Tuesday, May 27, 2008

A Personal Malaysian Tale

...I had overcome multiple hurdles in life and passed an examination deemed to be very difficult by international standards. I was not about to blow it all away by angering the UMNO government...

A Personal Malaysian Tale

This is a letter written by a very dear friend of mine, Hoe. It is a very poignant piece of writing penned at a time when all seemed lost and futile after an apparently victorious battle against the odds of life. It must be read in the context at the time and circumstances when it was first written, which was somewhere in mid-June 2006, right after the results of student intake into the local universities.

Fellow Malaysians and the Prime Minister Abdullah Ahmad Badawi, spare me some of your invaluable time as I narrate my personal Malaysian tale.

I am a 23-year-old Chinese Malaysian male born in a family of five in a northern state of Peninsular Malaysia. My father is a humble shop assistant who earns a small monthly salary. My mother is a housewife who very rarely leaves home as she has to care for my youngest sibling with severe Attention Deficit Hyperactivity Disorder (ADHD). My other sibling is currently studying Upper Six in a national-type school. She teaches Mandarin and Art tuitions to help the family make ends meet despite her examinations being less than 4 months away.

To begin with, I am not the brightest spark one can find around the neighbourhood. All my life, as far as I can recall, I have been a below average student who scores just above the passing mark. My best achievement was in Form One when I did somehow attain the first position in the second weakest class of my school. It was not something to boast about but I was proud that my bid for self-improvement did somewhat pay off. After my SPM examination, in which I passed with 5 credits, I opted for the STPM. Although I was well-informed that the STPM was and still is, very challenging, I had no other option as my family did not have sufficient financial resources to support my further studies in private institutions. Throughout the 2 years of STPM, I toiled as I could, failing my school-level exams time and again, yet each time returning a little more determined to pass the next one. Still, when the real examination came and went, I inevitably failed the STPM examination, having attained only a pass in the General Paper.

As I have mentioned, I am not the brightest spark around and I humbly accepted the results I was dealt.

I watched as my peers entered university to become engineers, computer scientists and doctors. While they were there, I took up multiple jobs to help supplement my family’s income. Two years later, still determined to attain a degree, I did the unthinkable and registered myself once again for the STPM. I gave it my best shot, burning the midnight oil as I am fully aware that only diligence and sheer hard work would be my ticket into university. When my second STPM results were finally released, I passed with decent, though not impressive grades in all subjects, even attaining a commendable Band 5 in my Malaysian University English Test (MUET).

Nevertheless, my application for a place in a local university was still denied, and I am fairly confident that it was not because I made the wrong choice of courses. Disappointed but not disheartened, I file an appeal as encouraged so in the local media, and I patiently waited and hoped that my final shot at university would be granted. The Malaysian Chinese Association (MCA) had an ‘appeals bureau’ and like most other non-confronting Chinese Malaysians, I opted to go through the MCA channels instead of the opposition parties. After all, I had overcome multiple hurdles in life and passed an examination deemed to be very difficult by international standards. I was not about to blow it all away by angering the UMNO government.

At this juncture, I suppose that my fellow Malaysians would not be surprised to find out that even my final appeal for any damn course in any local university was flatly rejected. After 6 years since my Form 5, having given my all, I have nothing to show. Zilch!

I would have quietly and humbly accepted this fact had I not read in a local daily quoting the Minister of Higher Education Mohd Shafie Salleh as stating that the government is committed to providing places for 120,000 “intelligent and qualified” bumiputera students who recently failed to secure placements in local universities, even to the extent of creating additional places for these students.

Such racism. Such favoritism. Such discrimination.

My simple word to Mr Prime Minister Abdullah Ahmad Badawi and his predecessor Mahathir Mohamad is this, that:
• We, the non-bumiputras, the third-class citizens of Malaysia are humans too,
• We too, may come from socially-disadvantaged and financially-constrained backgrounds,
• We too, have broken families and handicapped siblings who are fully dependent on us to provide for them financially and emotionally for the rest of their lives,
• We too, harbour hopes and dreams for ourselves and our loved ones,
• And personally, I am sickened by your administration’s indecent policies of racism, discrimination, and social injustice,
• And that I will succeed in life without your corrupted handouts, for I have the inherent qualities to be successful.

Thank you for your attention.

