Medical Mismanagement or Hopeless Communication?

Here's the original article on Malaysiakini, about a Dr whose father recently passed away in Hospital Taiping http://www.malaysiakini.com/letters/141502 .

In short he is saying there was mismanagement, poor conduct by the hospital staff & the doctors involved.

A 94-year-old Indian male with Acute Coronary Syndrome (ACS,minor heart attack) and possible chest (lung) infection who was progressively deteriorating in the ward, developed respiratory distress & hypotension (low BP). His son a Dr, believes he should've been in ICU/CCU, and that he should've been intubated and actively resuscitated whe he started to deteriorate. In fact, he (the son) started to do CPR and asked if he could intubate his father. The following day, the doctors asked if they could perform an autopsy to determine the cause of death.
It was a painful article to read, because it captured the father's final moments very vividly.

Responses to the article commented (more like complained) on everything : going to a Govt. hospital is a death sentence, Malaysian doctors & healthcare system is hopeless, too many medical schools resulting in mediocre doctors, the need for meritocracy in deucation, the country is going to the dogs...etc.

Let me be frank about something : the hospital & healthcare system is not a 5-star hotel with a menu where you choose the ward you should be in, or which specialist from what field should be treating you. This is not my response to the article per se, rather my feeling toward the more educated patinets out there, especially those who can afford the $$$$. Just because you have a chest pain does not mean you need a cardiologist. You may think your funny looking nails are due for a manicure, but don't be surprised if your GP sends you to a hematologist, a cardiologist or a hepatologist. Yes, a patient has a right to his choice of treatment, but treatment as counselled or recommended by doctors...not wikipedia

Sorry for the tangent. Here's an objective response to the article, by an Ida Bakar :
"I am writing in the hope to lessen your pain at the loss of your father. If your father had been admitted to a hospital in the UK, I doubt the outcome would be different.
1) it is highly unlikely that a 94-y.o. would be admitted to ICU
2)the diagnosis of ACS alone does warrant admission to CCU
3)presence of dentures can ensure the upper airway remains patent, detures are remained in situ during bag-mask resus
4)intubating your father will only prolong his agony; his heart and lungs have failed and his body was shutting down
5)the request for a post-mortem is not unsusual in a hospital death
It does appear here that the problem was one of communication. A Do-Not-Resuscitate decision was made. Perhaps a decision to keep him comfortable in the last hours of his life was made also. You mentioned the lack of monitors and drips, but the presence of a cannula may indicate that appropriate drugs were given"

Here's a snip of another comment, by a Tyrone, a doc with ICU experiencr :
"You father should have been given an opportunity to pass away with dignity and without suffering, hence no active resuscitation. A morphine infusion should have been started to alleviate any pain or discomfort; this is where the hospital staff should have acted promptly. You shouldn't have taken an active role in treatment because emotions would have clouded your medical judgement. Nonetheless, staff should have sttended to your concerns or explained to you why they did what they did".

OK. I'll be the first to say that in Govt hospitals, communication with patients leaves a lot to be desired. This is where we differ from UK, where patient counselling cn take up to an hour...if that were to happen here, we'll get a new letter in the newspapers saying that the waiting time in hospitals is too long. So patient education takes a back seat and usually delegated to nurses, monthly talks/briefings and to junior doctors. And in most instances, only the basic info of the disease, prescribed treatment is given...not much attention is given to alleviate concerns n giving patients peace of mind...

keyword here is PATIENTS....not relatives or mother-in-laws. And so far, for me as a student, this is where i come in : the bridge between the hard-core clinical stuff and the layman's perspective. Also, this is where private hospitals & clinics have the upper hand...there are no 'junior doctors' or specialized nurses, so the task of addressing the concerns falls solely on the consultant....which is also why some private docs give out their personal handphone number. This is actually why the general perception of 'doctors in private hospitals are better'. In terms of medical care, any Govt hospital wins hands-down. NEWSFLASH : if anything goes wrong in a private hosp, or a case seems complicated, they WILL refer to a Govt Hosp, any Hospital Besar. You will never see a govt. hosp, no matter how small, refer a case to a private hosp....unless it is because of a patient's request.

