself.

But it is never a simple, fail-safe neat trick. In came a man in his early 30s brought by the stretcher with an MA on it performing CPR to him. He was playing football when he suddenly collapsed on the field. We were already informed regarding the case beforehand and had already prepared one resuscitation bay area for him. Once he was safely transferred to the bed, the green curtains that cover each of the eight bays of the red zone, were drawn over Resus Bay 4. A number of things were done simultaneously - probes and cuffs were attached, lines were inserted, mask delivering oxygen was put on, and a small line of people queuing up for their turn to continue the CPR. Sheets of papers were filled up, passing of important figures and instructions were heard - all within the confinement of the drawn curtains separating between the attending staff and the onlookers.

However, there's simply no amount of curtains that can cover the anguish cries of his family members who waited patiently just outside the curtains. In between the thumping sound of the recoiling chest and the verseful of commands, all sounds and noises waved into frequency. Even during the hecticness of the situation, I could make out exactly everything that was happening. Of the soft voice of my MO explaining to the widow that there's nothing left that we could do, the beeps of the monitor yelling the level of Oxygen in the blood is fast diminishing, and the sobs of the deceased's friends who just arrived to the ED having learnt of the devastating news. It was getting all too familiar and all too painful. After everything is settled, I skirted again in between curtains in the red zone with only one or two glances towards the ones who are left behind. Again I said to myself, Death is ever impersonal.

Later at some time near midnight came in another patient, this time a middle-aged lady brought via a stretcher again being CPR by an MA from the triage. We quickly got into the usual routine and, "skreeet!", the curtains being pulled over. This time I handled with the things outside the curtains, namely getting the history of what's going on with her. The one standing outside was the patient's sister and after a brief of the history taking, I asked to talk to her son to tell me more about her condition as he was with her when it happened. In walked a teenager - lanky, medium build with dark brown complexion.

He gave off the impression of someone coming from a lower socioeconomic background, an impressionless kid coming from the suburban and rural areas - something that is actually expected. No 17-year old who spends time with school and friends should be knowledgeable about medicine and diseases, but it was a disadvantage all the same when taking a history from people apart from the patient themselves. Some patients don't even know or care about what's wrong with themselves, let alone of other people knowing about the health issues of the patient.

He said that his mother had been having breathlessness for quite some time now, and when he came back from exam that day (Day 1 of SPM), his mother told him that she had a fall. She didn't feel so good so she asked him to buy him dinner and so he obliged. She went to sleep early and sometime at 8pm she woke up and asked for water. The son later slept beside her and was startled when he noticed her mother's snore suddenly stopped. He tried to wake his mother up but she didn't wake up.

All the while when he was telling me of what's happening at home, I couldn't gauge his reactions at all. He was stoic. Unlike her aunt who was visibly distraught and near tears, he kept to himself and just stood at the corner beside the resuscitation bay silently. I couldn't see where his gaze was at and it was a bit unnerving. After more than half an hour of resuscitation attempt, she also succumbed to death. My MO then came out and stood in front of them, explaining that unfortunately the patient had passed away.

The aunt broke into tears and sobbed while hugging the nephew's head. Again, he was silent, but the gaze was no longer there. It just.. went away. He didn't cry, he didn't shout in anger, he was just neither here nor there. I did wondered, later that morning, whether he already expected the worst and was bracing for it to be confirmed. Imagine his love and his world gone forever but there she was, only inches from him. Imagine him going back home with one less person in it. The rest of the red zone was still the disarray and I was needed elsewhere, so after I was done I began to walk away from them.

And that's when I saw it - the curtains was pulled back a bit, not much, more like from the billowing of some unknown wind that lifted part of the curtain - of the boy, still silent, bending forward over his mother's head and kissed her forehead in the most serene and heartbreaking way of a son saying farewell to his mother. There's no tears coming out from him, only the act of love that will never be responded.

I was reminded that not all love are shown. Or need to be displayed. That we never know a person truly, only of what they choose to show. There are many layers of veil covering what's inside of us and what is outrightly display to others. When I looked at the deceased ID card taped onto the clerking sheet, I saw that of her round, smooth face covered with a scarf. It was a different person from the one I was doing crash intubation to.


It strikes me that for every patient that come to us, they are someone else's mother, father, spouse, child and etc. That in everyday's work, it's easy to forget that there are veils that cover who patients are and their mark into the world. That every patients have more than just a face and a name. Each and every one of them deserve as much respect and dignity when we are treating them. That at some way, we allow ourselves a few moments of time in silence just to think of them. And for that, I dedicated this piece of writing to remember them by, with prayers in-between, and a promise of work efforts that they all deserve.

The Drilling Noise of a Heartache

This is her first time setting foot there. The place is big and crowded with people. Not to mention the weather was scorching hot and sweaty. It was bad enough that it took her quite some time to reach there. The traffic was simply horrible made worse by the construction with loud drilling noise that has been going for months, obstructively holding up both lanes with its makeshift alternative routes. But it's the only road leading to the hospital she's rushing to come to so she had no choice.

She felt very uncomfortable coming to the hospital. She was never being warded before and her distant relatives who were admitted for one reason or another were never close enough for her to come and visit in the past. She loathes hospital and anything unholy that resides in it. The groans and cries of the sick, the smell of medicine and the pus, the sight of blood and the broken bones, or the very air itself that seems to be stagnant in the corridors and linger among the patients there - she couldn't stand it.

Until her father fall ill and was rushed there.

It was sudden but late. Sudden that it happened out of the blue and late in the sense of her being notified about it. She was furious, but the anger abated as fast as the cold fear that started to creep in. She wasn't at home with him when it happened. She didn't have a clue. Her mother was there with him, in the kitchen where they usually are for tea break. One moment he's there, talking while sipping his favourite black tea and next moment he fall to the floor, unresponsive. Her mother dropped to his side, frantically calling him unsuccessfully before dialing the emergency numbers.

 She only knew about her father late in the afternoon after her class. She had a mini quiz that day and she remembered feeling good about it since she had studied for the course consistently. Her phone rang while she was on the way back to her room. It was her mom, and when she answered she knew instantly from her mother's tone of voice something horribly wrong had happened. She wanted to go straight there to the hospital but her mother forbade it. "It is late and it's already dark", she said. She asked her to come the next morning. She said not to worry a thing, that she was already at the hospital with him. Then the call ended.