Insignificant Malaysian

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Monday, May 26, 2008

And Times I Didn't Screw Up (2)

.....the mention of his name unlocked a floodgate of intense memories and an archive of images made up of both still-frames and moving characters in a concoction of both grey monochrome and vivid colors.

And Times I Didn’t Screw Up (2)

I went shopping at Giant Supermarket yesterday. It’s not because I enjoy shopping there or because the goods are cheaper. It’s simply because there is no Tesco or Carrefour or many other reasonable hypermarkets around Kota Kinabalu. Unlike Peninsular Malaysians, Sabahans are not spoilt for choice when it comes to grocery shopping. Anyway, that’s beside the point. I’m not about to embark on a thesis about groceries and hypermarkets.

I had just locked the car and was walking towards the entrance. Three young men passed by from my left and disappeared from view before long. I paid no heed to them. There was no reason to anyway.


I glanced to my right and searched for the origin of the beckoning. One of the three young men was smiling cheekily at me and gave a friendly greeting wave. He was of average Asian height and had crew-cropped hair. He was donning a collared yellow tee shirt with black oil stains speckled all over. His shirt was not tugged and fanned out covering the belt and zip of his three-quartered pants with an army fatigue design. He was generally tanned except for an area of whitish discoloration over his left ankle. It was a surgical scar that was still in the process of healing and restoration.


The young man was about six meters away and had paused in his steps as though he was expecting me to head towards him. Somehow, I naturally detoured and subconsciously veered towards him. He looked familiar and was most probably a former patient. Tried as I could, I failed to attach a name to the person awaiting a reciprocal greeting from me. It took me a while to recollect my thoughts and memories and it will probably take much longer if not forever.

“Doctor, remember me ah?” he said in typical accented Sabahan Malay.

I stood an arm’s length away and tried for a second time to recollect some bit of thoughts and hazy images stored somewhere in the dusty annals at the back of my head.

I couldn’t, just couldn’t.

“I’m Valrus bah…” he said.

Like a jolt of thunderbolt to the mind, the mention of his name unlocked a floodgate of intense memories and an archive of images made up of both still-frames and moving characters in a concoction of both grey monochrome and vivid colors.

Valrus (not his real name) was a thirty-year-old Sino-Kadazan from Labuan, Sabah. I first came into contact with him roughly eighteen months ago when he was admitted into the orthopaedic ward for a non-healing ulcer over his left ankle. He was a regular happy-go-lucky, eat-drink and be-merry young chap not too long ago. He worked in a construction site back in Tawau, laboring by day and reveling at night. His wages were not much but were sufficient for him to get by with a steady flow of cheap Filipino tobacco and home-brewed liquor. He was carefree and prodigal, to say the obvious.

And then his left foot started swelling up. An ulcer appeared and refused to leave, not responding to standard antibiotics. Pus started to ooze from the ulcer the areas surrounding it. He could take it no more, and it came to a point when even walking became a painful chore of sorts. After six months, he was referred for further management.

I was not the first doctor to attend to him. I was however the first doctor to view his chest x-ray, which left me horrified. There was hardly an area of clear lung fields on his x-ray. It was arguably among the worst that I have seen for quite a while.

I questioned him further, attained much useful information and decided to investigate him for sexually-transmitted diseases. I examined him, detected an enlarged spleen and liver with fluids in the abdominal cavity. I ordered more tests and more investigations, starting with an ultrasound and perhaps later a CT scan of the thorax and abdomen.

Something was amiss with this young man, something more suspicious than an fist-size ulcer in his left foot. I listed the possible list of diagnoses: disseminated tuberculosis, viral hepatitis with liver cirrhosis, HIV with immunodeficiency, and probably all of the above.

I had great plans and enthusiasm for Valrus and was keen to probe further before rushing into any surgical intervention of his foot. The problem was, I was only a house officer back then.

It was then that the orthopaedic surgeons arrived for their ward rounds. They took a glance at the hideous ulcer, ordered a wound debridement and hastily moved on.

Left on my own, I decided to pursue the plans that I have laid out initially.

I forged the consultant’s signature for an ultrasound and discovered numerous areas of calcifications Valrus’s liver, spleen and kidney.

With that, I convinced the consultant that he needed a CT scan which later reviewed features of severe tuberculosis in Valrus’s lungs, spine, hip bone and mediastinal lymph nodes. If his chest x-ray was scary, his CT scan was doubly so, like Dark Water Japanese version to Dark Water US version. TB treatment was commenced.