I guess another point to learn from the story is, never underestimate the role of emotions, and how grief (or worse, impending bereavement) can affect somebody. Everyone has a hard time when witnessing death. Doctors may see it more often, hence dismiss it in another day at the job. But when it his home, when it stares you in the face, you WILL feel compelled to do something, ANYTHING, because afterall you were trained to 'rectify' any state/condition that is not functioning normally. This is why we have a lecture, Diagnosing Death....to know when to let go. Any person on the street can tell you if someone is alive or dead...it doesn't take a genius. But how do you tell when a person has death in line?

I guess that's enough for now. Back to school.

Arrividerci, Baby!

Wow...There's so much i wanna say, my head feels congested & i'm nauseated just trying to sort my thoughts out! But it's all good. Since finishing my Orthopaedics posting last Thursday and going home to Penang & back again, many things have happened (more like, a lot of normally-mundane things turned out to be awesome). I'm happy!!! See :) :) :)

give it a couple of days, it'll be gone once i'm back in my brain-dead medical school routine.

Just a concluding line for my ortho exam : i thought it was do-able; it would've been 'not bad' if i actually attended the first 4 weeks of class. I haven't submitted my case write-up though... Frankly it is not that i dont regret it; i just wanna keep the self-loathing quiet for now, ESPECIALLY because i am actually enjoying being alive instead of ruminating on how indecisive i am about being dead

now where was i? oh yea, PENANG. Seriously, i dont know why i dont go back more often. Its a whole different feeling, the minute i'm on the streets of Penang...regardless of taxi or mum's car, or my car. The scorching sun, the clear night skies, my quirky & moody little cats, the less-congested roads, my 'childhood' bed, the free-to-experiment kitchen...i tend to forget; it just hits every time i touch base. I'm wondering if i should work in Penang GH, right next to my 'ol high school SGGS. If i do then for one thing, at least my mum wouldn't be alone. The thing is, a part of me feels i should stay in UMMC...i've always had a strong sense of attachment to UM what goes beyond it being my alma matyr.

Anyway. in my flight back to KL, i happened to be sitting next to an Italian couple. Iattempted to make polite conversation but as it turns out, the husband doesnt speak English. At that moment, all i could think of was ''bon giorno", "ti amero", and "arrividerci", which loosely translates as 'hello', 'i love you', 'goodbye'....not exactly the words to say to a stranger u just met; unless of course you're in there for a one-night-stand, huhuhu. I spoke briefly with the wife, who told me they were in Penang for vacation...then they resumed their husband-wife conversation completely in Italian. I just sat there with my eyes closed, eavesdropping on a conversation to which i had no clue as wo what was going on....i was rather in awe coz i've never really heard conversations in italian before, aside from the brief opening scene in Angels & Demons.

So i spent the entire 45-minute flight lost in my own thoughts : i was ransacking my brain for all the Italian words i know. I came up with "aiuto", which means 'help'...i pressed on, then started singing my favourite Il Divo song, Ti Amero...."La notte schivole sormondo...que sia tormentera..." Heck, all i got from the song was 'one night', 'torment', 'lingering/continueing'.... In other words, not much prgress. Naturally, i proceed to what i can recall from the menu at Italian restaurants : tiramisu? quattro formage? de carni? spaghetti? lasagne? Even more useless for conversation...

I was beginning to get exahusted. I mean, if they were Spanish then i'd have better luck. I've always wanted to learn Spanish, and i did pick up a few phrases from my grandmother, and from songs & movies. See, TV does me a LOT of good. I havent had the opportunity to travel, but that is how i learn about the world & other cultures. of course, you'll need common sense to discern the 'hollywood fiction' factor from some of the stuff. plus, i love watching then discovery channel, natgeo, history channel, and sometimes discovery travel & the cooking channels. I guess what i'm trying to say is for some people out there who watch even more tv/series than i do and yet for some reason can still remain so close-minded and got no clue about other poeple's values, cultures, taboos, they have got to be the thickest numbskulls ever. Heads up peeps, this is what 'informal education' is all about.

and i digress yet again. now where was i...oh yeah, the italian food road block. fine. then i got an idea : i used to learn the piano, i was up to grade 5...we had to learn italian terms for music theory. Immediately i tried to recall : mezzo, moderato, allegro, adagio, lento, crescendo, allegretto, segno, maestoso, dolce, forte, presto, pianissimo, con brio, etc. Sure, it may not be enough for conversation but i was contented to at least know SOMETHING. By then we were about to land in KLIA. I was determined to at least say something in italian but i cant seem to work up the nerve for it...what if my understanding was flawed? what if my pronounciation is wrong, so wrong that they cant understand?

