The Young Sabahan (1)

The youth of Sabah are not any more or less teachable than the Malay bumiputras of Peninsular Malaysia. They are no less talented or skilful. They are perhaps, lesser beings in the eyes of UMNO and Barisan Nasional.

The one best method to condemn a community to eternal ignorance is by neglecting and forgetting it. In this respect, the youngsters of Sabah have been neglected for much too long.


The Young Sabahan (1)

The locum clinic I work for placed a 3X4 cm in the local Borneo Post recently. It was looking to hire a new clinic nurse to replace one who had left earlier in the month after eight years of tenure.

A total of 531 applicants from all over Sabah sent in their applications and resumẻ of sorts.

It’s not unlike an American Idol contest. The applicants were mostly young, jobless locals from the distant districts of Sabah. They had to undergo a grilling interview. The reward was less lucrative than the million-dollar record deals of a singing competition though. At the end of it all, only one will get the job – a pretty mundane and unenviable job.

Hilda is an eighteen-year-old Bajau lady from Kota Belud, about 200 kilometres from Kota Kinabalu city. The fifth of seven siblings, she had just completed secondary school, attaining a decent pass in the SPM examinations. Her life had come to a defining junction upon completion of her secondary education. Her family is unable to support Hilda for any further education. Heck, even making ends meet in this season of inflation is a struggle. She has come of age and was obliged to contribute to the family income. After eight months of being unemployed and unproductive, Hilda was under increasing pressure to do something about her life.

Opportunities and development are limited in Kota Belud.

It is never easy abandoning the comfort and confines of the familiar family nest. She is not keen to, but her options are limited. She can leave home and fend for herself in the foreign environment of Kota Kinabalu city, sending home her leftover cash, if any. Alternatively, she can resume her village life in Kota Belud, get married at a tender age and start a baby factory of her own, attaining grandmotherhood by the age of forty not unlike her own mother.

The first choice was unattractive and daunting, but was nevertheless more viable than specializing in copulation and reproduction.

Hilda was finally employed not because she was better, prettier or more impressive than the other hundreds of applicants. She was not fluent in English, far from it in fact, despite her documented ‘A’ in her SPM English. She did not write any better than the others or speak more confidently. Hilda was hired because she was willing to take up the job at the lowest offer.

For the next one year, Hilda will be working eight-hour shifts each day with one day off after three consecutive overnight shifts at the clinic. Registering patients, mixing and packing medications, phone calls and billings will be her tasks of the day. At the end of each month, Hilda will be paid RM 440.00. It runs up to about a RM 14 per day or RM 1.80 per hour – figure much lower than the standard market wages.

Without any form of self-transportation, Hilda needs to stay near the clinic. She rents a room in a flat no larger than half a badminton court. The flat houses thirteen other job-seeking young Sabahans. Hilda shares her room with another young lady. She pays RM 110 each month for her room slightly smaller than a Proton Perdana. Hilda is left with RM 330 for the next 30 days.

As comparison, my grandmother’s Indonesian helper commands a salary of RM 500 per month, with food and lodging privileges.

Stories like Hilda’s are a dime a dozen in Sabah. She is a bumiputera just like the Muslim Malays of Peninsular Malaysia.

Despite years of trumpeted, keris-wielding, battle cries of bumiputra-ism, the fruits of the New Economic Policy have eluded her for half a century.

Development is scarce in the districts of Sabah not because of the lack of funds or the absence of potential. Massive corruption at federal, state and district levels have swindled the locals of their pooled taxes. The unbelievable gambling debts of former Sabah chief minister Osu Sukam amounted to almost seven million ringgit. It a small testimony of how rich Sabah can be if its monies were entrusted in the proper hands.

National education has failed Hilda and the million other local Sabahans. Malaysian education is accessible to most folks, but at what price? Most schools away from the city of Kota Kinabalu are pillars of shame. With limited facilities, insufficient teaching staff and less than ideal environments of learning, national education becomes a farce in these district schools, not that it is any less a mockery throughout the country anyway. As in most national schools, the air is pungent with forced indoctrination and pro-government propaganda. Unlike their counterparts from the more urban areas, the young minds in the districts of Sabah do not access to alternative worldviews. Libraries are a rare sight, if and when they are available, the variety of reading material is limited. Internet is a foreign word - the people I’m writing about right now are not reading this web page right now and probably never will.

Like the many before her, Hilda complied with the teachings and contents of her education syllabus. It is written in her text books and declared by her teachers that the current Malaysian government is the best one can ask for, a government that was legitimately elected via a free, fair and just democratic process and one that safeguards the wellbeing and interests of Malaysian citizens regardless of race, religion and culture.

Life in her kampung was simple, quiet and tranquil. It could have been her be-all, end-all, her destiny forevermore if not for the fact that everyone needs to grow up and earn a living one day. As it turns out, life and survival in the real world requires more than an SPM certificate. She had trusted her teachers, her books and her school but evidently, her trust is misplaced. Sabah and Malaysia is a pretty different place that the one she had read about in her textbooks and the images she sees on her television screen. If our national school textbooks were kosher and to be believed, Malaysia is the utopia in every idealist’s dream. The reality of course, is that Malaysia is capitalist to the core supplemented with elements of communism, apartheid and Talibanism.

An erroneous and homogenous worldview in an unquestioning mind is precisely what UMNO desires from the rural population of Sabah. From Ranau to Kota Marudu, Tawau to Sandakan, Kudat to Tenom, keeping young minds in the dark about the realities of life will ensure continuous Malay supremacy in land where Malays are the minority.

Sabah has lost a generation or two to UMNO’s political hegemony.

The youth of Sabah are not any more or less teachable than the Malay bumiputras of Peninsular Malaysia. They are no less talented or skilful. They are perhaps, lesser beings in the eyes of UMNO and Barisan Nasional.

The one best method to condemn a community to eternal ignorance is by neglecting and forgetting it. In this respect, the youngsters of Sabah have been neglected for much too long.

Contrast their fate and deal in life with that of their Malay counterparts in Semenanjung Malaysia. The Malays have endless vocation institutions, double scholarships, training programs and re-training programs. Don’t Sabah’s youth deserve the same, or something similar at the very least?

I’m not one who spares the rod and spoil the child. I believe that man (and woman) should be taught to fish and not spoonfed indiscriminately. In the process of learning fishing, which I assure you might sometimes take a while, one still needs to hand them some fish every now and then.

I’ve worked in Sabah long enough to know that most young Sabahans are not typically those who will end up as ungrateful Mat Rempits and flamboyant Mat Minahs when given an opportunity to improve themselves.

They deserve a bigger role in life than merely providing cheap labor to the capitalists among us.

Hilda has no long term plans for now. She will not be sending any money back home anytime soon either. With her own survival hanging on a delicate balancing act, she will remain as one of the many faceless young Sabahans for the moment, if not forever.

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House Officers: A Rose By Any Other Name....

We can call these medical graduates housemen, interns or by the acronym H.O. One lady surgeon even calls them slaves. The fact is, house officers are indispensable in Malaysian healthcare.

The day house officers in government hospitals go on strike is the day Malaysian healthcare collapses and comes to a total halt.

There is...a dire need for a system that places an emphasis on accountability and meritocracy. The lying house officer must be brought to book, the incompetent house officer sent back to his books, and the outstanding house officer written in the good books.


House Officers: The Backbone of Malaysian Health

Hypocalcemia in Pregnancy

It was 3am in the morning. A lady at 32-weeks of pregnancy came to the hospital complaining of numbness and very mild weakness over her right hand that was limited to a few fingers. The first house officer who attended to her, Dr. Gua, had no definite diagnosis in mind. She took the routine blood investigations anyhow which included a calcium level. Her calcium level came back as 1.9 which was low. Alarmed and concerned, Dr Gua referred the patient to her obstetric medical officer who was similarly troubled. She too had no inkling of the underlying cause and in turn referred the patient to a fellow medical officer from the department of internal medicine. The trainee physician arrived dutifully in a short while, attended to the patient, asked a few questions and ordered a truckload of blood investigations. The barrage of blood tests included a thyroid function test, liver function test, serum phosphate, serum magnesium, renal function test, serum and urine cortisol amongst others. She was worried over the unexplained severely low calcium level and decided to admit the patient for intravenous calcium gluconate.

Once in the ward, a second house officer reviewed the patient. Dr. Ahmad read through the notes and asked some basic questions. He too, was increasingly worried, but for different reasons.

Here’s why.

The initial blood was taken with a tourniquet that was applied for a pretty long time. Such a method of blood sampling may result in an artificially low calcium level due to physiological changes around the area where the tourniquet was applied. In other words, the pregnant mother did not have low calcium to begin with. Intravenous calcium gluconate is dangerous and could have killed her instantly.

The story does not end here though.

Dr. Ahmad repeated the blood sampling without a tourniquet. The result of the second calcium level was 2.2, which was acceptable in pregnancy due to physiological changes in the blood constituents. His medical officer however, did not think so and again referred to the medical team for further advice. It was decided that the plan to give intravenous calcium gluconate should go on. The mother was started on calcium tablets thereafter. Dr. Ahmad remained unconvinced and suspicious of his superiors’ management throughout. He complied nevertheless.