I performed an abdominal tap and the results came back consistent with an ailing liver. His blood results came back positive for hepatitis C while his sputum revealed active tuberculosis. I referred him to the gastroenterologist.

Valrus also had an elevated calcium level in his blood. The orthopaedic surgeon scoffed at my suggestion that the high calcium level was due to combination of the physiological changes in granulomatous diseases as well as direct TB infiltration of the bones. I treated Valrus anyhow with aggressive hydration and diuretics, finally normalizing his calcium levels.

After a while, his tissue biopsy report came back and confirmed TB of the left foot. By this time however, that was already immaterial as he was already started on TB treatment.

Before long, he was discharged.

I never did see him again until yesterday, May 26th 2008.

He was undergoing treatment for hepatitis C and had decided to move down to Kota Kinabalu so as to receive an uninterrupted course of therapy. He’s working as a mechanic now, the black oil stains all over his shirt said it all.

Valrus said thanks and I replied with an acknowledging nod. We bid our goodbyes and went our separate ways.

Who says house officers can’t work without supervision?

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Friday, May 23, 2008

The Director's Chair / When is a doctor not a doctor?

“I wonder why I work in this dead end job. My hospital is shortstaffed and my hospital director doesn’t seem to be doing anything. He’s like a puppet who leaves everything to God, classical ‘insya allah’ response to everything. The work I do does not commiserate with the pay. Job satisfaction is at an all time low…”

The Director’s Chair
I watch House on a regular basis. I don’t really enjoy the medicine in House. The strength of the movie lies very much in its wicked combination of soap opera and sarcastic humor, especially those coming from the title character himself. I download House episodes in torrent files so I have been able to watch up to the finale of season four.

There was one episode where the doctors were to undergo their annual assessment. House, the archetypical anti-establishment personality that he is, gave identical feedbacks for all his subordinates. In addition, Dr. Gregory House gave Cuddy the hospital director a very blunt and direct assessment of herself.

Among other direct-to-the-point messages, House told Cuddy that “You think you’re a doctor, but you’re an administrator.”

Entertainment will always be far from reality and science fiction will always be fake science. There is much truth and food for thought in House’s comments about his superior cum hospital director though.

All over the world, then and now and definitely for eternity, medical doctors give up on clinical practice for reasons as variable as one can imagine. All medical graduates started off with clinical work though, slogging as house officers/interns, sauntering about carrying out their superiors’ orders before becoming medical officers/residents barking orders themselves.

The Worth of a Medical DegreeBy the end of medical school, most people should have an idea whether their character is suited for clinical work and patient interaction. The few wise ones with much insight will readily concede their dislike of a doctor’s life and will not pursue a medical career any further upon their graduation from medical school. Some folks lament that the five years of medical education were wasted and a huge sum of taxpayers’ money were squandered.

I beg to differ.

A medical degree is just that – a science degree. It doesn’t make anyone smarter or more valuable. By any chance, the average medical graduate starts off as useful as a solar-powered torchlight in a massive power blackout. There is no way anyone will know for sure whether they will like the life of a clinician until the person has gone through the five years of medical school. It is perfectly fine and well that a medical graduate decides not to pursue clinical medicine upon completion of medical school. There is no joy in forced coercion. The person may not make a safe and caring physician anyway.

Then there are those who conquered medical school on a high note. They were all geared up to seize the hour and have even made up their minds to be a knowledgeable physician or a skilful surgeon or a non-bullshitting neurosurgeon. They hit ground zero after a few months upon realization that a doctor’s job isn’t as glamorous and as rewarding as they initially thought. Despite their vast knowledge or admirable surgical skills, many patients simply have conditions that will not respond to the most aggressive medical intervention. Disheartened and disillusioned over the apparent futility of their work, these well-meaning doctors end up with an empty fuel tank and bow out of clinical practice. They don’t end up as bitter losers in life though. Most of them will eventually discover their true calling in life and find it more fulfilling than strutting around in a super hot lab coat and a stethoscope around their necks.

Essentially, finding meaning in our daily work grants all of us a passion to live this life, regardless of our profession. Some doctors derive great satisfaction in mutilating gullible Sabahans in a bi-weekly bloodbath and dub it neurosurgery in action. Some desire greatness but don’t make the grade for clinical practice. These end up as administrators in the form of hospital directors more fondly known as the pengarah in local Malaysian dialect.