It took her a few hours of driving to reach the hospital. Her mother told her that her father was transferred to the ICU. She may know not much about hospitals, but she knew enough that ICU is where the very sick people are being treated. Her mother told her a bit more about her father's condition but she found it near impossible to comprehend fully without looking at the issue with her own two eyes. Her grip on the steering wheel clutched tighter as she pressed the pedal harder.

When she arrived, she saw her mother is sitting on a long bench outside ICU beside her friend. They were talking, unaware of her approach. She saw her mother was still able to smile and talking energetically with her friend. She came to them and shook hand with the lady before asking about her father's condition. Still smiling, she said that they should be able to enter to see him very soon. There is a limit to the number of visitors that can come visit at a time so they were waiting for turns. So they waited and she just listened to them talking.

Then when their turn came she went inside with her mother at her side. There, in the corner was her father with a lot machines beside the bed with wires and thin tubes connected to here and there. There was a long and big tube connecting one of the machines that entered her father's mouth as well. Every rise in her father's chest made the machine beep with a soft sound. Her father's eyes were closed. He looked weak. She tried calling him but the nurse told her that he wouldn't be able to respond as he was heavily sedated. She stifled a sob.

The young doctor nearby came to them and started explaining about her father's condition. He told them that there's a huge bleeding in the brain causing him to lose his consciousness. With him being intubated there is a risk of him choking on the content of his stomach and causing infection back up to the lungs. His blood pressure has to be supported with multiple medication as it was too low. The chance of recovery is very abysmal, very slim, that they have to be ready to expect the worse. She couldn't comprehend anything beyond that point. Her mind was elsewhere. Her sight went blank. She was dimly aware of her mom's grip in her hand. She walked off in a dazed and sat back on the bench outside.

Outside, there were two guys sitting on the bench as well. They both work as doctors and had went in earlier to visit him. One of them is the son of the visiting friend. They were talking to her mother's friend. Then her mother sat down as well and they talked to her, explaining in a simpler way of what's going on with her father. There was nothing new that she did not already know, so she just sat there silently. The noise of the construction drill just outside the hospital seemed to drill into her broken heart, boring it bit by bit with each passing time. 

She couldn't see how her mother is handling the news this well. She was still be able to greet those who come and visit, ushering them to go inside the ICU with a smile. She was finding it very difficult to even open her mouth, let alone having to deal with all this. When they parted ways with her mother's friend, she said to her that she has to be strong for her mother. That if her mother breaks down as well then nothing will go well. Her eyes were already wet at the time. How pitiful of her mother, how she wishes that her mother is given the time to properly be sorrowful. That being strong all the time isn't always the good thing. That behind every smile and every warming words, there is a sadness that needs to be heeded.

Mother's Love

What strikes me the most here in Paediatric posting is how strongly I was shown that a mother's love is the fiercest of all. Whether it's the new mother with the firstborn or the middle-age ones with lots of children. There's no compare of how strong their love of their child is.

Restrain your judgement to the mother who passed down her HIV blood to the baby boy who is still sick with various complications of the retrovirus disease infection. He's been admitted here for 7 months already. But when you look at how the parents never leave the baby's side, at how the mother only look at the baby all the time, even sleep with the baby in the small crib - you know. You know that her love is real.

You may have already encountered the real fussy and the dreaded overly-anxious mothers who don't trust doctors with their babies. The shouts, the complaints, and the mere look of distrust as they think we have no other work to do but to make their babies suffer for a number of accusations. But see properly and you can see that in between lines of worry or in the glazing eyes of fury they do what they do is because they are terrified for their child's safety. That is love in primal instinct all mothers of every creature has. The fierce love.

No matter how sick the child can be, or how hopeless the prognosis is - no mother I see abandon their love of their child. You see it in the children's silent tears. You heard it in their cry asking for their mother. You witness it from the shine in their eyes when they see their mother. You know it is true. That's love.


You see it more often in those moments. But you see it too in the moments of despair. When the mother was not there when the child is scared and lonely. When the child is very ill and neither the mother nor the doctor can do anything at all to make it go away instantly. Love is equally abundant both in sickness and in health. Love is there before the child is even born and love will always be around when the child leaves the world earlier than their parents.

And in lights of recent tragedy, I give my heartfelt love to the ones we all missed. To every children I loathe to take care of, I give you my love all the same and assurance that you are all loved. That whether it is shown, or seemingly abandoned, you are loved just by being born. To the ones who prompted me to write this post - the Indian and Malay mothers that took care of their bedside Chinese girl when the girl's mother is not around, I was deeply moved. A mother's love has no racial or religious boundaries. Thank you for showing me your love.

And last but definitely not least,
I love you too, Mama.

Sensational Surgical Stories

Per rectal is the surgical fave like how VE (per vaginal) is for O&G lol

Can't believe I'm near the end of my Surgical posting. I remembered I was feeling restless working in the ward during the first three months. At the beginning, that feeling of having to get accustomed to new environments, new bunch of people, and new stressors at work is something I truly hated. Not all wards are unpleasant - there's one I really like working with because the staffs are a bit better than the other two, but I was really counting days to leave ward work and to start peri work.

For the record, any surgical-based posting is not something to my liking. It's not that I hate it - I just don't prefer it. There's something about surgical that really does not resonate well with me. In the first place, I hate being in the OT (operation theatres) because it's freaking cold and I had to lower myself when assisting the surgeons because I am quite a tall person. It hurts my back and I am not a fan of wearing scrubs and rubber boots. Secondly, I am really bad with anatomy so it goes against everything in Surgical to be poor at identifying which arteries or nerves supply which organs etc. 

But ultimately I am bad with anything and everything huhu. I just know how to do work - just a functional houseman but not really a lighted bulb person. I'm not even a hardworking doctor. I just do my job diligently without causing any issues to my bosses. The keyword here is: be a safe doctor. That's the minimum that you need to achieve.

There is a few cases throughout the four months in Surgical that have an impact on me. I never had the time to properly dissect each event and do a reflection on it, so this time I'm just gonna list them all out and briefly remind myself why each of them is important to remember them by.

1. Confused man yanking his catheter out

A male person with severe head injury after getting into motor vehicle accident - he was not fully conscious, in a lot of pain, and he sensed that a rubber tubing was inserted into his penis (it was a urinary catheter as he couldn't control his own urination) so in such a confused state, he proceeded to remove his hands from the restraints he was on in bed and savagely tried to pull the catheter out. 