In retrospect, the pregnant mother presented with symptoms very typical of carpal tunnel syndrome. It was the right timing at 3am, the exact symptoms and in the ideal patient. There was no need for any blood investigations or any possibilities of an impending stroke whatsoever.

House officers and the Quality of Malaysian Healthcare

The public healthcare of Malaysia will rise and fall with the services of the house officers. I do not know about the rest of the world but this is fact for Malaysia.

The first personnel to attend to a newly admitted patient in the ward is usually the house officer. The ill patient who suddenly takes a turn for the worse is usually referred to the house officer on-call. Blood investigations, applications for radiological procedures, referral letters and discharges, and basic clinical procedures are all carried out by the house officers.

Without house officers, much work will not be carried out or would have to fall upon the shoulders of the medical officers.

We can call these medical graduates housemen, interns or by the acronym H.O. One lady surgeon even calls them slaves. The fact is, house officers are indispensable in Malaysian healthcare.

The day house officers in government hospitals go on strike is the day Malaysian healthcare collapses and comes to a total halt.

The Malaysian Medical Association (MMA), when they are not boozing away in the MMA house, has been fighting for the rights and welfare of house officers for decades now. I say aye to more rights and welfare and renumeration for house officers, yet I also know pretty well that we have a very variable and colorful population of house officers in the civil service. Not all of them deserve their basic salary of RM 2137.70 much less their much acclaimed right to greater benefits, higher allowances, more oncall claims and automatic promotion to a U44 grade officer.

I only have the experience to compare Malaysian graduates from local universities to Malaysians who graduated from foreign institutions.

Truth be told, despite all that they say about the low standards of our medical schools, the majority of our local medical graduates fit in fairly well into the local healthcare system. Fitting in is not synonymous with competency and excellence but most of our local graduates nonetheless are able to function in a system they are familiar with.

Granted a chance to work with foreign graduates in a foreign land, I just might be singing a very different tune. However, I am not even for a moment under the delusion that other nations naturally produce more ethical and more knowledgeable medical graduates.

I do know however that in most developed nations, there is a prevailing sense of responsibility and a emphasis on a culture of accountability.

That is something that is sorely lacking in our healthcare services.

The ‘Don’t Know’ House Officer

All doctors do not know something to certain extent. In fact, all doctors will not know anything about something if you prod them hard enough. Personally, I studied pharmacology rigorously like a mad man in medical school and naturally, I take pride in knowing something about drugs and toxins. If someone asked me something about the histological variants of ovarian tumors however, I will reply with nothing less than a stupid blank stare and declare with no shame that gynaecology is not my forte.

There are many house officers who however, seem to know nothing about all things. It’s really anyone’s guess whether this has always been the trend even in the good old days of Tanah Melayu or whether such a dunno tak tau culture is the result of half a century of race-based intake into local medical schools. The NEP policies have given rise to a complacent lifestyle among both Malay and non-Malays students. Why study hard when one has been having things served on a silver platter one’s whole life? Why study hard when one can pass an exam because the marking standards have been lowered to cater to the ‘special children’ with special rights?

House officers from foreign universities are not naturally better though.

The most reasonable and objective statement is to evaluate each house officer as an individual and not from the university one graduates from. We have a great number of lousy, undeserving students entering local universities both public and private institutions and they are not restricted to any particular race. We also have an abundance of mentally-challenged personalities graduating from India, Ukraine, Ireland, Indonesia and China. No doctor should be identified or stigmatized by the university one graduated from. The final competency of any medical student is really all about the person’s own initiative.

Unlike graduates from computer science and social arts and food technology, medical graduates upon completion of their studies are never ready to get up and work. A ‘don’t know anything’ house officer is terrible, but not beyond help. A conducive training environment made up of willing teachers, understanding superiors, supportive nurses and adequate facilities will make a world of a difference.

The ‘Don’t Know, Don’t Care’ House Officer

A forty-something man was admitted for hemorrhagic stroke. After a few days in the ward, he developed pneumonia and required mechanical ventilation. The house officer on-call whom I’ll just name Dr. Chong was entrusted with the task of sampling the patient’s arterial blood gases. He did so, but did not know how to interpret the results. Even so, he did not seek help. At 8 a.m six hours later, the patient died. Postmortem, the notes were reviewed and the results of the blood gases taken before the patient’s death were nothing less than shocking. It showed severe combined respiratory and metabolic acidosis.

Dr Chong is the kind of house officer I categorize as the ‘don’t know, don’t care’ type. These are characters that never fail to baffle me. I wonder what these clowns are doing in the profession of medicine in the first place.

They don’t know, not because they have cerebral palsy or severe mental retardation.

They don’t care, not because it’s not their business, but because they are callous, indifferent or simply uninterested. They appear to hold firm to the belief that ignorance is bliss. No matter what is happening, what instructions were given and how these house officers are reprimanded, their response is always along the policies of ‘don’t know, don’t care’.

“Doctor, patient is in pain…” – Don’t know, don’t care.

“Doctor, patient’s potassium is only 2.6…” – Don’t know, don’t care.

“Doctor, how is my surgery going to be like tomorrow?” – Don’t know, don’t care.

“Doctor, I am having a cough and a fever…” – Don’t know, don’t care.

These house officers are beyond help. As the person battling at the frontline, they do not seem to realize that the things they do and do not do at a certain time can make a big difference to a patient’s outcome. Perhaps they are not truly beyond salvation. Perhaps when one of their own family members die or fall ill, they might turn over a new leave and change for the better.

The ‘Don’t Know, Don’t Care, Bullshit Non-stop’ House Officer

These are the most dangerous and perhaps the most difficult to see through. Some people are born to talk, and then there are those that are born to bullshit. They are not necessarily smart. In fact, those who knew them well and long enough might even suspect them of having mild dyslexia. They are not caring, far from it in fact.

They are however very capable of putting up a face as though they are sweet, empathic and all that’s noble in a doctor’s holy heart.

They slither out of troubles and crises, and I use the word ‘slither’ because these doctors are serpents. Deceitful and cunning, eloquent and loud, these doctors will do anything to save themselves from trouble.

Outright lies, dubious documentation and clinical sandiwara are their practice of the day.

I’m reminded of someone I’ll call Dr. Marvin each time I come across such deceitful doctors.

Dr. Marvin was a graduate from a local private university in Melaka. He’d disappear for hours to have his cigarette session. When confronted about his disappearance from the ward, he would feigned that wide-eyed innocent look, stare you back in the eye like Shrek’s Puss in Boots and exclaimed regretfully that he came across some frail old osteoporotic lady on his way back from the busy clinic who required his assistance climbing the stairs to the second floor. When he failed to turn up for work or oncalls, he would swear on his mother’s grave that his father had a heart attack at home at 6 am in the morning. His father must be a very blessed person, because the senior Marlin has had twelve supposed heart attacks in the preceding two weeks and is still mysteriously alive with no symptoms of heart failure.

Unsurprisingly, these are the house officers most liked and favored by their superiors.

Unlike the don’t know, don’t care house officer, the ‘don’t know, don’t care, bullshit non-stop’ house officer are truly beyond redemption.

The ‘Know Something, Can’t Do Anything’ House Officer

House officers have for far too long been erroneously labeled as being a homogenous group. They might be the lowest in the hierarchy of the administration but they are never all equal and same. Similarly, just because one is a medical officer, specialist or consultant does not mean that the person possesses greater knowledge and more astute clinical acumen.

A young lady at 18 weeks of pregnancy was admitted to the High Dependency Unit for “UTI sepsis”. She was experiencing high fever with shortness of breath. Urine tests showed an ongoing urinary tract infection (UTI). She was treated with antibiotics and hydrated vigorously. Upon completion of the antibiotics, she was swollen all over the body. Her feet were both so puffed up that she couldn’t even wear her own sandals. Fluids were accumulating in her lungs, her abdominal cavity and even around her genitalia.

The consultant obstetrician came and ordered for a full workout to exclude tuberculosis and HIV.

The specialist in turn thought the source of the infection was from her genitalia. The so-called specialist refused to listen to the house officer’s objection and ordered an emergency surgery to incise and drain the ‘labia majora abscess’.

The medical officer complied.

The patient complied too and went under the knife.

There was no abscess.

In the midst of all this stupidity and narrow-mindedness was a house officer name Dr. Mel. Unknown to and unlike the consultant and his team of esteemed specialists and honorable residents, Dr. Mel had sat down and taken a full medical history and performed a complete and thorough physical examination. Dr. Mel had done something none of the obstetricians did. He listened to the young mother’s heart and detected a murmur. Dr. Mel put it all together and opined that the patient’s fever was because of infective endocarditis that had set upon a heart that was defective to begin with. The ongoing generalised edema was the result of heart failure.

He was sure that the obstetricians were wrong. He was sure that the patient had no supposed ‘labia majora abscess’. He was sure that sending the patient for surgery was a dumb and lousy idea. His hands were tight though. In a feudalistic system however, who will listen to a lowly house officer?