This article is based on a series of phone messages sent to me by a medical officer working in a district hospital in Peninsular Malaysia. Dr. Hashim is a close friend of mine and a former coursemate back in the University Malaya medical school. He was a natural smart ass who put me to shame in studies, remembering and mastering most of what he read at the first exposure. I have highlighted his messages in italic form.

Out of Touch

“I sometimes fell so angry, I want to grab my hospital director by the shoulders and shout at him to open his eyes and see that we are facing a big problem.”

I found myself nodding in agreement with Hashim’s statement as I was reading the message. Doctors who cease doing clinical work inevitable lose touch with whatever is happening at ground level in the wards, in the emergency department and operation theatre. Anyone seated comfortably in an air-conditioned office the whole day attending long winded meetings about lofty policies and rigid protocols will surely forget the endless orgy of blood, gore and grime taking place in the general wards every hour.

That is precisely why the perception and worldview between a practicing clinician and an administrator is as different as schmaltz and nasi lemak.

The clinician does his ward rounds and shakes his head in despair at the sight of patients sprawled all over the crammy ward in every nook and corner, cross-infecting one another with cough, cold and diarrhea. He feels helpless because his sincerity and concern for patients’ welfare is inhibited by the somewhat dumb and irrelevant policies set in place by the administration.

The administrator does his ward rounds too but sees a totally different picture. He sees the barren walls of the wards and chides the ward sister for not decorating it with colorful posters and cute little cartoon characters.

Both clinician and administrator busy themselves with figures and numbers. The clinician is concerned about the patient’s high blood pressure and low hemoglobin while the administrator is all worked up over statistics and records for his precious ‘key performance index’.

At the end of each working day, the clinician gives out a dispirited sigh because another of his patient had breathed his last under suboptimal care. The administrator too retires to bed but not before much griping and whining because his own administrative superiors are breathing down his spine.

Out of Sync

“He’s been forced to do clinical work the past few days. Otherwise he will do nothing. Once in a while, he’ll come to see a few cases in the emergency department or help the outpatient a bit.”

Most people will agree that the biggest problem with public healthcare services is the protracted waiting time. From the casualty department to the outpatient clinics to the pharmacy the size of the waiting crowd is nothing less than daunting to both doctors and patients. The number one administrator of the country, our esteemed and most wise Health Minister has vowed to reduce the waiting time at outpatient clinics. He thinks of many ingenious and extravagant ways to minimize the long and dreary waiting time. He has hitherto suggested computerized prescription, 24-hour pharmacies, drive-thru dispensaries and extended general clinics. In the process, he has proven himself to be the number one administrator most out of sync with events at the frontline. Like a broken judebox humming an outdated tune of the past, his ideas just doesn’t gel with the actual needs of the people.

Healthcare is not fast food business and pharmacies cannot be operated like a McDonald’s Drive Thru shack.

The determining factor of a patient’s waiting time at the hospital is really not so much about how the medical staff operates or whether there are sound policies in existence to ensure a smooth delivery of services. The ultimate factor in determining the length of time a patient needs to wait before receiving treatment is simply the absolute number of ill people.

Even a McDonald’s drive thru are not spared long queues if there are many hungry customers making large orders.

Therefore, the only way anyone can reduce the waiting time of patients at government hospitals is to reduce the number of people seeking medical care or to provide more clinicians and treatment centers. It doesn’t matter whether one has lofty slogans and grand ideas, for as long as there is a mismatch between the number of clinicians to patients, the agonizing wait at our public medical centers will continue to be the norm.

Regardless, administrators who only administrate and shy away from clinical work are not helping to resolve issues but contribute to them.

Out of Reach

“This guy just doesn’t get it. We’ve approached him many times before over the last two weeks, even pleading with him and yet it’s the same thing. He’s real thick, like a bloody slab of granite. How he ever became hospital director is really beyond me.”

Most Asians were brought up to practice diplomacy and good manners in their daily affairs especially in times of disagreement and conflict. In our feudalistic upbringing, we are taught to not to confront, not to question and to believe that the higher authorities know what is best for us.

Some characters are simply out of reach though, no matter what we do to make them see the blatant mismanagement that is unfolding in before our eyes. The hospital may be in such a bad state yet the administrator thinks that it has never been better. The administrator has selective blindness to the broken-down elevators, the squeaky hospital beds, the overcrowded medical wards, the snail-paced pathology investigations, the defective ambulance services, the over-profiting hospital canteen and the overpriced essential goods sold by the koperasi.