So we were getting our luggage, and the man said ;bon voyage. i said, wait first (the cabin doors were still closed). Just when the people ahead started walking out, both husband and wife said 'bye bye' to me...i turned to look at the husband (he was sitting next to me, afterall) and said, "arrividerci" and oh how their faces lit up! She said 'ah, brava!' and he smiled and repeated 'arrividervi'. I guess they were taken aback, coz they weren't expecting it. The were impressed, and i was pleased with myself. Walking toward the arrival hall, i was giggling to myself, and i was skipping with joy for actually finding the guts to say that one word. You see, earlier this year i studied Mandarin for a while and wasnt very good at it; and although i do know a few words & phrases here n there, i have yet to be able to muster the courage to speak with my chinese classmates/friends/patients...for the same reasons i mentioned earlier. I am too self-conscious for my own good, too egoistic to risk embarassment.

Then in the taxi, i had a chinese taxi driver whom i noticed had classical features/deformity of rheumatoid arthritis : boutonniere, swan-neck, z-shape, radial deviation of the wrist. I asked him about it, and he's had it for >20 years. Apparently it doesnt hurt when he drives. He gave me the same advice i've heard time n again : to master a language, u have to speak; it doesnt matter if they laugh at you.

So in summary; I had a great weekend. For now, arrividerci baby!

A Moment of Clarity

I was on Facebook for a few hours just now, waiting for my Farmville crops to be ready. I had run out of my usual online time-killing things to do, then i got a bright idea : inbox-messaging friends.

To be frank, i haven't socialized much in the past year or so. Most of the times i prefer to be by myself...i just had no mood for it. Even when friends try to ask me out, i reluctantly agree and end up cancelling in the last minute. Of course, friends/acquaintances in my immediate surrounding markedly shrank a long time ago when i left my initial MBBS 2005/2010 and joined with the juniors...even more so since they've graduated & started working in hospitals all over the country. So, in my everyday there is a steep drop even in casual encounters; hardly any more hi's or hello's from the 150-or so familiar faces walking down the corridor. Friends outside of med school hv always been tough to hangout with coz they're working or back at their home state.

As a result, i feel lonely a lot of the time. I don't blame them for it...well maybe i blame them about 30%...the rest of it is me not wanting to be around people, feel the need to be alone..and the part of me that doesn't understand why i do it; i just have to. Heck, most times i dont think i'd be any good for company, that i'd probably bore those who ask me out or come over, and i didnt wanna feel bad if i had 'dampened' the whole outing. So might as well stay in by myself & be bored by myself.

Anyway. Like i said i was waiting for my Farmville crops to mature & i was feeling rather joyful & i started messaging my friends, one after the other. With each message i typed, i felt a lil more uplifted. Somehow it felt like everything was clear now, and i had a certain calm embrace me. The feeling itself wasn't overwhelming...but when i realized the feeling, typing, 'talking' to my friends, I felt my old self. It was good. It felt wonderful. I felt like i had clarity, that i was being like my old chatty jovial self. Suddenly now, typing this, I begin to miss my friends...I miss chatting with them...I miss the feeling of security, knowing they will be there for me if i need someone to turn to.

It is in moments like these, that i 100% believe that i do indeed suffer from depression. In moments of clarity like these i can look back at my weariness, it-doesnt-matter feelings, incredibly boring & lethargic everyday then say for sure that the sloth-like existence cannot possibly be my own conscious doing...because they never feel right, and sometimes they don't even feel real. I never felt truly rested no matter how much i sleep, I never felt truly unburdened regardless how little i take on or even when i choose to do nothing. I know i am better than that, that i am capable of a lot more...but when i am in the slum, i never believe it, and think that i indeed subconsciously want to destroy myself. Even worse when people around me too start blaming it on me having a bad attitude, being lazy and irresponsible.