His conscience got the better of him in the end. Dr. Mel secretly arranged an echocardiogram for the patient. It showed a mitral valve prolapse with calcified valve leaflets. He restricted the patient’s fluid intake to 500 cc per day. Within a week, the patient was fit to go home. The last I heard, both mother and child were safe.

Summary

No doctors can fully rid themselves of the humbling title of house officer.

At best, every doctor is an ex-house officer whether one is now a consultant, a specialist or a private practitioner. Not all competent house officer ends up as a specialist and similarly, not all specialist was once a competent house office.

The specialist of one discipline may very well be as competent and knowledgeable as a house officer in another discipline. The obstetrician will fumble around when faced with an orthopaedic patient.

Thus, there is no need for arrogance and unnecessary show-off.

There is however, a dire need for a system that places an emphasis on accountability and meritocracy. The lying house officer must be brought to book, the incompetent house officer sent back to his books, and the outstanding house officer written in the good books.

This article was about house officers – their quality and qualities, their ethics regardless of ethnicity.

The contents of this article can easily be extrapolated to medical officers and specialists and consultants in fact.

After all, the consultants of today were the house officers of yesteryears.

For example, the ‘don’t know, don’t care, bullshit non-stop’ HO of 1980 is a neurosurgeon today.

Sigh…..











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Dr. Rikki

Not a word came from him. Not a movement did he make. The fringes of his blood-stained white coat fluttered in a mini-frenzy as the squeaking, jaded ceiling fans blew his way. Against the sun, his tiny frame casted a long and forceful shadow.


Dr. Rikki

Marked furrows were forming between his tired-looking eyes, his expression slowly transforming into a frown. The teeny hazel eyes strained against the scorching afternoon sun, consigning eventually into a vague squint. In the cramped and crowded medical ward, a neck and white coat was not exactly the ideal outfit. Sweat trickled slowly down his temples, coalescing finally into a pool that drenched his short-sleeved turquoise shirt. His black neck tie was oversized in proportion to his tiny frame, hanging a few inches after his rusted belt buckle.

I stood an arm’s length away, keeping mum, observing this senior doctor in deep, concerted attention. There was no smile upon his pimple-scarred face. He had sparse graying hair that was otherwise trimmed neatly to an inch’s length. This great man must be at least forty years old but it was also possible that years of striving and struggling to be the knowledgeable man he is today have aged him beyond his time.

Scrawny and thin, his hands stayed put in the side pockets of his black pants hanging a distance above his ankle, revealing a pair of holed black socks wretched from years of repetitive wear, wash and tear. There was no definite expression upon this overworked and underpaid Dusun doctor. His bent and hunched posture bore evidence to the years he must have spent silently and lonesomely burning the midnight oil in the noble hope of serving his community one day.

This was a day like any other. A young lady laid in her bed, breathless and exhausted from whatever was rocking her frail, ailing physical body. At the end of her bed stood the pensive doctor, deep in thought and away in a restricted zone of his own.

Not a word came from him. Not a movement did he make. The fringes of his blood-stained white coat fluttered in a mini-frenzy as the squeaking, jaded ceiling fans blew his way. Against the sun, his tiny frame casted a long and forceful shadow.

It is true then, what we medical students were taught in medical school. So much information could be gathered from a mere general inspection of a patient lying before us without the need of touching, pricking or prodding a distressed soul. I wondered what was going through his mind. If only I could get a sneak peak at the long list of probable diagnoses he was conceiving all by himself.

A few other doctors gathered nearby, around the patient, beside her but not at the bed’s end. They were young and well-built, both cheerful and nerdy, talkative and restless. How unbecoming of these junior doctors to be distracted and uninterested even as their consultant physician remained focused and unrelenting over the pitiable young lady.

The consultant brushed aside an irritating sweat droplet that had made its way into his left eye.

It was then that I saw his name: Dr. Rikki, a name that I will remember forevermore. The sound of cymbals and drum roll played ceremoniously in the back of my mind. Behold Dr. Rikki – the first consultant physician of this house officer’s budding career.

It was then that Dr. Sam broke the mellowed ambience. He was one of the three younger doctors surrounding the patient.

“So what do you think Dr. Rikki? Do you think the sodium level in this patient is normal?”

?????

Now, wait a minute. Did that medical officer just posed a daring challenge to his consultant specialist, in a very rude manner nonetheless?

Dr. Rikki remained silent, his authority and wisdom under siege from a subordinate unaware of his rightful position.

“Dr. Rikki, if you don’t know the normal sodium levels, you can refer to the reference figures attached with the blood results,” Dr. Sam persisted, handling Dr. Rikki the patient’s charts.

I almost fell back to the ground in shock. Like a fool, I’ve been looking up to the wrong figure among the crowd. I have mistaken a fellow house officer for a consultant specialist.

The drumroll in my mind ceased abruptly, the cymbals came to a crashing halt.

Dr. Rikki (not his true name) remained interesting and enigmatic though, but mostly for very different reasons. As I worked with him or rather worked him out, I discovered a wealth of incredulous enlightenment, if I were right to deem it as such.

Dr. Rikki was indeed forty something years old. An indigenous local Sabahan, he was sent on MARA scholarship to Indonesia to study medicine, in spite of the fact that he never did apply for medicine or was ever interested in medicine in the first place. He went anyhow, and stayed a duration exceeding twenty years. He failed his first medical school, attempted to return but was pushed by MARA to complete his medical degree in another Indonesian medical school. It was then that he fell in love and married an Indonesian Chinese. The couple would go on to have four children – in Indonesia. As the responsibilities of fatherhood mounted, the then MARA scholar Rikki took an extended break from medical school to raise his brood. A man’s gotta do what a man’s gotta do, even if it was at the expense of Malaysian taxpayers’ money. He remained under MARA scholarship until the day he finally graduated with a medical degree from Indonesia – fifteen years later. He did not immediately return to Sabah though. The newly bestowed Dr. Rikki stayed behind in Indonesia for another few years. Only God Almighty will know what he was doing there.

Over the next few months of working with Dr. Rikki, it was obvious that he was pursuing all things but medicine all those years in Indonesia.

He made ridiculous clinical errors that will go down in hospital records as urban legends.

He discharged a patient with intravenous medications. The bent old lady came back to me with two boxes of bottles and drips but no tablets or pills.

He sent a patient with active tuberculosis home with all the goodies of vitamins, iron and double calcium supplements, but no anti-TB medication.

He started a drip regime for a patient in sepsis: three pints of normal saline and two pints of ceftazidime. What was he thinking, a life-long prevention of melliodosis infection?

A stroke patient was started on tube feeding. Most doctors will start slow say, at 500mls/day. Dr. Rikki started slow too, at 2mls/day.

His English was incredible, in a very absurd manner. Like advance kindergarten teachers, we taught him how to spell A-O-R-T-A and A-S-T-H-M-A, dictating each alphabet to him. Our blood pressure was rising faster the price of oil per barrel in USD.

When a lactating mother assured us she was breastfeeding well, Dr. Rikki scribbled in the notes: Mother says breast is well.

We all need amusement in our daily work, but not when it’s dangerously funny. I thank Dr. Rikki for all that and more.

I do not have any idea where Dr. Rikki is now. It would be interesting to know though. He’s definitely not in the hospital anymore. Rumors are that he left to pursue farming in Papar. Others say he was sent back to medical school (again!).

I may sound judgmental and holier-than-thou in writing the truth about him. Seriously, I don’t blame him for being slow, I blame him for wasting my father’s taxes and for being unwilling to improve and learn on the job despite the repeated chances.

What’s my point in writing this article?

Amongst others, some of which are stating the obvious:

• First impressions are deceiving. I felt like a fool after that first meeting in the ward.

• The BN government has wasted enough of our money handling out scholarships by ethnicity.

• Sabahans won’t necessarily treat Sabahans better. So stop this crap about work permits for Peninsular Malaysians when Filipinos are entering the state in sampan-loads every day.

• Tertiary education is not in the best interest of every person. Some are better off owning a farm in Papar, to sell papayas and become rich.

• Our Ministry of Health is full of hot air each time it speaks about quality control. Dr. Rikki worked for 18 months before the Ministry decided to take remedial action. If he saw just three patients per day, he would have endangered the lives of 3X30X18 = 1620 patients. Any one of them could have been your father and my grandmother.

• Possessing a medical degree is not reflective of anyone’s grey matter. It is true that empty vessels make the most noise, but not always. It is also true that diam-diam ubi berisi, but not always too.

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SKT 79, so how now?

Sincerity and good manners are relevant only to patients, not to a healthcare system riddled with pride, prejudice, racism and cronyism.

How does one react and behave when the future you’ve been working for is suddenly snatched from you?


SKT 79: so how now?

I checked my SKT today or rather, my friend checked it for me.

Hopeful but not overly, prepared but not for the worst, it was still much of a surprise that I only managed a mere 79 points for my SKT of 2007.