The director sees what he wants to see and ignores what he doesn’t like to hear.

He dwells on the trivial, insignificant and irrelevant, like ensuring each department and subdepartment has a personal corporate mission and vision that is penned oh so wonderfully and magnificently.

When complaints arrive at his desk and ears, the director behaves like a typical bureaucrat. He delegates all that is unpleasant and ugly to his subordinates who proceed to sweep most things under the carpet so that the issue concerned is eventually forgotten with time.

My friend Dr. Hashim is spot on. The big guy in the administrative office just doesn’t get it no matter how we try.

Out of Work

“He’s got this ‘what to do?’ attitude that needs to be slapped the shit out of him.”

It is pretty ironic that most administrators appear so preoccupied with the petty issues yet appear so helpless when the really significant issues loom and demand a definite solution. I’m quite sure Dr. Hashim’s big boss meant that he doesn’t know what to do for that particular problem brought up by Dr. Hashim.

The other possibility is of course that his superior was asking Dr. Hashim if there were anything for him to do because he has no work left undone. I believe that there is no end to administration work. I also believe that a lot of administration work is unnecessary and irrelevant.

In this respect, I can think of no better example apart from the issue of doctors’ white coats.

The classical white coat may appear elegant to the lay person and has for ages been the trademark for the medical profession. In reality and especially more so in the tropical hot and humid weather like Malaysia’s, the lab coat is cumbersome and serves little purpose except for the lady doctors to keep their wallet and stuff. It is also a source of infection, a formite to transport resistant, hospital-grown bacteria from the wards to town and back again. Lastly, white coats are usually not white. There is always some part of a patient left behind upon it – a drop of blood, some diarrheal stains or a suspicious pee-like stain. It is not surprising therefore that authorities in the US and UK have abandoned the ageless white coat in favor of hospital scrubs, throwing the coat out along with neck ties and other bodily accessories like watches and bracelets.

However, our administrative doctors here have a different opinion altogether.

Instead of promoting patient safety and reducing cross infections, they make it compulsory for doctors to wear white coats. The hospital I’m working in has appointed a nurse in each ward to jot down names of doctors found lingering without their white coats and submit these names to the director’s office at the end of each month for disciplinary action. It’s like having a prefects’ board within the hospital, the head honco of whom is the high and mighty pengarah himself.

Whenever my name gets written down by the ward prefect, which is like every single day, I would tell the prefectorial staff nurse that there are better and more constructive things to be done, pointing towards Gapong Balinting lying over bed 35 in his whirlpool of torrential mucoid stools or Lambinah Gagau in bed 12 wailing in great discomfort over her worsening bed sores.

It is because of such nonsense that I sometimes believe that doctors in administrative positions seriously have nothing better to do.

Out of Drive

“I wonder why I work in this dead end job. My hospital is shortstaffed and my hospital director doesn’t seem to be doing anything. He’s like a puppet who leaves everything to God, classical ‘insya allah’ response to everything. The work I do does not commiserate with the pay. Job satisfaction is at an all time low…”

I have earlier written about the different doctors who give up clinical work and why. For as long as I have known Dr. Hashim, he has been nothing less than enthusiastic to learn new skills, gain greater knowledge and meet a variable pool of patients. I have sufficient reason to believe that his passion for medicine especially the field of obstetrics has not changed since medical school.

If he does give up on clinical practice because of job dissatisfaction brought upon by an indifferent hospital pengarah, he’ll make up the last group of ex-clinicians – those who are through with clinical practice because of non-clinicians who do not understand the circumstances a clinician goes through.

It will indeed be a sad day for Malaysian healthcare if more clinicians like him leave the service because of superior-subordinate disharmony.


I am not anti establishment. I believe that we will all benefit when we have a system with sensible rules and sane regulations. The opposite is also true I assume – we will all crash under the leadership that is out of touch, out of sync, out of reach and out of work.

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Monday, May 19, 2008

The Thin Red IV Line

Small minds take pride in small things, but small things sometimes make a big difference....

The Thin Red IV Line

The year was late 2005. The patient was an obese pregnant lady all set to deliver her first baby in UM. The attending doctor was a trainee obstetrician who moved with an air of agility. The four of us then medical students were entrusted with the task of setting an intravenous line for the first-time mother. We tried and failed, re-tried and failed again….and again.