I felt that i had to write within this moment, before it slips away and i become my shadow again. All i want, just like evryone else, is to be happy and to be able to experience happiness. I want this clarity to just last longer, no need for forever. Just last long enough so i can get things done, and feel like I actually do exist, and that this a life, that i am not just an empty vessel floating through time.

Good night.

Of Weddings, Graduation and Upcoming Ramadhan

Last Saturday i attended the wedding of a former schoolmate of mine, Ezureen Ezani. Its the first of such weddings that i attended, though quite a number of my MRSM Taiping batchmates have entered a new phase in their lives. Some are engaged, most are newlyweds, others have welcomed their first child, and a tiny number of them are already pregnant with baby number 2.

Oh, how time flies. Apparently it has been 7 years since the lot of us left high school & SPM. Friends, former friends and even teachers have gone separate ways. Of course, being at Ezureen's wedding was like a small reunion of a handful of individuals; no longer clustered in 'gangs' or 'couples' or 'classmates' . I had fun! Oddly enough, there wasn't really any nostalgia. Everyone was here-and-now, celebrating our mutual friends' journey into marriage. I guess the lot of us had fun chatting & eating & laughing, we just HAD to have our own afterparty : Karaoke @ Wangsa Walk. Perfect Timing, coz Kemek (my karaoke buddy) & I havent been to karaoke for so long. Usually our karaoke trips are an all-girl outing, so this is the 1st time we have guys in the bunch. Frankly we were surprised to feel at ease, comfy enough to make fools of ourselves belting & screaming out of pitch for 2 hours.

Tired & happy, my day wasn't over : I had an Orthopaedic on-call shift that night, which also turned out to be fun and very informative.

The day before that (Friday) would have been a big day for me had i stayed on with my previous batch : Graduation, class of 2010. To be honest i anticipated a wave of depression to hit, just like it did they day they passed their final exams a few months back. Thankfully it didn't. The person i was really looking forward to see is my old roomate, Dahlia. She's a quiet girl, very hardworking and smart. Although i always say Dahlia is stiff, 'has no feelings' and hardly socializes (its the truth, she admits so herself!) but through the years we did become good friends. I was happy that she too really wanted to see me. I thought i was just going to meet her, say 'hi' amongst the crowd of graduates....i mean, i didnt want to interrupt her plans & celebrations...instead she asked to chill out in my hostel room & hv a quiet chat. Working life IS tough afterall, and after 2 months she has yet to receive her paycheck. I guess i just miss having her as a roomate & study partner.

Ramadan starts tomorrow. One month of fasting, before Raya celebrations. Regretfully this year i failed to 'pay my debt' if u know what i mean. Its a big deal to some people, and to others it means nothing. Me, its one of the things i usually make an effort to do in recent years. Perhaps if u'd notice, this is just another notch in the way things have been going on since late 2008....how i've completely let myself go; let go of discipline, of responsibilities, of decisions, and of everything i m 'supposed' to be. And now slowly & reluctantly i m resuming control of myself and my 'life'. I was never a failure, but now i'm halfway to becoming one....and i dont even know why. This posting (Orthopaedics) marks my worst/lowest point of academic participation thus far, possibly putting my future (exams/graduation from med school) in jeopardy. I dont even like myself for that, and it adds on every time i think about it. What does Ramadhan have to do with all this? Nothing, i guess. Its just another day of another month, except that i dont get to eat or drink during the day.

I gotta go to sleep now. Hope i make it to my 8.30 ward round tomorrow. Toodles!

Fill in the Blanks

Its been quite a while since i last wrote anything. The last few months for me felt rather uneventful, slow. Not that they really were, but it just felt that way. For some reason i've felt persistently bored, as if my emotional thermostat was stuck on 'blank'. Whatever feelings of enjoyment or sadness, anger or enthusiasm were short-lived and merely reactive. So naturally, i had no opinion on anything yet my thoughts were swarming left right and centre on god knows what...

I'm still not quite 'fine' yet, though i cant put a finger on it so really, questions like 'are u ok' or 'whats wrong' will be met by a stoned expression & a stiff, uncomfortable chuckle. It is 4.30am and i wanna kill time till i'm due for ward rounds so here goes.