Still doubtful that I was given such a low mark, I rechecked it myself at the office. The young girl in green tudung was friendly and cooperative. Despite the time being very close to lunch hour, she brought out a thick, dog-eared record book. I scanned through the pages, found my name and took a long look at the points.

True enough, just as I had suspected.

I did not get 79 points.

My friend had reported it wrongly.

It was a 78.

The SKT is an acronym for Sasaran Kerja Tahunan. It is an annual evaluation exercise whereby heads of departments or specialists-in-charge grade their subordinates based on a few pre-set criteria on a scale from 0-100. It is very much a subjective and arbitrary means of assessing a doctor’s overall work performance over the preceding one year. More often than not, the final tallied points are hardly reflective of the individual’s capabilities and commitment to one’s job. The lazy doctor who disappears from the ward five times a day and sleeps throughout his on-call may very well end up with the same mark as one who goes the extra mile for one’s patients. Ass-licking and ball-carrying go a long way, to put in as bluntly as possible.

The main significance of the SKT is mostly for doctors who plan to apply for specialty training through the master’s programs conducted by our local universities. In view of recent changes in the external exams for the surgical fields, most doctors have little choice but to pursue their specialty training via the master’s program. A minimum SKT of 85 for three consecutive years is a basic criterion before one is eligible to apply for specialty training in a local master’s program. For the bumiputra doctors, an alternative specialty training program is available through Skim Latihan Akademik Bumiputra (SLAB). For non-bumiputras, we are essentially left at the mercy of our superiors to determine our future, or the lack of it, with one quick stroke of the pen.

Realising the weightage that the SKT plays in one's career, some department heads have set policies that no doctor's SKT should ever be lower than the magic number of 85. As such, every Hisham, Chan and Komaladevi will receive a commendable score regardless of one's actual work performance. It defeats the whole purpose of an annual assessment so I really wonder why anyone should even bother to work hard when ass-kissing will propel one to the top.

With an SKT of 78, my chances for a placement in the local master’s program is essentially nil.

Zilch. Zero. None. Non-existent.

What should I do now?

I can go on the whole night whining like a loser about how the macha who boozed and snoozed on the job got a better mark because he boozed and snoozed with the macha specialist who graded him. I can go on exposing the wrongs committed by this same specialist who graded me, how I stayed behind till the wee hours of the morning cleaning up the mess he created to a bleeding patient. I can write on and on because I’m writing the truth but I won’t.

I need to think think hard and ponder deep.

I need to weigh my options at this juncture.

Righteous anger is still anger. Bitter truth is still bitterness.

“My peace I give to you, peace not as the world give but peace that comes from heaven” – Jesus Christ

I do not think it is easy for anyone to sit down calmly and endure injustice flung into one’s face.

Sincerity and good manners are relevant only to patients, not to a healthcare system riddled with pride, prejudice, racism and cronyism.

How does one react and behave when the future you’ve been working for is suddenly snatched from you?

Shrug…It was never mine to begin with anyway.

I’ll weigh my options.

At this point, I can:
• Sit down and shut up. I can choose to wait for another year or two and hope someone fair and just will accord me the minimal points I need to apply for masters. By the time I am eligible to apply for a masters course, the SLAB products who were once my juniors will be my lecturers. Then again, life is not a race, or so they say…

• Get on my knees and appeal to the kind-hearted boss to re-evaluate me. I’d have to put on a gay smile, speak some niceties, do tip-toe dance or two and hope it’ll soften his callous soul. Think I should do that?

• Join the masters program as a private candidate. Pay RM 20,000 to learn under SLAB lecturers only to be left without a job upon graduation. Not a bad option in fact.

• Forgo my ambition of ever specializing, serve out my compulsory government service and open up a general practice somewhere in Kota Marudu.

• Quit medicine altogether and join a pharmaceutical company or a direct sales scheme.

• Pack my bags and leave for a foreign land and join the fight in a survival of the fittest.

• Commit suicide and hope the racist leaders of Malaysia will learn their lesson. Fat chance that’s gonna happen.

Still thinking. Still pondering.

It’s not easy. It never was.

“My peace I give to you, peace not as the world give but peace that comes from heaven” – Jesus Christ

Guide me Jesus.

Amen.

Read more!

SLAI or SLY?

A popular Malaysian blogger, Ong Kian Ming (soon to be Dr. Ong Kian Ming) who writes regularly for Malaysiakini and educationmalaysia.blogspot.com enquired about the SLAB/SLAI programs. This was my reply to him, which i will share with you all.

SLAB/SLAI: A World Of A Difference


Dear Kian Ming,

Sorry for the late reply.

The link that you attached was not accessible.

Nevertheless, the SLAI program is something recent. UM did not have such a program, at least not when I left UM in 2005. In theory, the SLAI and SLAB programs are both equal and identical.

In practice however, there are marked differences between the two.

A reasonable analogy will be like how the Ministry of Higher Education claims to practise meritocracy in theory but puts in place a very devious mechanism to ensure the continued dominance of the bumiputra Malays.

By its name, it may appear that SLAB is a program that caters to all bumiputras – both Muslims and non-Muslims, Malay and non-Malay bumiputras. A close friend of mine, a Kadazan bumiputra once met up with a senior professor of Universiti Malaya to enquire about her eligibility for the SLAB program and how she can go about applying for the scheme. The senior professor of Public Health, who was also the then Deputy Dean of the Medical Faculty gave a very nebulous answer but essentially told this friend of mine that non-Muslim bumiputras are basically not eligible for the trainee lecturers’ program. I was there personally so my eye-witness account is essentially all I can offer you as solid evidence that the SLAB program itself is a mere smokescreen to ensure Malay supremacy among the academic ranks.

The SLAI program is really something else. It stands for Skim Latihan Akademic IPTA (Institut Pengajian Tinggi Awam). There are no ethnic criteria attached to it but in view that the bumiputras already have SLAB to cater to them, you are very correct to assume that SLAI is therefore in existence to cater for the non-bumiputras.

If at all the SLAI and SLAB programs can ever be comparable to each other, I can only say that both does not emphasize on meritocracy. The few non-bumiputras I know who are currently in the SLAI program were not among the top students in their classes. Apart from that, the terms and conditions after one successfully completes one’s studies under the SLAB/SLAI programs are similar.

This is perhaps where their similarity ends. On closer scrutiny , one can see great discriminative practices between the two programs.

I am only covering the medical fraternity as I do not want to make any misleading statements that may not be true for other fields of knowledge.

For starters, the SLAI program for non-bumiputras or rather non-Malays, are open to all specialties in theory but greatly constrictive in practice. Competitive disciplines and specialties in high demand are very much closed to non-Malays. These include opthalmology, otorhinolaryngology, orthopaedics, general surgery, anaesthesiology, radiology, obstetrics and gynaecology. Non-Malays keen to pursue SLAI training will have to contend with non-clinical fields like the basic sciences (physiology, biochemistry, anatomy), public health, or less competitive clinical disciplines like internal medicine. This is in stark contrast to the overwhelming presence of bumiputra Malays in the SLAB programs for the aforementioned hugely popular surgical disciplines.

The number of successful SLAI candidates pale in comparison to the number of SLAB trainees. If you are interested, you can view the individual departments’ academic staff and compare the number of SLAB to SLAI lecturers currently in the Faculty of Medicine, University of Malaya. This is the link. Assuming the website is updated (it is not!), there are only three non-bumis currently pursuing an academic program under SLAI. The ratio of SLAI:SLAB candidates is therefore easily 1:10. As such, I can’t see how anyone can portray the SLAI program as equal and equivalent to SLAB.

The process of applying for SLAI is also more rigid and stringent. Conversely, there have been many instances where the bumiputra doctors who never even applied for a SLAB placement were simply given an offer to pursue SLAB. More often than not in fact, the bumiputra Malays are given the luxury to take their pick from a few disciplines. One Malay colleague of mine wsa invited to choose between internal medicine, orthopaedics and obstetrics and gynaecology! Such privileges are of course not accorded to the SLAI candidates, who must decide on what they want to pursue when applying for the training program.

As with most other government schemes in Malaysia, the process of entering these academic programs is littered with political elements. Once again, I’m using Universiti Malaya as an example. There is an uncanny overwhelming presence of royalties among the SLAB lecturers and trainee lecturers. We can see this clearly in the departments of orthopaedics, otorhinolaryngology and ophthalmology. The number of academics with preceding Tengku-s is really a cause for suspicion. In addition, there is a great element of family business as well. The daughter and son-in-law of UM’s ex-vice chancellor, Professor Annuar Zaini are both in the SLAB programs of paediatrics and general surgery respectively. As far as the academic records are concerned, they were both merely average students while they were pursuing their basic degrees in UM. A father and daughter team is also currently in the Department of Social and Preventive Medicine. There is nothing improper about any father-daughter team except for the fact that the Professor himself was also the person who processed his daughter's application papers. It is not unlike the corrupt practices of late Zakaria Mat Deros. Sons and daughters of Datuks and other UMNO cronies are also abundant in the SLAB program. The SLAB program is thus one that is lacking in transparency.

I am not sure if there is any solid method to substantiate these allegations except through my personal daily observations and ground knowledge.