It was impossible, we thought. The lady was just too fat and chubby and uncooperative. We gave up, approach the trainee obstetrician and related our woeful malady to her. She mumbled something inaudible, prepared a tray and moved with haste towards the patient. She applied the tourniquet, made a few swabs on the skin and with one simple prick, secure an intravenous line in a large vein somewhat proportionate to the patient herself. She cleaned up her trash as she was getting to leave, remarked that it wasn’t that difficult after all.

I was left impressed and wowed over. It was a surreal moment, one that made me all too keen and enthusiastic to acquire the skill and art of setting an iv line where others have failed and given up.

Housemanship and Procedures and Obsession Over Heroism
As medical students progressed in medical school, it is very much a norm to discuss and ponder over the choices for our housemanship training or internship.

Most people would want to apply back to their hometowns for reasons that are obvious. Family and loved ones and longtime animal friends are still the things that matter the most in life.

The more ambitious and decided ones would already have an institution of their choice to provide training in the discipline that they were interested in. A small lot prefer to stay back in teaching hospitals and universities either because they believe they’ll receive more sound training and teaching or because they intend to pursue a career in academic medicine.

Then there are those whose primary aim is to secure skills and hands-on training. These medical graduates might voluntarity transplant themselves to Sabah believing that they get to do more and see more. It is widely believed that hosue officers in Sabah more practical training in bedside procedures and surgical inteventions. True enough, house officers in Sabah get more opportunity to do much more than their counterparts in West Malaysia. Most house officers in Sabah who have completed their rotations would be pretty skilled in chest tubes, internal jugular catheters and endotracheal intubation. Those who have graduated to become medical officers in the district hospitals are performing Caesarrean sections, appendicectomies and minor orthopaedic procedures on a daily basis.

I have had my share of brazen, whimsical medical procedures and my fair share of failures and complications as well. Even so, nothing beats the insertion of an intravenous (iv) line.

Young doctors have an inherent obsession over clinical procedures and clinical skills. There are a number or reasons for this phenomenon.

Most doctors are by nature kiasu and of type A personality. Each wants to outdo the other in studies and clinical skills and career advancement. The state of Sabah’s healthcare provides a fertile ground for fledgling doctors to learn and polish their diagnostic and therapeutic bedside procedures.

Perhaps it is because the seniors and predecessors of these medical graduates once boasted about their audacious exploits in the course of their training in Sabah and encourage these new doctors to follow their pathway into Sabah likewise. Some of their claims are plausible and true, like house officers being accorded a chance to perform pericardiocentesis. Some are totally preposterous altogether. A senior medical officer once claimed that he performed a partial gastrectomy all by himself as a house officer in a patient with perforated stomach ulcer. These tall tales might have an inch of possibility or it’s simply a case of misery in need of company. If a doctor made a foolish mistake and ends up trapped in Sabah, one might as well con and drag many others into whatever predicament one is in.

Television series play a role too, I suppose. Medical dramas like House, ER and that lame Hong Kong ER-wannabe have a tendency to depict doctors performing daring and gallant interventions with supernatural impressive results. Such miraculous total turnarounds are of course rarely seen in reality or more often than not, at painfully slow speed and usually with significant residual physical impairment. Nevertheless, it leaves a lasting albeit erroneous impression upon the medical students or aspiring doctors.

More recently, the Public Services Department (JPA) started an attachment program for potential government scholars in medicine. The high-achieving potential JPA scholars are made to rotate around the hospital departments over a period of two weeks to observe the daily life and work of doctors in government service. Instead of observing the struggling house officers rushing about in their daily duties of taking orders and carrying out menial tasks, these pristine minds are made to observe among others, complex surgical procedures and valiant resuscitative efforts. They just might end up going back desiring to be the super surgeon or emergency physician they have just observed in action without knowing that the long term ultimate outcome is not necessarily sweet and beautiful.

In short, medical students and later medical graduates are exposed to a basketful of wrong ideas of clinical medicine. Instead of improving their skills of history taking and recognition of ominous clinical signs, they are aspiring to insert their first chest tube and perform their first lumbar puncture. Instead of reading pharmacology and mastering very basic procedures like blood taking and intravenous cannulation, they are studying syndromes and dreaming of intubating their first patient and be called a hero thereafter. They are in fact jumping the gun in the midst of their obsession over risky clinical procedures and epic interventions without mastering basic skills.