Because a catheter is designed to have a balloon at its tip that can be pumped in the bladder once inserted (so that the tube won't come sliding out on its own), it can't be removed by pulling it out without deflating the balloon first. So that person tried yanking it out. The tube was stretched and stretched and when he couldn't get it out, he let go of it. Yep, it retracted back like any rubber does - straight into his penis and abdomen. He grimaced in pain and I couldn't do anything. Blood started to come out from his penis because of the self-inflicted injury and I was left with my mouth open, wordlessly gaping as I silently cursed in bewilderment.


I was at that time, holding his other hand and body from falling out of the bed. It happened so fast and that's the best I could do. It taught me that with people having severe injury to the head (and brain), they must have a lot of extra safety precautions. I have to anticipate the things that may go wrong and to be alert with the changes. It happened during the first week of entering Surgical so it really did nothing to improve Surgical's first impression to me.


2. Four foreigners being shishkebab-ed with parang

I was working in ward when my leader asked me to become a runner for a multiple MTP (massive transfusion protocol) cases in ED. Without missing a beat I agreed (anything to get away from the ward) and I started running to ED. Long story short, four foreigners were assaulted with parangs. All of them sustained bad penetrating injury with lots of blood loss, so MTP was activated to all of them. Runners (there's four of us) are tasked with the job of getting all the blood products from the blood bank as quickly as possible. In this case the transfusion is required direly to replace the blood loss. It was very tiring. I think I lost some kilos from running up and down the stairs many times that day.

I am making a mental note to never, never, ever set foot in Klang again once I'm finished with my housemanship. There is so many weird cases that I am certain won't be happening in more peaceful area.


3. Man choked on fishbone

A young man was choking on a fishbone during meals at a wedding. It was a big one based from the drawing he made. Apparently following that he took a page straight out the old midwives' tale - he pushed more rice down his throat in an attempt to relieve the choking. It didn't work, obviously. He vomited blood the next day and was admitted for an upper tract scope assessment (OGDS).


After the morning rounds in the ward we all started to do the morning tasks. For that patient, we had to get his consent to do the scope. As I was available at that time, sure, let me do it so I can tick him off the ward job list of the day. I was busy filling up the form at the cardiac table in front of his bed so that all the patient needed to do is to sign the front and the back page of the form when a student nurse interrupted me to inform that the patient is vomiting blood.

I already know the patient's case. So I said to her that it is expected to happen. It was a small amount, we are planning to do scope anyway, bla bla bla. I was a bit crossed for being interrupted. I just wanted to finish my work fast so I can move on with another patient after that. Then the patient vomited again. And again. AND AGAIN. He was holding the yellow plastic bag to contain the vomit but the blood he vomited was wayyyy to much. I was still holding the stupid pen and paper form in my hands, watching him as he bled all over the bed and onto the floor (and my pants and shoes too).


I quickly said to her, go get help. Now. I straight away called my colleagues as well and we attended the patient. He was in a dazed and not responding to our calls - a sign of shock due to blood loss. My internal bell is ringing with frantic alarms. The patient was pushed to acute cubicle, we ordered first stage blood for transfusion straightaway and patient was pushed for emergency scope. I was so caught up with wanting to finish my work I had neglected the thing that mattered most - the patient. Sufficed to say this is the biggest lesson I learn throughout this posting. After the incident I tried to stop any work I was doing when I need to attend to patients. I also avoided from eating fish for weeks afterwards. Seram mak.



4. Elderly lady with low blood pressure.

I kinda make it up when I met this elderly nenek who were admitted because of surgical site infection. Her thick abdominal skin was infected and was removed, leaving muscles exposed. One day when I was reviewing her in the morning, again one of the student nurses informed me that she had a low blood pressure. I asked her to repeat the measurement and the reading remained low.


This time I properly took my time and examined her thoroughly. She indeed had low blood pressure, and together with such a big wound across the belly, I suspected that she was in shock due to blood loss. Her gauze packing under the vacuum dressing appeared to be soaked, so I thought there must be some active bleeding happening. After ordering for a pint of run-fast crystallloid resuscitation, putting her on high flow mask oxygen, ECG and cardiac monitoring, I straightaway called my MO to inform him.


I felt good when thinking back of my plan at the time when I saw the patient. I was able to think calmly and did the right thing. My MO didn't correct any of my continuation of the plan - we both agreed to it and worked on doing them all. But after that he forbade me from touching any high-risk patient because he said if I started touching the patients sure more issues will come out of it afterwards HAHAH. The sad news was unfortunately weeks later I was informed that the patient passed away eventually. I was a bit saddened because she was such a softie and I tried my best to comfort her when she was in pain. Inalillah.



5. MO getting into a motor vehicle accident.

One of our MOs was involved in an accident and was admitted here. Long story cut short: this incident had prompted me to have a Takaful. I have a friend who is a Takaful agent and after a very short consideration, I took a Takaful with a few adjustments made that I think will benefit me the best. Takde kuasa aku nak kena admit kat hospital gomen, lagi-lagi kat tempat kerja aku ni. Kalau betul terdesak for operation, maybe yes, but afterwards nak mintak transfer balik ke private for better nursing care. Hey, that's my two cents anyway.

_________________________________________

There's only a week or more left for me in Surgical. I just need to complete my logbook, present my slides on next Friday, planning on what to do during my four-day EOP leave before return to the vicious cycle of hellhole tagging in the worst department of all - Paediatrics! NIGHTMARE OKAY. I AM SO NOT READY. KILL MEH

Jonah

The first time I've heard of this term when I was in final year of medical school. I naturally didn't understand much about it because it's hard to understand things if you're not part of it. Siapalah aku kan time tu, just a medical student yang blur blur dan tak paham apa-apa. But in essence, I roughly deduced it means someone who when at work will attract incidents that will make their work shift eventful.

Kata-kata orang yang bangga dengan dirinya yang jonah

The term jonah is a slang word used exclusively among healthcare professionals in Malaysia and is very popular among housemen and staff nurses. Medical officers used the term less, and it is almost unheard of among specialists to utter the word in conversations. It is often used to tease colleagues who often appear to have very eventful work shifts when compared to other colleagues. We usually tease them in light-hearted manners, although I've once witnessed a staff nurse throwing a bitchy temper when she learned a 'jonah' MO is oncall during her shift.


As a Muslim we believe in qada and qadar (takdir dan ketentuan) and accept that no such thing exists - no person is unlucky and to truly believe in jonah is a thing of khurafat. To just tease each other with it is fine. No harm done.


In a working environment where there is no consistency in the form of work load, I find that it is peculiar that such a word is coined to describe people who bring 'troubles' to work. If you work in the ward, yes, there are jobs that are a constant - a work routine that we do and follow as standard operating of procedure (SOP). For a houseman, that would be to do morning reviews, trace the blood investigations / formal imaging reports / formal lab reports, follow ward rounds, and performing the tasks ordered by the MOs or specialists. That much is expected.