A great number of SLAB graduates are currently holding influential positions within the faculty. Generally, their privileges extend beyond the completion of the SLAB program. Some have been promoted to head of departments and professorships, bypassing more experienced and competent lecturers. Most of these SLAB graduates went on to pursue further training overseas on a university scholarship, at the expense of other non-bumi lecturers that joined the academic ranks by merit. This is also the major factor behind the resignation of many non-Malay academics from the university. It remains to be seen whether the privileges of further training and education will be accorded to the SLAI candidates.

My personal opinion about the SLAI program is that it is in reality a sly move by the Higher Education Ministry to appear meritocratic while resuming their racist means of managing Malaysian tertiary education.

I hope I have shed some light on your enquiries about the SLAB/SLAI programs.

Regards.

Read more!

Times I Screwed Up (2)

Like a frozen scene captured on film, the ambience of the moment remains as vivid today as it was then. A crumpled photo of a golden-haired, bearded Jesus lay on the floor, his hands clasped in prayer with loving eyes towards heaven. Tan’s wife had been holding the photo just a while earlier. From the corner of my eye, Tan’s wife stood a metre or two away watching us anxiously in our futile efforts of bringing a dead man back to life. To the medical personnel, he was just another patient. To her, that was her companion in health and sickness, love and war, life and beyond. Tears streamed down her flushed face, each droplet refracted into an array of mini-lucent colors by the golden Sabbath sun rays. Her weeping was tangible but inaudible, silenced within the helter skelter of chaos. Even as Tan laid there in



I Remember


“Can you please come now? I’m really sorry. But I really don’t know what to do. Tan is desaturating with low GCS.”

Like a horror dream, the phone call jolted me from sleep. I rummaged and stared at my clock. It was 5.00 am on a Sunday morning. It took me a while to absorb the reality of the situation. Did my colleague Yati really call to ask for help?My handphone confirmed the phone call. If Yati had indeed called me, then Tan was indeed in distress.

He shouldn’t be, though. There was no reason for him to be in distress, not at all.

Fifty-something year-old Tan was admitted two weeks before that. A Sino-Kadazan from Keningau, his name was fully Chinese yet he spoke no Mandarin or any Chinese dialect. Like most Sino-Kadazans, he was Chinese only by name but not by culture or language. Like most Sabah folks too, he was especially trusting and simple-minded.

Tan was a survivor. He was first admitted three years prior to this for a massive heart attack. From the medical records, his heart stopped beating for almost ten minutes. Most patients do not survive asystole and usually even if they do, it is not without severe significant brain damage. Miraculously, Tan survived that life-threatening episode and his heart started beating at a normal rate and rhythm again. He did not escape unscathed. He suffered a stroke during the resuscitative process which left him paralysed on the left side of his body.

Even so, Tan made a gradual and almost complete recovery to regain function of his body. Within a year of the heart attack and stroke, he was back in his estate, tapping rubber nonchalantly in the company of his wife. He was a little sluggish in his movements but he got by nonetheless. Where help was needed, his loyal lady saw to his needs. Life went on for the ageing couple. They had children who were working in the city but were contented in the humble nest they had built back in Keningau.

Everything was fine and quiet and blissful until Tan fell while working in his estate one rainy dawn.

He was admitted for surgical management of a broken left hip bone. We traced his records and were amazed that he pulled through a massive cardiac event with minimal functional impairment. The medical and anaesthetic teams reviewed him and cleared him for surgery.

Yati and I were both house officers back then. She was a graduate from Universiti Islam Antarabangsa (UIA) with wealthy parents well-connected to both UMNO and Anwar’s PKR. We had worked well in our previous postings and had cooperated effectively in the management of most of our patients. She was the first to attend to Tan when he was admitted.

Tan came to my attention when he first complained of difficulty in passing urine. I asked a few questions and looked at his charts. He was also constipated and nauseous. He was on morphine for pain relief. The culprit was immediately obvious. I struck off the morphine from his charts, put him on laxatives and assured him that the urinary retention and constipation will soon come to pass. I was reluctant to insert a urinary catheter despite the insistence of the staff nurses. As far as the staff nurses were concerned, all they want is one less complaining patient. From a doctor’s point of view, everything is about the possible risks against benefits to the patients. In Tan’s case, the underlying reason for his problems was obvious and there was no reason to put him on a urinary catheter.

I left for the clinics. I returned two hours later.

Unknown to me, in my absence, the staff nurses had persuaded another house officer to put Tan on a urinary catheter. I was less than amused but did not pursue the matter further.

Tan was scheduled for surgery soon. An outbreak of a fungal infection over the planned surgical site however prevented us from performing surgery until the infection has cleared.

One week later, the skin infection showed little signs of imminent recovery. Unsurprisingly, Tan developed a urinary infection due to the indwelling catheter. I started antibiotics and tried to remove the catheter but it was stuck, simply stuck. The balloon that held the catheter in place would not deflate. It was adamant and unrelenting despite all our measures. We referred to the urology team for assistance. The urology medical officer, a UKM graduate took three days to come to attend to Tan. Under ultrasound guidance, he punctured the balloon of the urinary catheter and successfully removed it. It only took fifteen minutes.

Tan was fine again, or so I thought.

The night before Yati’s call, I had checked on Tan, just six hours prior to her SOS call. Tan was well and cheerful and even bade me good night. His wife had just given him a new hair cut. The ward was too stuffy, warm and humid that Tan had opted for an army crew cut. He looked younger and definitely much neater in his new crop. He looked like a bald version of Phua Chu Kang, only a little greyer and wrinkled.

I will never forget the scene that greeted me that morning when I reached the ward. Tan was barely conscious. In fact, he was barely breathing. He was running a fever of 42 degrees. His oxygen saturation was only 86% on high flow oxygen. Apart from the oxygen supplement, little else was done for him since the time he deteriorated. In her panic of the sudden and unexpected downturn of Tan, Yati had somehow forgotten basic resuscitative measures. It didn’t help that the orthopaedic registrar on-call was incompetent and irresponsible.

Personally, I was outraged and furious but that was not the time for a blame game. Amidst the need to rush and the urge to yell, a list of probable diagnoses raced through my mind. Tan’s blood pressure was low - it could have been another heart attack. He was breathing but not responding – it could have been a stroke – an infarct or a bleed or something like that. It may be a deep vein thrombosis with migration to the lungs. It could be a fat embolism from his long bone fracture. It could have been respiratory failure from orthostatic pneumonia, if that was possible.

We inserted lines and tubes and a new urinary catheter. That was when the truth surfaced. No urine flowed into the catheter or rather, it was not urine. It was pus, frank pus – thick, foul-smelling, green-colored fluid.

It was not a heart attack or stroke or any embolism. It was a simple urinary tract infection that had set in from the catheter. Despite his apparent general wellness, Tan had been increasingly ill all these while with pus forming in his urine, his bladder and up to his kidneys converging finally as pyelonephritis and full blown sepsis. By now, all our efforts were in vain, like a chase after the wind.

We commenced CPR soon after. Like a frozen scene captured on film, the ambience of the moment remains as vivid today as it was then. A crumpled photo of a golden-haired, bearded Jesus lay on the floor, his hands clasped in prayer with loving eyes towards heaven. Tan’s wife had been holding the photo just a while earlier. From the corner of my eye, Tan’s wife stood a metre or two away watching us anxiously in our futile efforts of bringing a dead man back to life. To the medical personnel, he was just another patient. To her, that was her companion in health and sickness, love and war, life and beyond. Tears streamed down her flushed face, each droplet refracted into an array of mini-lucent colors by the golden Sabbath sun rays. Her weeping was tangible but inaudible, silenced within the helter skelter of chaos. Even as Tan laid there in lifeless bliss and heavenly awareness, my thoughts were tumultuous with troubling images of an elderly lady wandering alone in a wide and misty rubber estate. Beneath my apparent energy and vigor, I was in fact very numbed and sore within and without.

Lying there was a patient who once conquered a stroke and a massive heart attack. He was now losing a battle to a urinary tract infection. Such irony.

Tan died two hours later, after we exhausted our armamentarium of inotropes, atropine and cardiac defibrillator and maximum ventilator settings.

Throughout the whole episode, only the two of us then house officers were at the forefront. The specialists came, took a peek, shook their heads, gave a grin and left. The medical officers came and had no clue what was going on.


Tan didn’t die however because of incompetent medical officers and uncaring surgeons.

He died from neglect – and that would never happen if I as a house officer then were more vigilant.

Read more!

News Round-up

News Round-Up.

Of late, this web log have taken on a more personal note, publishing stories about me, myself and I, when so much else is happening throughout the world.

I don’t know about the rest of you out there but I haven’t consistently read the mainstream papers for almost two years now. I am not too willing to pay RM 1.80 for The Star or the New Straits Times over here in Sabah, especially not on a daily basis and even more, for a package of well-edited lies. I rely on Raja Petra Kamarudin’s Malaysia-today for my daily updates. It has served me well thus far.