It is akin to a baby attempting to eat walnuts when they have yet to wean off breastfeeding.

The Belittled IV Line
Personally, I feel that one of the most important clinical skills a house officer must acquire is the setting of an iv line. The principles behind intravenous cannulation form the basis of many other complex and skill-demanding clinical procedures.

IV lines are lifesaving, much more so than a costly internal jugular catheter. Patients have died unnecessarily because the attending doctors did not secure adequate intravenous access for drugs, fluids and blood products. In the same vein and no pun intended, critically ill patients on the brink of death have been successfully resuscitated because functioning iv lines of adequate caliber were set in place.

IV lines permits continuous treatment especially in patients requiring regular doses of antibiotics or cancer chemotherapy. Patients with difficult iv access often receive irregular and insufficient doses resulting in the development of bacterial resistance and failure of treatment.

Almost every patient that is admitted in the hospital has an indwelling iv line. It is a symbol of both captivity and liberation. The removal of an iv line usually implies an improving patient planned for discharge very very soon.

The ubiquity of the all-important iv line is also the reason of its being underappreciated, at least in Sabah – I think.

In many developed countries like the United Kingdom, blood taking and intravenous cannulation are done by specialized ‘phlebotomists’. In Peninsular Malaysia, in probably almost every hospital, the job of securing a proper intravenous access falls upon the doctors, and almost always the house officer. In Sabah, the task of setting intravenous lines is entrusted to the nurses and the justification for this is that our doctors are seemingly just too busy and overworked.

Strictly speaking, staff nurses are not trained or accredited to set iv lines, despite the fact that the more senior ones tend to do a much better job at intravenous cannulation than many doctors. I have nothing against nurses inserting iv lines for patients. It’s just that the ward nurses are overworked in their own right. In addition, the house officers are not learning this essential clinical procedure.

I find it peculiar and embarrassing that some house officers trained in Sabah are so skilled in setting catheters in almost every part of the human body but appear pretty useless when it comes to setting a simple iv line.

Size Matters
When someone else’s work is thrust upon us, it is natural for any human to search for an easy way out or to do the bare minimum just to get it over with. It is not in the nurses’ official job description to set iv lines, so there is no reason why they should go the distance to ensure that the patient’s iv access is the right choice, right size for the right procedure. In their rush to complete their endless clinical duties and needless paperwork, nurses have discovered that the smaller iv lines are much easier to set and require less time.

As a result, we have patients going for major surgeries with a minute iv line that is barely running. How in the world is anyone able to transfuse blood at an adequate rate if the patient suddenly bleeds uncontrollably in the middle of an operation?

The pampered house officers meanwhile have become complacent, taking for granted that they are under no obligation to set iv lines throughout their tenure in Sabah. In fact, it seems that the house officers in general want to have nothing to do with anything related to iv lines. They may examine the patient and detect that vague cardiac murmur but will not realize that the patient’s iv line is blocked, swollen, infected or simply inappropriate.

Sad and scary stories about iv lines are abundant and outrageous.

When patients deteriorate out of a sudden in the wards, doctors suddenly realize that the patient does not have sufficient intravenous access for drugs and fluids. I have had my fair share of scare under these circumstances.

The Recalcitrant House Officers
While the house officers are obsessed and fixated about fancy procedures, I am preoccupied with securing iv lines, if that is not already obvious by now. In addition, I believe that all house officers should be competent in the skill of setting iv lines before graduating to more ‘glamorous’ procedures like bone marrow biopsies.

My conscience is clear in the sense that I have spent hours by the side of patients trying to secure iv lines for their surgeries the next morning or for that all-important medication. Personally, I find great satisfaction being able to attain an iv line in patients where others too have tried but unsuccessfully. It is not groundbreaking open heart surgery but nevertheless an achievement in its own sort.

Small minds take pride in small things, but small things sometimes make a big difference to simple folks.

I have tried to convince the house officers to take the initiative of setting iv lines without waiting for and prodding the nurses to do so. Admittedly, I have not been very successful. Manners and diplomacy do not work with everyone, some doctors need to be chided and admonished fervently before they will get out of the not-my-job mentality into the I’m-doing-it-for-the-patient way of thinking.

In the meantime, I am getting impatient and furious when patients turn up with inadequate iv lines due to the apathy and couldn’t-care-less attitude of the house officers.