What is also expected is that no two patients will present identical workload to the doctors / staff nurses. Similarly there is no two days that are identical. We expect that the number of new admissions to the ward differ from day to day and that different patients can collapse or deteriorating at any time. There is simply no consistency in that. We cannot say that a day which has 12 admissions and two patients desaturated of oxygen as a 'troubled' day because no matter how bad any day is, it is all within expectations when working in a hospital. Dey, kalau kau tengah attend CME hospital then tetiba ada orang collapsed kena heart attack itu baru eventful, macha.


Nevertheless, it is a culture I enjoyed to be a part of at work. More than once I have been labeled as jonah (even though I think some people had it worse than me). I used to hate it very much being a jonah when I was in Medical because working night shift in Medical means you will be busy working clerking a handful of new admissions and taking patients' blood for the whole ward. Granted, during my time I always have a colleague working with me and we don't have to rely on the runner for blood taking, but I absolutely loathed it when other things happened like relatives wanting to speak to the specialist to make complaints, patients making a scene or developing blood transfusion reaction at midnight (hence it is imperative to not transfuse blood after 6 pm unless it is absolutely necessary!).


I don't mind if things like patient developing a temperature or a low blood pressure or even an active patient (as opposed to a DIL) collapsed and needing CPR - it is within my responsibilities. But to handle things that are time-consuming and irritating in nature? Things like wrestling with a severe head injury patient to prevent him from yanking out his urinary catheter and failed, then watching in horror as blood dripping out from his penis due to the injury he himself inflicted, or trying to calm a patient down as he angrily shouted at us wanting to sign an AOR (At Own Risk) discharge form (which then my specialist said go and refer him to psychiatrist for delirium at freaking 9pm WHICH IS NOT THE CASE! HE JUST WANTS TO GO HOME, and which we did discharged him close to midnight eventually after calling the patient's whole family for a psychiatry evaluation and conference), or attending a staff nurse who had an ankle fracture after she slipped on the floor in the ward (yes, I even pushed her on the wheelchair to do the X-rays at 11pm, gosh that was funny and annoying at the same time) next to a patient's bed who late at night we heard a loud bang as the patient also fall to the floor as he tried to get up from his bed (and failed). LOL thus an incident reporting was issued.


That is what I personally think what a jonah is about. Sometimes all I could do is to gape open-mouthly at the absurdities of what is happening in the ward. Other times I would find myself grasping at my hair and screamed silently in consternation - being jonah is absolutely a true exasperating moment you have to experience it yourself. You will come to be proud of yourself at the end of your work shift - either because it finally ends or you managed to emerged unscathed with no harm to patients done - and calmly accept the fact that yes, despite dah mandi segala air mandian bunga, avoiding all red undies and clothes, dah sembahyang cukup-cukup siap tambah solat hajat tolak bala - you are indeed a jonah.

Why I (kinda) Like Being a Doctor

I have come to realize that I have never write a post, a proper one, that shares insights of what being a houseman is all about. You know, the one post that is just full with positivity, optimism and general good vibe feeling when reading it (Wait, I haven't? What did I write all year long then?). Sure, I wrote about my misfortunes and my depression and my encounters with patients but it's about time I write some good things instead. This blog is becoming darker with each post (thanks, sis, for pointing it out cis) so some sort of a balance is needed here, fellas.

Feel-good, positive vibe coming right up

And so here I am, as promised, after some time of pondering and wrecking my brain to figure out my key highlights of being a doctor. I will try my best not to sound generic and cliche like what most doctors or future doctors like to tell. Yes, I am sure some of them would say they like being a doctor because of that satisfaction of seeing their patients getting better or because it's a noble profession etc. yeah I'm sure they mean it but it's not meeeee, okay? You want my honest feelings of why I sometimes don't hate being a doctor (sheesh, fine, I like being a doctor) so let me have my say here.

I guess the first time I feel satisfied with what I am doing right now was just this recently when I met this patient that I clerked when he first came in and subsequently under my daily review (meaning I know the case inside out and can present to the specialist without even touching the BHT ceh ceh ceh). I had to request for a KUB ultrasound imaging for his acute urinary retention (meaning the urine won't come out) and so I had to present it to the radiologist on that day. The radiologist listened to my presentation attentatively, asked few questions and we even ended up discussing about the case.


What I want to say is that it feels kinda great (it's actually a fantastic feeling for me) when the one we are referring to (or requesting for an imaging) genuinely wanted to know why we are requesting or referring to them. You will be surprised at how often you will encounter people who are irritated or annoyed whenever we approach them. When we present, they are not looking at what's really wrong with the patient, instead they would find reasons to reject the referral or request.


I mean, I GET IT that they can't approve all requests or accepting just any referral made to them. But their lack of interest or the annoyance of the possibilities of their work to be increased is just.. well, fucked up. That's why when that fortunate encounter happened, I feel very satisfied doing what I do. That was one of the rare moment when I feel that I truly work in a team (an interdepartmental one, too!) for the benefit of someone else. Even if my request is denied or when the referral is rejected, I feel satisfied aplenty if they explained properly why they think the rejection is warranted.

NO NO NO NO NO 

only happy thoughts here, fellas. Happy thoughts. Positive vibessss

Moving on, another reason why I kinda like being a doctor is related with the patients themselves. Okaaaaayyyy, it does sound a bit cliche but I can't help it, can I? Don't get me wrong, who would not feel brightened when patients who were near death's door when they first admitted slowly get better and were discharged with leaps of improvement? The last patient who recovered like that made all of us grinning from ear to ear whenever we were reviewing him. Such a wonderful feeling.

But most of the time, I wouldn't care much about the patients that way. When you work in a big hospital with such a high patient turnover rate (meaning a lot of patients admitted and discharged at one time) and being in charge with a lot of patients, you will miss the luxury of being emotionally spent in every patient that you found. Often you will just be glad that patients are being discharged so that you don't have to take care of them anymore HAHAHAHA it's trueeeee! You will see, this will happen often enough especially when the patients are difficult both to treat and to please. 