It’s been more than a month now since the so-called political tsunami of Malaysia. Those among us wishing and itching for change must be getting pretty impatient by now. I don’t know. I’m based in Sabah, the bluest of the bluest BN state. Things haven’t changed much for me and certainly not for most of the local Sabahans. The rare times I do read the news, it all sounds so yesterday.

Racist remarks teeming with tones of Malay supremacy are still very much the norm. The latest is from the crown prince of Kelantan, one Tengku Faris. The feedback and backlash from the Malaysian society in general seemed pretty pale when compared to the backlash in response to similar remarks by the UMNO bohemians. The most firm-worded statement had to come from Karpal Singh, who remarked that Tengku Faris’ remarks bordered on sedition. The relative silence from the Malaysian society especially the Malay politicians is a testimony of the prevailing cloud of feudalism among Malaysians. Just because a racist remark came from a human with so-called royal blood doesn’t make it any less racist and rude. We all bleed red and breathe air and rot to nothing after we’re dead. Turds smell like turds be it whether they came from ‘commoners’ like us or ‘royalties’ like this Tengku Faris fellow. Call a spade a spade and call a turd a turd, even when it’s a royal turd.

Crime is still prevalent. I don’t know about the police’s response and attitude to it though. Personally, I feel that the cops of Sabahland are much more courteous and committed to their duty. A friend’s house was broken in juts two days ago. It was a well-planned heist with the principal targets being his high-end laptop and other costly gadgets. The Sabah cops recovered his belongings within a day and arrested all the suspects who turned out to be my friend’s next door neighbours. The Sabah police force also made a remarkable breakthrough in the recent abduction of a 22-year-old Universiti Malaysia Sabah (UMS) student. Both suspects were caught but not before the young lady victim was allegedly sexually assaulted. The arrest of both suspects was only possible with effective communication between the police teams across the state. One interesting point to note in this case of abduction is the fact that the abduction was witnessed by the four friends of the victim. These fiends however, waited two hours before lodging a police report, by the time which the victim was already midway on a terror ride from Likas to Keningau.

It is really mind-boggling why four university students waited for two hours before making a police report on her abduction. Are we producing graduates that are so stoopid and dumb and retarded these days? What in the world were they thinking?

Speaking of UMS, I wonder if Malaysian parents are aware of what institution their children are entering? To many Sabahans, UMS is their pride and forte. The university is supposed to be a reward of sorts for Sabahans’ undying support for the BN regime. After more than a decade in operation, UMS has turned out to be yet another NEP factory. In fact, it is so very pathetic that it can’t even train its own NEP products. The SLAB program for UMS is apparently held in a twinning effort with UM, UKM. Closer to the medical fraternity, some have renamed that the Medical Faculty of UMS as University Myanmar Sabah. It’s really a more appropriate name in fact. Most of its medical lecturers are Burmese. I have nothing against persons of Burmese origin. Some of my own lecturers back in UM were Burmese and some were excellent teachers. Something is terribly wrong however, when most of the lecturers are foreigners from Burma and the Middle Eastern states of Iraq and Egypt. It simply means that UMS was never ready to start a medical school in the first place. There was a time when these Burmese lecturers-surgeons were allowed to operate in the hospital. Except for a few minor surgical procedures, ALL of the other patients died post-operatively – mostly from poor surgical techniques or post-operative neglect. I really pity Sabahans in this respect. They came with high hopes but left with a corpse to bring home. Realising the exceptionally high rate of perioperative mortality among the Burmese surgeons, the Surgical Head of Department decided to put his foot down and cease the daily slaughter of innocent Sabahans. The Burmese surgeons are still operating though, but usually under supervision. Note the emphasis on ‘usually’ as opposed to ‘always’.

Apart from quality, UMS is a slaughterhouse in its own right. Located in Likas, an area densely populated by UMNO’s Project IC citizens, I have lost count on how many UMS students have been victims of violent crime since the day I started working in Sabah’s healthcare.

The Sabah Chief Minister has proudly proclaimed that the BN state government will be building more detention centers to house illegal immigrants. It simply means that more of your money and my money will be used to raise these Filipino and Indonesian children so that they can grow enough lean meat to rob our houses later on.

Tenaganita’s Irene Fernandez and other human rights advocates insist that no immigrant or refugee should be stigmatized and blamed for the increasing crime in Malaysia. I beg to differ. Common sense must always prevail over emotions and personal beliefs. Are Filipinos and Indonesians in Sabah more prone to commit crime than the local population? Facts and figures and news reports may lie and bluff but the harrowing tales and scary accounts of the victims do not. I feel Malaysians should really keep a lid about the human rights of Filipino and Indonesian migrants and re-focus on defending the sovereignty of our borders and seas instead.


I don’t get many readers, if at all from the Philippines but seriously I hope one or two of them will read this article. The population of Philippines has risen to a massive 88 million according the latest Filipino census. This explosive figure is alarming the Filipino government especially more so since the nation is facing a shortage of rice and other essential items. Nevertheless, the predominant Catholic nation remains obstinate on the use of contraceptive techniques. In a nutshell, they are more fearful of angering the Pope than sending a million children to death by hunger.

While the Filipinos have their hands full attenuating hunger and a bulging population, the Pope himself is no less busy over in the United States. He is still attempting to downplay the prevalence of paedophilia among Catholic priests to the extent of defending an Archbishop who defended his church’s paedophilic priests.

Humans are really funny and stupid at times. We put our faith in man and men in religious robes instead of God almighty who created the heavens and the earth and all within it. To me, all humans are prone to temptation and failure.

We’re all turds in our own ways and to varying degrees. We cannot pretend that we’re not turds, not even when we’re dressed in fancy flowing religious robes.


Read more!

And Times I Didn’t (1)

There’s more to life than living and dying. Being alive isn’t necessarily a beautiful thing and death isn’t necessarily something horrible. As Mel Gibson as Braveheart proclaimed, all of us will die, but how many among us truly lived?

Jaunah was only 46 years old but had already developed a wide range of diabetic complications. The first time I saw her, she was lying motionless in an isolated bed in the orthopaedic ward. The mother of five and grandmother of two was a chubby lady. Catatonic and staring blankly towards the ceiling, she blinked occasionally in an apparent pensive and mellowed state of mind. Her left leg was no more, amputated below the knee for a severe infection involving her left foot. The remaining lower limb seemed destined to follow suit. The bandage around her right calf bore testimony to a recent surgery to remove a collection of intramuscular abscess.

A dirty catheter protruded from the right of her neck. It was an internal jugular catheter inserted weeks ago to enable hemodialysis for her failing kidneys. Years of uncontrolled diabetes and recurrent bouts of severe infections had damaged her kidneys to a seemingly irreversible state. A tracheostomy tube prevented her from verbalizing any sound, word or exclamation. As such, no one knew if she was depressed or angry, hungry or thirsty or in pain. Bad lungs, prolonged ventilation and repeated surgeries had made tracheostomy a crucial intervention.

A bed sore in her buttocks measuring the size of a human palm emitted a foul-smelling stench, revealing the muscles and bones that lie beneath. It was badly infected with a potent organism doctors name MRSA.

A young lady and a small girl waited by her side every morning. Her daughter-in-law had resigned from her work to care for Jaunah. With the reduction in her household income, a baby-sitter was beyond her means so the young child had no choice but to spend her days in the infectious environment of the hospital. By evening, Jaunah’s son assumed his rightful responsibility of caring for his mother. He traveled from Kota Belud every day after work. It was a daily journey of 180 kilometers.

I read through Jaunah’s case notes. They stacked up higher than a Britannica collection. In a patient with multiple issues, a sense of chronology will put things into a better perspective.

Jaunah was previously well, until she started developing multiple areas of abscesses. She had undergone repeated surgeries for infections in her cheek, buttocks and thighs. It was during this time that she was found to have a poor kidney function. When her condition stabilized, she was sent up to the ‘extension ward’ to recuperate. One night, she developed total blindness in both eyes. Further investigations suggested a stroke involving the area of the brain responsible for deciphering vision. She was blind since then with further deterioration of her general health and kidney function. Jaunah was started on regular dialysis thereafter.

In the morning rounds every day, the surgeons and consultants virtually passed her over. They had practically given up on her. She was referred for ICU care. The intensivists came and suggested a DNR instead – Do Not Resuscitate. To be fair, it was actually a reasonable option as ICU beds are always in a state of acute shortage. I was left with the unenviable responsibility of counseling the family regarding her resuscitation status.

Her husband arrived after a whole week of waiting. He was of tiny frame, had thinning silver hair and bore an uncanny resemblance to Abdullah Ahmad Badawi. Years of kerja kampung had taken its toll on him. His wrinkles and sun-scorched skin painted a man beyond his years. A devout Muslim, he was submissive to the will of God and any eventualities but was hopeful that the doctors would not just give up without trying.

I was practically left to handle the patient by myself since then – a house officer with no experience or formal training in intensive care. With the help of my colleagues especially Dr. Bee, we made major decisions in the daily management of Jaunah. It was unprecedented – two house officers left alone in charge of an ill patient with little chance of total recovery.