1. My Grandma's 77th Birthday
Saturday 10th July. I dont know whose idea it was, but i have to say there were lotsa bumps on the execution of the party. i mean, i live in the same house as my grandma, but i only found out about the party when i picked my mum up (who came all the way from Penang mind you). Regardless, it was a huge turnout...5 or 6 cars worth of relatives, ud think it was a Raya openhouse! We ended up with 4 birthday cakes, some murtabak + pasembor and other 'snack' food but no 'real' food. Not to fret, Dima Marlina & her Domino's coupons saved the day! Heck, even Dominos sounded confused, coz i had to call and order twice that day...huhu. It was fun, really, seeing my grandma blow 30-something candles on the many cakes. She was happy, pleased, that's all that mattered. She said to me today, she never had such a big party, maybe she it was all the excitement or because of the shock that she's getting sick today (she's getting the flu).

2. OZ
OZ....The name on the street for the Oswald State Correctional Facility, Level 4. Haha. Its a tv series, by HBO waay back in 1997-2003...6 seasons altogether. I've watched it twice back in 2008 when i was doing my elective in the pusat serenti. And I've watched it again twice the last few weeks. Its a show about life in prison, and will probably be one of the most gripping, brutal, real and unique show u'll ever see. Man I love it. Super testosterone (haha). Gotta thank my dad for intoducing it to me. I haven't watched Prison Break, but to be frank, i'm skeptical coz i dont think something truly realistic & gory/intense would be able to be that mainstream. Anyway. I made my sis watch it and now she's hooked. Our fave characters : The O'Reily Brothers...i love Ryan & she loves Cyril...played by real-life brothers Dean Winters and Scott William Winters, respectively. And heck, their brother, Bradford Winters also came in as one of the writers for the show. But really, there are so many good characters that anyone who watches Oz will have a hard time picking favourites.

3. Schindler's List
When oNe came to stay with me a month ago, i was surprised to find this movie on her external hard drive. Its one of those movies i've heard of but have no idea what its about. I watched it, initially confused coz half of the dialogue was in German or Polish then in Hebrew or Yiddish but then somehow it didnt matter; the message was clear. Its a true story about the events during the Holocaust and how a man named Oskar Schindler managed to save the lives of almost 1200 jews from Poland. The movie haunted me; made me want to watch it again and again. It made me surf online to read a bit more on the Holocaust, Schindler himself, Amon Goeth, and whetever that was related. One particular night i scared myself shitless, reading on human vivisection (surgery/dissection on live victims without anaesthesia), human 'medical experiments', mass executions....all done by the Nazis to the jews & other prisoners...even the Japanese did the same thing during their occupation of China...they did that plus 2 other sick, grotesque practise : CANNIBALISM and 'comfort women' (kidnap village women & put them in brothels to 'serve comfort' for the soldiers). yeeesh. I didnt dare turn the light off that night.

4. Medical School
Not surprisingly, i'm getting the same feelings i had the last time : why does it matter? what the hell am i doing here? i'm not a doctor, i'm just a smart-ass in a white coat. Yeah, those feelings. Going to sleep & wishing i'd evaporate into thin air. I've finished my Medicine posting & my Psychiatry posting (i wish i had my head on right; i wouldve enjoyed it a lot more) and now i'm in Orthopaedics. Oh, we also had 3 weeks of OMHS (Organization & Management of Health Services) and my group was posted in Putrajaya. Boring as hell. Compared to the previous project trip to Maran in 3rd year for CRP (Community Residency Programme), i felt completely useless & out of the loop. All i did was interview the guy i was supposed to, wrote my report, & helped 1 editor with a teeny bit of editing. I'm just glad that's over, but it also means going back to the wards and unpredictable class schedules. hmmph. I just wanna be able to feel excited & interested...my reflex is to avoid it like a plague, or put if off until abso-freakin-lutely necessary, i.e. crossing the bridge when i get there. As if on cue, somehow on days that i have class suddenly i cant wake up, completely knocked-out in a 16-hour coma. Frankly right now, i'm contented if i complete/submit my assignments, do my on-calls & vaguely know about the posting. I couldnt care less about making the 80% attendance mark or to be as good as evrybody else. One day, this will change. I cant live with myself like this.

I guess that's it for now. Till next time, ciao!