I have lost track of times I resisted from doing this facial expression when dealing with difficult patients. One classic example: Approaching patients to draw blood and I didn't even start or anything yet and then they will make a tssch sound and scolded me as to why I need to take their blood everyday. A proper scolding, mind you. Like it's my fault they got sick or something. Jadi doktor memang best sebab boleh kena marah dengan semua orang dari patient ke relative ke staft nurse ke specialist yeay~

So how do I, a fairly cold-hearted bastard (as claimed by some), enjoy the nature of my profession? Amazingly I do enjoy interacting with my patients, and they more or less also appear (I hope!) to enjoy interacting with me. I do this by doing a lot of small things, really. I found that small talks, gestures, and tiny acts of kindness often reciprocated with grand gratitude from them. Be it just an insight to their meals and the shared feelings towards the taste of the hospital's diet, a lending hand to sit up or for a walk to the loo, offering my hand for them to hold whenever they are in embarrassment during a procedure or scared shitless with the state they are in - they appreciated your presence very much. Even if they don't tell you. Even if you don't think it matters much.


At times, they make it known they are grateful. A gentle pat in the back while I was doing my work to inform me that they are going home now, a good morning/bye bid whenever they see me, or a simple sentence like, "Ahh, you are the one I want to see, doctor" can make me swell with this yucky thing called happiness. Thank you for thanking me. Sobs.

And the third reason why I love being a doctor is how this "noble" profession, which when you think of it, IS NOT noble at all when all you do is doing gross stuff like sticking your finger literally into people's arse or vagina and slicing off dead tissues and rotten flesh from their sacral sore or diabetic foot, is how it makes me hmm.. humble. (AM I, THO? HUMBLE??)

In a self-reflecting note, I think I am. I don't make a fuss about me being a doctor, no, not really I should think. Blogging about being a doctor is a different matter. I'm talking about my humility while being someone in the profession of taking care of other people's health that I don't think of myself as being superior to others. Working in a hospital you are bound to meet a lot of people from various walk of life. Most often than not, doctors are indeed, humble (some of them, la. Mana yang berlagak nak mampus tu pergi mampus LOLOL). 

I guess I am arriving to the same conclusion that they might have already drew years ago when they started working that as a doctor, be it a first-posting houseman, a senior MO or a consultant, that we can't possibly know all the things. Even if you know so much about your specialty, you can't possibly be able to treat the patients with just your expertise. Older, experienced doctors often know about this, that's why some of them are blissful to work with. They know their own strengths and limitations, and they do not hesitate to ask help from other department.

At this point of being just a houseman, to me, being a doctor is all about doing tasks they entrusted to you whether you know it or not. The point of doing them is to learn about why you are doing it and how to do it properly. The why can be learnt from books or from your superiors, but the hows is more versatile. Never, ever, be arrogant enough and not asking for help. I love to ask the staff nurses on how to do things like suturing, preparing IV drugs, bladder irrigation, and thousands more things. They KNOW more than you do. Sometimes, patients also know more than you, because they have been dealing with it longer than you do. Do not feel ashamed, even if you think it caused bad impression of you to them. It's better to learn and do things right than being arrogant to admit that you don't know and doing it wrong.

So that's it! Yeah, it's mightily a short list to begin with, but these are what making me keep on going. At days I will lose all hope and nothing will feel right, but on some days, when these happened, I think I don't regret for choosing to be a doctor. My advice to future doctors and aspiring students alike is: Chin up. You can do it. Good luck with your endeavour!

Of Raw Rage that Galvanized Grief

There's a rage in every grief. It can be a small thing - the silent clench of hand, the murderous angry stare that aptly targeted to everything and everyone, or the slow, hot drops of tears as curses fly at the world and its unfairness. It can also be huge and eruptive - the wretched wails, the uncontrollable violence and mayhem, or the sheer explosive of raw anger at the misfortune that befall.


I've witnessed the latter kind of grieving anger today when one of the patients died, in the day of relative tranquility often found when working over the weekends. I have seen a lot of families with their relative succumbed to death in the hospital. It was never a pretty sight. It was a horrid affair, it is horrible to witness, and it sticks to mind too long when it should have been long forgotten.

The Man Who Asks Too Much

Sometimes it is unrealistic to be true to your profession. The four cardinal ethics of being a doctor that has been repeated over and over in my university days (and still stuck to my mind) are patient's autonomy, beneficence, non-malevolence, and justice. Briefly, it means that patients have their own rights, we must do good, do not harm, and be able to fairly decide which patients are more in need for the limited resources at your hands. But just by being ethical does not make you a doctor. It is only one of the many facets of the existence of being a doctor.

Ding!

As I have a few more hours to kill before going to work later this evening, I want to talk about something hashtag #irritating that everyone will encounter when you are in this hospital. Well I am not naming my hospital, but maybe some of you know or don't know where I work, anyway let's just leave it as it is. That something #irritating is called,

THE LIFTS.

You may laugh and pointed out how callous or petty my topic is but believe me, the lifts they have in this place can and will drive you all to nuts. As opposed to new hospital buildings which have more than one lift lobby, my hospital only have one main lift lobby with 5 + 1 lifts and a smaller lift lobby at the far back that is used for VIP or royalties. The far back one has two lifts and they are also connected to multiple floors of operation theatres. 

Now, to all visitors and staff alike, the lifts that we use are the ones in the main lift lobby. There are 3 lifts in a row facing two lifts opposite and another one lift to the side that is for sanitation materials and waste use. Let me draw a quick sketch of the plan of the lifts in the main lobby:

Okay just imagine this is it, alright? It's not accurate so don't bother pointing it out.

Now to begin with,

Ever since I started working here close to 11 months now, LIFT 4 has never been operational. There is always a stop sign in front of its doors saying close for maintenance. Or wait, there might have been in the past, now I don't even remember about that lift because I never use it.

Lift 5 is reserved only for patients, in the sense that the patients being transferred in wheelchairs and in bed. The transit is both ways, either from ED to the wards or from the wards to Radiology department for imaging or being sent to different floors such as ICU or to OTs. There are security guards stationed at every floor that keep track of the movement of that lift to ensure that the waiting time or the transit time of the transferring patient being kept at the minimum.

I have no quarrel with that lift. That lift is a good boy.

The remaining lifts are straight a-holes. 

Lift 3 can go between Ground floor up to the 6th floor. Now I am in Medical posting at the moment, which are in the 7th and 8th floors. Yes, I can always use that lift and take the stairs to my ward, and yes, it will keep me healthy, 

And the #irritating thing about that lift is that its bloody doors won't even shut off properly. Imagine being in my situation; you are late / tired / in a hurry / claustrophobic and the lift decided that as the doors almost close it opens the doors back 2 to 3 times. There is no one outside who is pushing the buttons and no one inside pressing the open door button but that damned lift still like to toy with my feelings and wastes a good 5 minutes just to close the bloody doors. What a dick.