We decided to replace the dirty tracheostomy tube as well as the over-aged dialysis catheter.

I spent almost an hour securing an intravenous cannula for Jaunah to undergo surgery.

When Jaunah developed upper gastrointestinal bleeding, we referred her to the gastroenterology team for a life-saving scope.

We controlled her sugar tightly and stabilized her blood pressure.

When she developed yet another severe lung infection, we took the liberty to prescribe the most appropriate antibiotics. In times when the specialists give up and walk off, the bulk is passed onto the house officers who must step in and rise to the challenging occasion.

Jaunah began to show tremendous improvement. She was passing urine well without the need for dialysis. Her infections have settled except for her bedsores. Her tracheostomy was finally taken off and I heard her voice for the first time after a month. She spoke as someone who had never spoken before, telling me the terrible and crazy things that happened to her during her stay in hospital.

It was also the last I heard from her. A few days later, she was transferred out of the ward to recuperate in the ‘extension ward’.

I heard from Dr. Bee that she was the noisiest patient there.

Shrug…

Jaunah died about two months later. I never knew why.

One may look at her death as a cornucopia of wasted efforts after so much money and time and intervention.

I’m only glad she had the chance to say goodbye to her husband before she passed on.

Sometimes, that’s more than sufficient.

Read more!

Anak Di Rumah Mati Kelaparan...Astro Di Bumbung Kecapi Kegemilangan

Sixty kiometers from nearest town,
Sixteen km of dusty gravel road,
Sixty square foot of living area,
Sixty coconuts to harvest each day,
Sixteen ringgit of income per day,
Six-month pregnant wife,
Six young mouths to feed,
Six safe methods of effective contraception,
He chose sixty channels instead.

How to progress with such mentality? Read more!

The Reward For Dilligence

Very upset. Worked so hard as houseman only got 76 for my 2007 SKT. Wanna leave this stupid country.

That was the SMS I received from my colleague Dr. Bee, medical officer of Kinbatangan on my back from Kota Marudu today.

I was driving at 80km/hr along the treacherous Kota Marudu-Kota Belud ‘highway’ then, but could not help but feel angry over the news.

Dr. Bee like myself, graduated from UM and assumed housemanship in the state of Sabah by choice.

Doctors come to Sabah for many different reasons. The kiasu ones are here under the impression that a working stint in Sabah will earn them extra points in their pursuit of the local Masters specialty training. Some are here because they were told that the training and working experience here in Sabah are much better and wider compared to Peninsular Malaysia. I can’t comment on that, because I have never truly worked with the Ministry of Health in Peninsular Malaysia. My short attachments in the Klang, Banting and Tanjung Karang hospitals are not sufficient for me to make a proper comparison. Of course, there are always the jerk doctors who come to Sabah preying on the gullible local ladies. You can read my other posting for real-life stories.

Dr. Bee however, came to Sabah with nothing to gain and everything to lose – her spouse, her family, her friends, the comfort of home. I believe she came to serve the community of Sabah and verily I say, she has lived up to her personal pledges.

In the eighteen months of my working experience with Dr. Bee, I only have words of praise for her. She was among the top graduates in my class but unlike many other brainy doctors, Dr. Bee was competent and well-balanced in knowledge, work and character. She came to work early, examined patients thoroughly and demonstrated sincerity in her dealings with patients. She was so dilligent and motivated that other doctors took her for granted and pushed her around.

If I were to find any fault in her, it would be her uncanny fetish for all things afro. That's none of my business, though.

There have been a many emergencies and events whereby she was one of the few reliable hands around. There is no doubt in my mind that without her assistance and support during those times, a large number of patients would have had a very different and worse outcome.

She had had her share of frustrations and downcast while serving as a house officer. Sadly, this is the exactly the case with Malaysian healthcare. Lazy, moronic and irresponsible doctors get off scot-free while diligent, responsible and knowledgeable doctors like Dr. Bee get trashed. It’s a sickening system, to say the least. The hardworking doctors end up with more baggage and liability while doctors who go AWOL remain AWOL with no accountability.

Having studied real hard and basically smart to begin with, there were times where Dr. Bee just couldn’t reconcile with the occasional doubtful conclusions of some of the clinical specialists. In a feudalistic system like Malaysia’s, differing opinions are not tolerated well, much like the culture so rabid among our politicians.

Being pint-size and soft spoken, Dr. Bee was an easy target for the wicked bosses among us. It was really distressing to see her on the receiving end of verbal harassments from those racist, sexist, shit-full orthopaedic surgeons and NEP products.

While she was as frustrated with the system as I have been and still am, she remained ever enthusiastic and firmly focused on the big picture that is patient’s well-being and best interests.

We have gone separate ways and function independently as full-fledge medical officers now.

I have no doubt however, that Dr. Bee continues to maintain a self-imposed standard of excellence in her daily work in the interior of Sabah.

It was therefore remarkably upsetting that a doctor like her received a mere 76 marks for her annual work assessment called the Sasaran Kerja Tahunan (SKT).

Is this the reward for diligence in the civil service?

What the big deal about SKT, one might ask?

Sigh…

For non-bumiputera doctors like Dr. Bee and myself, the SKT points are very much a determining factor in our application for the local Masters program. The SKT points MUST NOT BE BELOW 88 FOR THREE CONSECUTIVE YEARS before we are eligible to APPLY for a specialty program.

Contrast the above criteria with the criteria set in place for Malay doctors who are accepted into the Skim Latihan Akademik Bumiputera (SLAB) program. Essentially, there are no specific criteria in place for the SLAB program. In fact, one may not even need to apply to join the SLAB program. I have had Malay colleagues who were simply offered to choose from a variety of SLAB specialty programs.

With an SKT of 76 points, the chances of Dr. Bee being eligible to apply for specialty training is practically nil.

Anyway, do we really seriously think that NEP products groomed in a racist system will be fair and considerate in their assessment of non-NEP products like Dr. Bee? Will they be able to empathize with the struggling non-Malay doctors striving for career advancement while juggling their daily work? Will they give a leg up and lend a helping hand the same way they were given crutches and wheelchairs to roll about?

To my dear friend Dr. Bee, take heart and don’t be discouraged. Study hard and kick their NEP asses. Above all, stay the same – a wonderful and dedicated clinician.

Now I wonder what my SKT is for 2007…..


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Kera di hutan disusukan....Anak di rumah mati kelaparan (2)

Schools for Indonesian children will soon be sprouting up around the state of Sabah. After a “brainstorming session” with the Indonesian Consul General, the Ministry of Education has decided that Indonesian children in Sabah should not be deprived of a chance at education.

The first of many to come, Sekolah Indonesia Kota Kinabalu (SIKK) will reportedly be built in Alam Mesra, a high-end commercial zone in Likas, Sabah not far from Universiti Malaysia Sabah (UMS). In the same news report, it is estimated that a total number of 5,500Indonesian kids are already studying in 72 learning centers across the state of Sabah, mostly run by NGOs with the official endorsement of the Malaysian Ministry of Education.

The Indonesian Consulate General, one Rudhito Widagdo also claims that “there was no such term as illegal Indonesians for the Consulate” his countrymen “would enter Sabah legally and comply with Malaysian Immigration law by bringing along valid travel documents”.

Well, birds of a feather flock together. So do lying liars and politicians from both Malaysia and Indonesia.

For those who are unfamiliar with the overall state of Sabah, take my word that the local population in the rural districts is still very much entrapped in pre-Independence living conditions. The waves of development have evaded them deliberately for fifty years now. Opportunities for education are still very restricted and many of the district schools are wasting away in a pathetic state. Young girls getting married at the age of 14/15 is not uncommon. Meeting a 32-year-old mother of twelve children raises no eyebrow. Basic necessities like treated water, electricity and sewage treatment are foreign terms to a massive size of the rural population.

It is thus a great mystery as to why the UMNO government is more concerned and caring about trouble-making Indonesian street kids when our own Malaysian children are in an equally miserable state of existence. Then again, maybe it is not a totally unexpected move under Project IC.

While I am personally outraged at the misplaced priorities of UMNO, my final response to Sabahans will be: SERVE YOU RIGHT.

While the people of Peninsular Malaysia have woken up and vehemently rejected the perpetual corruption, mismanagement and arrogance of the UMNO government, the majority of Sabahans have opted for cowardice. Their fear of change and upsetting the status quo has now returned to collect its debt.

UMNO has long set its lustful eyes on the rich state of Sabah with the ultimate goal of establishing total Malay supremacy and eternal Islamic dominance.

The UMNO-back eradication of USNO in 1990 paved the long-awaited entry of UMNO into Sabah Borneo. There was no stopping UMNO since then. Like a black hole, UMNO wasted no time to devour all possible sources of wealth in the Land Beneath the Winds.

UMNO then attempted to dilute the predominant non-Muslim population of Sabah by encouraging the immigration of Muslim Malays from Peninsular Malaysia. By appointing these government officials to positions of authority in Sabah state agencies, UMNO hoped to solidify its position in Sabah before the local population awakens from its slumber. When this effort failed to occur at a desired pace, UMNO became impatient and opened the floodgates with the treacherous Project IC/Project Mahathir.

The face of Sabah has since transformed irreversibly and radically.

These new migrants arrived at Sabah’s shores in droves. They bred at a rate that put armadillos to shame.

Had it not been for the alternative news media, Project IC would never have come to light. Malaysians will still be in sweet oblivion hearing the perpetual niceties about Sabah being the model of racial unity and harmony.

The Malaysiakini scoop on Project IC arrived a little too late however.

With the chief minister’s throne firmly in UMNO’s possession now, the state government resumes its act of treason even more arrogantly and brazenly. After years of uninhibited immigration, the Muslim population has reached a sizeable figure by now with the selective issuance of Mykad and bumiputeraship to the Muslim Filipinos, Indonesians, Timorese and Pakistanis.

With such a massive foreign backing, UMNO has no fear now to up the ante and insult the native Sabahans right at their faces. Sekolah Indonesia Kota Kinabalu is but merely one such example.

UMNO’s plans for Sabah are anything but complete. Political hegemony and economic monopoly will never suffice. UMNO will not rest on its laurels until the Islamization of Sabah has reached the degree seen over in Peninsular Malaysia.

Even as Catholic churches are operating from humble shacks on squatter land, the UMNO state government has been erecting posh mosques all over Sabah. Even a district with minimal Muslim population like Pitas has a mosque fit for a prince.

Sabahans can justify their support for the Barisan Nasional all they want. No one will deny that Sabah politics is unique and complex. The people of Sabah have been sold out by both the Kitingan brothers as well as UMNO, and their remaining choices are once again political parties originating from Peninsular Malaysia like PKR and DAP. It is understandably not easy for Sabahans to reject their bumiputera feudal warlords in Barisan Nasional. Nevertheless, some things are plain to see. UMNO has no sincere intention to prosper the natives of Sabah.

In fact, it is very much the opposite. By merely neglecting their needs and adversities, UMNO is practically committing a bloodless genocide to the predominant non-Muslim population of Sabah.

In HINDRAF’s terms, it is ethnic cleansing. Personally, I dub it as an outward betrayal of the gullible and ever-trusting Sabahans.

Now what will Sabahans call it?

Anu bah?




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Times I Screwed Up (1)

There are times when good intentions and random acts of kindness are just never enough.


Times I Screwed Up (1)

There are patients whose names I can never remember, even when they greet me on the street. In times like these, I try my best to fake recognition and camaraderie, but my unrehearsed act almost always fails me. Then there are patients that I’ll try my best to forget, but their names and their faces keep on emerging in times they’re least expected.

Nyuk Lan (not her real name) was admitted for a left hip fracture. At a ripe old age of eighty nine years, a trivial fall at home on a dark Sabah dawn was all it took to break her osteoporotic hip bone.

To make things worse, an osteoporotic fracture was just one of Nyuk Lan’s long list of issues. A chronic smoker, she was at an extremely high risk of developing orthostatic pneumonia due to prolonged bed rest. Her blood pressure was also sky high despite repeated measurements. She was most probably an undiagnosed hypertensive for a great number of years. She was mildly anemic, which is not uncommon among elderly folks her age. This is usually due to multiple interacting factors.

I was not the first person to attend to Nyuk Lan. Nyuk Lan only came under my care after her concerned daughter approached me complaining that the elderly lady was having severe dizziness and nausea with abdominal pain.

The first attending doctor had prescribed a combination of pain killers – paracetamol, ibuprofen and tramadol. Strong medications but poor choices for a frail old lady, I thought. Ibuprofen can trigger severe gastritis while tramadol frequently causes dizziness, nausea and vomiting and high blood pressure among ladies. Naturally, I stopped the medications, prescribed other pain killers and gave some reassurance to the patient before moving on.

I took a keen interest in Nyuk Lan’s care since then, to the point of being possessive. Elderly patients are truly fragile, more prone to developing adverse reactions to all medications and usually in greater severity. While in medical school, I had made it a point to read pharmacology as thoroughly as I could, mostly at the expense of other subjects, especially those I truly dislike like obstetrics and gynaecology.

Over the next few days, I gradually took over the daily management of Nyuk Lan, successfully identifying her growing list of issues. Clinical practice very much revolves around the ability to identify possible threats, treating and preventing them in the process.

Nyuk Lan was planned for surgical repair of her hip but her other medical issues need to be optimized before proceeding with operation. Statistics were not on her side. Among elderly folks with osteoporosis, 10 to 25% will die within the first year after a hip fracture regardless whether any surgical intervention was performed. Nyuk Lan had more than just osteoporosis to battle with.

She had underlying chronic lung disease from years of smoking. I made sure she was receiving chest physiotherapy alongside the appropriate medications. She was hypertensive so I stabilized her blood pressure. She was constipated just like many other elderly folks. Mild laxatives eased her discomfort.

Above all, she was still anxious despite much reassurance. She had never been hospitalized before, what more a surgery. The granny requested for some vitamins and supplements to speed up her healing after her impending surgery in a few days’ time. I looked at her charts. She was anemic. I wrote her a common cocktail of supplements - vitamin B complex, folic acid and iron tablets. She was grateful, more at rest, more confident of being able to recover from surgery later. She slept well that night, reportedly for the first time since admission.

I felt good. I slept well too.

The big day came and went. An elderly lady with multiple medical issues had successfully undergone a hip surgery under spinal anaesthesia. Three days after operation, the consultant surgeon saw her fit to be transferred to the ‘extension ward’, located 500m away from the main hospital building. I had my doubts over the wisdom of his decision.

Five nights later, I received a call from the extension ward. Nyuk Lan was in pain and breathless. As I rushed up, the possible lists of diagnoses ran through my mind – a heart attack, inadequate pain relief, pneumonia, pulmonary embolism, exacerbation of her chronic lung disease and so on.

She was indeed in pain, but not too breathless. I ordered an ECG and the relevant blood investigations. The ECG machine was faulty, but from what I could decipher, there were no obvious changes of a heart attack. She was having abdominal pain, she described it something longstanding and not new. I administered some medications for gastritis while awaiting blood results, which will take a while in our retarded healthcare system.

I informed my colleague on-call regarding Nyuk Lan’s condition, reminding her to trace the blood results.

The next morning, Nyuk Lan was transferred back down to the main hospital. Her condition had deteriorated overnight and her blood results were very suspicious of an overwhelming infection. My colleague on-call the night before had conveniently forgotten to trace the blood results. The nurse on duty was incapable of interpreting the grossly abnormal reports and did not inform anyone.

I attended to Nyuk Lan. She was still conscious, but in severe pain. She was severely dehydrated and running a high fever. Her blood was very acidic and her kidneys were failing rapidly. Despite all our resuscitative measures, we knew she was dying and our efforts were in vain. We had missed the boat, the crucial timing when we could still have saved her life.

I guess Nyuk Lan knew too. With whatever strength she had left, she asked me for some ‘vitamins’ to see her through the moment when she’ll breathe her last. I served her the medications myself.

She died later that evening, surrounded by shocked family members.

Cause of death: sepsis of unknown origin.

The next day, her daughter came to the ward to collect the death certificate. She was in grief but well composed. She showed me a photo of her beloved mother taken two years ago and remarked how much weight she had lost since the onset of the chronic abdominal pain and constipation. She thanked me one last time, especially for the moments I was kind enough to giver her late mother the vitamins she requested.

Vitamins?!

Somehow, it all suddenly came together like a eureka moment. This time however, I was overwhelmed with shock, regret and guilt.

Chronic abdominal pain and constipation in an elderly lady was highly suspicious of underlying colon cancer. The anemia, the poor appetite, the unexplained weight loss – it all seemed to piece together now. Everything fell in place like a completed complicated jig saw puzzle.

Post-operatively, she had required morphine for pain control, which worsened her bowel movement. The night she was in severe pain, she had not passed motion for days and was most likely experiencing subacute intestinal obstruction due to an obstructing tumor in the colon. Protracted intestinal obstruction could have easily resulted in severe sepsis. My vitamins comprised iron tablets, which were notorious for causing constipation.

I was essentially dealing her a death blow. I had killed a patient that I had sincerely wanted to help.

There are times when good intentions and random acts of kindness are just never enough.

I don’t know. Maybe I’m being too harsh on myself. There is no way anyone can prove that Nyuk Lan had underlying colon cancer. There is no means by which anyone can prove that my iron tablets drove the final nail into her coffin.


Who would have thought that iron supplements can kill a patient? Which sensible doctor would have ordered a colonoscopy on a patient with hip fracture? Even if she was found to have an underlying tumor, which surgeon would have operated on an 89-year-old lady with multiple comorbidities?

I can justify myself all I want. It will easily appear sensible and pardonable to most listening ears. It will even stand in a court of law should this case ever become a medicolegal contention.

Still, one knows by intuition when one has erred. They say to err is human and to forgive, divine. Well, my error which can never be proved or disproved has caused the loss of someone’s mother, grandmother and great grandmother.

It could have been my own grandma, and the knowledge of that only adds to the guilt.


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