The next #irritating lift is Lift 2. This one is an epic one because you can only press the buttons 7th and 8th floors. They used to put a plastic cover but they changed it to a freakin' metal cover with three square holes so people inside can only press G, 7, and 8. The idea is that this lift is meant for people who wish to go to Medical wards faster. That idea is a novelty and naive at the same time simply because it won't stop people from stopping that damned said lift from other floors! So what's supposed to be quick ride upstairs or downstairs can be equally exhausting and long if the lift stops at every floor to load and unload people.

Adjacent to it is the Lift 1 which is supposed for people to go from Ground floor to the 5th up to 8th floors. During the peak hours there will be a guard manning the lift from the inside who will stop people and ask which floor they are going. If the answer is less than 5, they will stop you and ask to use other lifts. In practice, this is also a dick move because like I explained earlier, have you seen the annoying bloody lift directly opposite like?

Apart from that, Lift 1 has this #irritating quirk which that in between the stops, it will sometimes reset all the buttons. All the lighted floors will disappear and if you are not quick enough, what's supposed to be a going up lift will suddenly become a going down lift when someone downstairs is calling for the lift. This, my friends, is enough to make anyone scream with frustration especially when you are from 8th floor going down to Ground floor and on the 1st floor it happened and now it goes back up to where you came from. #TrueStory bro.

Most of the times, Lift 6 comes to the rescue. But it has its own drawback as you will be sharing it with huge waste and sanitation bins. The floor sometimes is wet from the leaking bins, and sometimes it is as smelly as the darkest pit of Tartarus, and one time it lost all lighting and air ventilation for a week and hence the smell magnifies to a hundred-fold. I had to be in complete darkness with odors of garbage and human piss or whatever bodily fluid there are  but that lift is the only lift with no stupid quirk that #irritates me to no end.

Now that I let it off my chest with this rant of mine, I do feel lightened up. It is as if my spirit has lifted up!

Maybe It's Just Medical

There is a few things that I wanted to blog about, mainly about leaving my second posting Orthopaedics and another is about the daunting aspect of entering Medical posting. In between, there are things worth mentioning as well. But things happened during that time, and when it subsided many more things had pressed me to adjourn the writing.

And hence, a super-packed confusion hella of post today.

Thank you Orthopaedics for being nice to me. Not everything is nice in it, but overall better than my first posting. I feel disappointed towards my viva performance but after a while, knowing you passed out of pity and be graded more towards performance (and your lack of issues) as overall instead of knowledge is definitely better than not passing your viva and having to be extended for another two months. Even though you do feel shitty afterwards because it did not went as well as you hoped.

Entering Medical is a bit funny to me. People called us seniors because I'm the third poster already when in fact I feel as useless as a strata rock under the sun. It's not like I know any better. It's not like I can draw blood any faster. In fact, my venepuncture skills more or less is at where I came from - minuscule on average, lucky at best. There are tonnes more things I don't know. I don't even think I learnt much in my two previous postings.

So when junior housemen said things like, "Kau takpe, kau dah senior," "Ala, kau dah power, kau senior," I was like, "Tang mana aku powernya?" I'm still scared shitless when patients desat in the ward, I still don't know what to do when nurses came up to me to show that the patient's DXT is deranged, I still don't know what to do when patient's BP is dropping or sky-high. So far I'm not liking my latest week of working night shift here.

But I'm learning. That's all I have to do. I'm learning.


I have entered the third week in Medical now. The first week is the tagging week where I had to complete my taglog by simply listing up a number of procedures and asking MOs signature for each of the procedure. The second week I worked at night shift, where people who had already underwent Medical posting are green with envy looking at the number of houseman working at night - two, to be exact. I for one have no complaint about it. I certainly couldn't cope working alone at night at the moment, and the time when HO shortage to come is inevitable eventually. But for now, I take what I can.


I still couldn't adjust to the busy working condition in Medical. I wasted my post night sleeping due to fatigue. When I woke up, I still feel tired. Not to mention there's a tonne of things I want to read about but all the time I have left I either spent it sleeping or complaining about the need to sleep. Partly there's Orthopaedics to be blamed. The working condition in my previous posting was so chilled and relaxed it felt like a holiday compared to Medical here.


When I'm under a lot of stress and being overwhelmed with fatigue, that's when my health deteriorates. I do get sick easily and the frequency of me catching illness is so often I can predict when next I will fall ill and won't be able to get up to work like I normally do (for instance, today I don't feel so good). Anyway, when I do get sick, I still go to work - but I'll be covered with a face mask all day and my mind would get sluggish and I won't be responsive and cheerful. I'll be a walking zombie, ordering medication and checking more zombies in this place I called a hospital.

A Mother's Strong Back

No one has ever truly appreciated what I do as a doctor and how I do it. I am in Peri team almost two weeks already - everyone has to be in that rotation for a fortnight - and I am counting days to finish with it. Being in Peri means you are going to do a lot of walking (and running) from patient to patient, ward to ward, and inevitably, from building to building.

I am covering the Ortho cases from the medical female and isolated medical wards which consist of the entirety of the 7th floor. There are four of us hamba orang (HO) covering the whole hospital that includes Paeds, Surgical, ICU, etc. so we divided among ourselves on which wards to cover. There is a lot of pro and cons covering certain wards, for instance: Covering as a Peri Ortho in Surgical ward will give you very few patients to review but the cases are severe. That is because the patients who are treated under two departments such as Surgical and Orthopaedics very usually mean that the patient is of multiple trauma e.g. motor vehicle accident.

And for me covering the medical ward, the usual cases I see are the diabetic foot ulcer, pressure sores, and infection of the skin (cellulitis). The cases may be simpler and after a few days, become repetitive, but the number of cases that I have to review every day is simply stagnantly a lot and burdensome. 

And for that reason, coupled with being chewed and gnawed by my super scary specialist after not presenting cases properly during round (because I didn't have the time to review them all), I had to come early to work every day. Like, super early as in I start reviewing my first patient of the day at 4 am in the morning. That's how early I have to be. And in the hands of newly and fresh MO out of the oven, work became inefficient and as a result, I hardly be able to go back from home on time.

There's one patient I met in the medical ward that strongly reminded me of my late great-grandmother, Nenek Ik. I was notified that there is one patient to be admitted into female medical ward from the Red Zone Emergency Department. She was brought to the hospital the night before, and only late in the afternoon the next day she was stable enough to be transferred upstairs.


She was septic and her conscious level is deteriorating. We were referred by Medical team to have a look at the cause of her sepsis which is her back sore (sacral sore). For those of you who don't know what sacral sore is, you can try research for it from Mr Google or Grandpa Wiki. The way I usually explain to the patients and their relative is sacral sore happened to the person who was bed-bound for a long time. What happened then is that the body's gravitational weight put a pressure on the point of contact between the body and the mattress. Don't be shock - even though the mattress is soft and comfortable, the long contact pressure of your body onto it can cause a break in the skin (like melecet, or bergesel) and once the skin breaks, then the muscle, tendons, and even bone follow suits.

Skin is one of the vital organs of our body - it is waterproof and the first wall of defense from micro-organisms that cause infections from entering our body. Thus when the skin breaks, the layer of body tissues underneath it are prone to infections.


When I came to see the patients, one of her daughters was sitting in a plastic chair at the end of the bed. I was unsure whether she has been with her mother since last night or she just newly arrived to accompany her mother to the ward but nevertheless, seeing her mother's poor condition I had to retrieve the information from her instead. She has nine siblings, and she is the third eldest. Her mother previously lived with the 5th son for a few years but for reasons unclear then she lived with the 6th son for the past 5 months.


She claimed that her mother memang dah nyanyuk sejak enam tahun lepas and needed assistance for eating, bathing and etc. When I asked what exactly happened that led to the admission to the hospital, she said she didn't know much but the one who is taking care of her mentioned of her not being responsive and was rapidly losing consciousness. They straight away brought her to the hospital. When I asked about the wound at her back, she said she didn't know about it.


At this point, my mind went straight away towards Nenek Ik and the similar circumstances of her illness. My voice went strange as I fought the anger in my voice from leaking out. I had to put down my pen as not to show to her my hands that were actually shaking. I had already read the review the ED Ortho team put down. The wound was big, necrotic, emitted really foul smell with pus discharge and slough.


"Anak lelaki yang jaga mak tu, bila dah perasan ada luka kat belakang badan mak dia tak bawak pergi jumpa doktor ke?" I asked her.

"Tak, dia tak bawak pergi jumpa doktor," she replied.

"Kenapa ya tak bawak pergi jumpa?" my voice went a quarter octave higher.

"Saya memang taktahu doktor," while shaking her head slowly a few times.

"Dia ada bersihkan luka mak tak?"

"Ada."

"Berapa kerap dia bersihkan?"

"Tiap-tiap hari dia ada cuci, doktor."

"Habis tu kalau dia cuci setiap hari takkan dia takperasan bau busuk?"

"Dia perasan, doktor."

"Bila dia dah perasan bau busuk tu pun dia still tak bawak pergi jumpa doktor?"

"Saya memang taktahu, doktor. Saya tak jaga mak saya."


Right on cue, four more family member came to see their mother. I was unsure whether all of them are the patient's children, but if they were, then that made two sons and three daughters were present when I reviewed the patient.


"Ni ha yang lain boleh bantu doktor" - while speaking to the rest of them while retreating to make way for them to come forward - "...saya dah takboleh nak tolong. Doktor nak interrogate korang pulak."


They also gave similar answers to why nobody taking care of her pressure sore properly. The daughter then showed to them (and me) the wound she snapped from the ED downstairs. It was small, roughly the size of the thumb that was black (gangrene patch). From the picture I couldn't determine where the sore really is but I highly doubt that is the extent of her wound.


Then one of the sons asked me the reason for the mother's illness. While I explained to them about sacral sores again I asked about their mother when one of them held up a handphone and told me I could ask the one who was taking care of her directly.


And lo and behold, the exact same story he told me, now added with excuses. He mentioned that because he was busy with business (berniaga, not cooperation that kind of business), he didn't have time to bring her to see a doctor.

"Habis tu siapa yang cuci luka belakang mak?"

"Saya la, doktor"

"Macam mana encik cuci luka mak encik?"

"Saya lap kemudian saya cuci dressing luka dia tiap-tiap hari."

I had stopped listening to him. I was so fed up and I handed the phone back to whoever that gave it to me in the first place while the caller on the other end was still talking. I had enough. Then I spoke to them all.

"Saya dari bahagian doktor sakit tulang. Saya sini nak tengok luka belakang mak ni sebab luka ni yang menyebabkan mak jadi sakit macam ni sekali."

I added, "Oleh sebab tu, saya nak encik berdua (while pointing towards the sons) untuk tolong saya pusing badan mak supaya saya boleh tengok luka mak. Yang lain pun boleh tengok sendiri luka mak macam mana. Sambil tengok luka saya kena ambil gambar luka tu untuk memudahkan kerja doktor yang merawat."

So I pushed the bed a little bit so that I could stand on one side while the other two could stand on the other side. I instructed them to don on the gloves and taught them on where to put their hands for the turning. Then on my count of three, I asked them to turn their mother's body 90 degrees side way.


And the sight of the wound was horrifying.


The older son whimpered. "Ya Allah, Ya Allah.. Mak.. mak.."


Once I quickly snapped a picture for documentation, again on my count we carefully turned their mother back on her back. Then the crying began.


The son's legs gave in as he cried into his sister's shoulder. The sister had to support him halfway, herself crying upon witnessing the actual wound on their mother's back. I heard him repeating himself, "sampai hati buat mak macam ni. Sampai hati buat mak macam ni." I could only pat him gently over the shoulder as I gave them space to grieve. The younger daughter slumped against the wall, covering her mouth as she cried. The anger I felt initially burst away, filled suddenly with a profound pang of sadness. I was reminded of Nenek Ik, again, and how she, too, went down when no one had properly taken care of her.


I had nothing to say to them. Nothing left to say that could help them. I finished writing down the findings and I ended my clerking with a heavy heart. I felt disturbed at the sight of them all and there was a huge lump in my throat whenever I glanced at their direction. I went back from work later that day, hoping to write this all down but the sight of the wound, the patient's dying condition, and the reaction from them made me stopped halfway and thought of my own mother.


There is no way I will let that happen to Mama. There is no way Mama will be treated in the future, even when the memory and the body should fail her. There is no way I would let it happen.


May Allah granted all mothers the highest order of jannah, for they have carried all of us and the burdens of the world on their stong back, thus so truly the heavens lie at their feet.

Work Diary

[0700 hour]

Jolting myself out of bed in a frenzy. Yesterday I accidentally slept at 8 pm on the floor and woke up at 12 midnight, feeling woozy but hungry. In a dazed I ordered some McD chickens online and could only go back to sleep at 2 am. With no time to spare I had a quick shower (more like a splash, really. I don't think my body had even dried properly before I rush to the hospital), gulped some water and out of the room. Subuh prayer? Ke laut.

[0715 hour]

I remember the nurse in the MFU (Maternal Fetal Unit) of the O&G clinic asked me to come again and help Mr R today. No such luck. As soon as I stepped into the Ward 1A, the nurse called me and asked me to review this one patient I had met briefly yesterday.

She is a 40 years old lady, Para 5 (meaning she just delivered her 5th child) who delivered her baby some time yesterday around 4 pm. I was working AM shift this week, meaning my shift starts from 7 am till 5 pm. In some, rare good days, I can finish my work on the dot and can go back at 5 pm. On bad days such as yesterday and today? Not so punctual. 

I received a call yesterday from the Microbiology lab informing that the lady's viral screening is reactive for Hepatitis C. At first I thought oh okay maybe the patient hasn't delivered her baby yet or that she is in her first trimester (because I haven't seen this patient yet) but no, she is a postnatal patient.

Bewildered, I soon noticed that she has never went for antenatal booking or any antenatal check up at all throughout her entire pregnancy. That means, she is an unbooked, unscreened mother. Those two words alone can cause a headache to any doctor, made worse if she is already delivered, became worse still when her blood is positive for antibody HCV, because we don't know anything about her and her pregnancy at all or whether the baby is also infected or not.

Why antenatal check up is important? Because a lot of things can go wrong during pregnancy. There's high blood pressure with protein in your urine that can trigger seizures called pre-eclampsia, diabetes during pregnancy that can cause baby to grow big and developing low fetal blood glucose neonatally, miscarriages that come with bleeding and pain and passing out blood clots and pieces of the undeveloped foetus. The baby could be upside down or even horizontal, the baby could have deformities, the baby could be already dead but the mother didn't notice it.

In short, antenatal care is important. We have good antenatal care system in Malaysia, you know. Just ask your mother or any pregnant friend that you know to show you their "pink" antenatal book. Every health aspects of the pregnant woman is being assessed, beginning with scan dates to confirm the gestation of the baby, the woman's blood group and viral screen for HIV, Hep B, Hep C, her weight, height, etc, blood glucose monitoring, blood pressure monitoring, anaemia check-up, baby's kick activity chart, and many more.

Heck, if I have to describe everything that is in that pink book, I won't finish it by the time I become an MO. Just go and have a look at it yourself. I once met a patient who had her antenatal care in freaking Australia and she only have documents (no antenatal book like us) with her that she compiled in a folder. It was disorganized and we had to rummaged through them all and even then there is a few key information missing. Granted, seeing as she is not an Australian she only went for a private check up but hey, in our lovely Malaysia yang pemurah, all warganegara and also bukan warganegara who are pregnant can do their booking in KK (Kinik Kesihatan) and get the antenatal book. After this please la don't be so quick to condemn Malaysia teruk la itu la ini la ni benda bagus depan mata ni korang takpernah nak guna elok-elok.

[0720 hour]

The staff nurse had informed me that the patient is complaining of abdominal pain. She went to the toilet a few hours before and noticed that her pad was soaked with blood and blood clots. She didn't report it to the nurse. She only mentioned it when she had the pain.

I was cursing in my head. Blood clots and heavy bleeding pun takkan nak diam je? Tu kan benda abnormal it's not natural after delivery to get bleeding that much. Dah ada 5 orang anak kot takkan tak reti-reti lagi. DISCLAIMER: THIS IS ALL IN MY HEAD. I AM A PROFESSIONAL AT WORK. I TALK TO MY PATIENTS WITH SMILES AND SOFT TONE OF VOICE. Then I hurriedly informed an MO while getting ready to prepare speculum and a torchlight to figure out what the heck is causing the bleeding.

[0730 hour]

I took some blood from the patient and sent it to the lab. 

[0745 hour]

The MO asked me to insert the branula for the patient. I failed. But the needle is still there and the MO took over. She godek-godek the jalan and it went in. Wait. I am talking about a different patient here. By this time there was a number of patients I attended simultaneously. And by the word 'attend' I mean running here and there doing errands ordered by the MOs and the staff nurses alike.

[0745 hour]

Got the result of the blood. Haemoglobin is 8.0 which is a 4.3 drop from yesterday before delivery. The MO asked me to change the GSH to GXM and get 2 pint of packed cells for the patient to get blood transfusion. I filled up the request form and hurriedly went to the Blood bank.

[0750 hour]

The guy in blood bank said the blood can be collected in half an hour's time. I went back to the ward.

[0900 hour]

Finished clerking the subacute cubicles after being interrupted multiple times to do here and that. Saw that MO is fishing out a huge chunk of retroplacental clot the size of a songkok from the patient yang bleeding tadi tu. Oh em gee where the heck the clots came from?

[1030 hour]

Saw a new case coming in and no one else to clerk this patient. So I went to clerk, because that's my job. Oh, early labour. Simple enough. But she is supposed to be check for vaginal examination half an hour ago, which means I'm already late. Then the HOD (Head of Department) came to the rounds. That means I have to drop everything I'm doing and follow the round. Shite.

[1130 hour]

Just finished the round. I had to ask a colleague to do it instead.

[1300 hour]

I lost track of time. Did prostin review template and awaiting for the MOs to asssess the Bishop score for the patients ongoing prostin.

[1600 hour]

Still haven't eaten anything today. The only meal I had is that sinful McDs from last night. Oh, got some free time! Went to perform Zuhur prayer.

[1620 hour]

A patient that is supposed to be electively admitted this afternoon just came.

JUST GREAT!! Why waste your time when you can waste mine??! There are three discharge cases to be done. IOL list is still not done. I kept looking at the watch and sigh in defeat.

[1715 hour]

The PM shift housemen came to work. Whew. But I can't go back yet my work haven't finished. Then there's a shout for an emergency Caesarean case. I tried to ignore the case because night housemen are there but... sigh I had to help. So I helped called the Paeds housemen and inform them about the case.

[1800 hour]

Another new case that arrived before 5 pm but went unnoticed until now. Great. I grabbed the BHT and start clerking the patient. Nasib baik case senang ceh ceh. 

[1900 hour]

Performed solat Asar. I know I know I'm such a horrible man oh God forgive me for praying so late. Went to confirm that everything is settled. Okay, looks good.

[1917 hour]

Punched out the card. Now thinking about the Western restaurant that I found a few days ago. Looking forward to stuff my face with much food.