Perhaps I should start behaving like the medical officer I vowed to myself I would never become….

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Saturday, May 17, 2008

Horny Old Men, Ominous Omen

For most men, the aroma of an expensive fragrant emanating from a lady’s body is a stimulus that invokes great excitement. For a doctor with allergic rhinitis, it is an inciting stench to his olfactory nerves.

Horny Old Men, Ominous Omen
Some people’s reputation precedes them. And then there are those whose scent precedes them.

The Forbidden Fruit
The petite young lady had a name too complicated to re-spell and too difficult to pronounce verbally. It had all the Xs and Ys of a typical Chinese name translated into han yu ping ying. Her perfume reached the consultation room long before the person wearing it did.

For most men, the aroma of an expensive fragrant emanating from a lady’s body is a stimulus that invokes great excitement. For a doctor with allergic rhinitis, it is an inciting stench to his olfactory nerves.

She took a seat and looked reserved. With a tight blouse that exposed half her bare back and a scanty skirt barely reaching her knees, she was in an outfit more suited for a Saturday night club, except for the fact that she was in a medical clinic on a blistering Monday afternoon. She had no wrinkles upon her face tarred by deliberate heavy make up. Glittering silver-colored, love-shaped earrings dangled liberally from her sides, partially hidden by her loose, wavy hair dyed to a striking blonde. An equally eye-catching necklace with a sapphire stone in its center brings completion to her underlying flamboyant personality.

A middle-aged man with a familiar look joined her in the consultation room soon after.

Unsurprisingly, heavily-accented Mandarin came from her as I took a brief medical history. Her symptoms were typical of a urinary tract infection. Additionally, she had also missed her period by 3 weeks and in a young sexually active lady, it’s pregnancy until proven otherwise. As she exited the room for a urine sample, the familiar-looking Chinese man appeared fidgety as he took a seat too. He was obviously concerned over his partner’s possible pregnancy and hesitated a while before enquiring about clinics that provided abortion services around Kota Kinabalu.

He had been to the clinic before probably a fortnight or two before this. His name was Wong or Tan or Chin or something like that.

He had come to the clinic with his wife and young child not long ago. He did not seem half as concerned back then, preferring to stand indifferently by the corner of the room instead of peering over my shoulders as I was examining his seven-year-old son. His wife was obviously in daily charge of the family, being able to provide a precise medical history and participating more proactively in the on-going consultation.

Her external appearance was a far cry from her husband’s China doll. There were no stunning cosmetics, no heavy metal accessories and no nail varnishing. Her hair was unkempt with scattered crops of grey strands bearing testimony to the unrelenting demands of motherhood. She was plain, simply plain.

The Invasion of Marriage
Illegal immigration is an irritating issue for most nations, but the Malaysian government is perhaps the only one resting complacently on its laurels with little interest to rid the land of people with no right to step foot into the country.

Malaysians are not angry enough over many national issues that adversely affect us individually and as a nation. A certain group of the population may even in fact turn out to be beneficiaries of what others may deem a looming national catastrophe.

The power-crazy UMNO politicians for example, have their saliva drooling at the thought of the massive influx of Muslim Filipinos and Indonesians into Sabah. At a lower hierarchy, horny old men are gleaming with lust at the sight of young, uneducated, unskilled foreign women.

Some say these extramarital affairs are none of our business as they take place between consenting adults. It is true that one party is more than willing to trade their bodies for money and temporary ‘love’ and the other more than stupid to risk contracting sexually transmitted infections for the sake of a short-lived bodily pleasure. Personally, I do not give a damn when horny old men contract multiple infections from their foreign sex slaves. My prime concern is the increasing breakdown of marriages and the long-lasting adverse effects on the mental health of both wife and children.

The invasion of the marriage institution is not limited to any particular race or nationality, although a China doll was used as the case illustration here.

I have had ladies fully veiled except for the face and hands coming in to enquiring about the charges for a dilatation and curettage. They can be foreign Muslim ladies who’ve slept with local men or local women who fell for a non-local Shah Rukh Khan lookalike. They can be little dragon ladies with an elderly Chinese sugar daddy or a desperate local lass who had a one night stand with an unknown male companion.

Marriage infidelity is one thing that affects all communities, albeit in differing degrees. It is also intrinsically linked to unwanted pregnancies and subsequent abortions or baby dumping.

The pious folks and legalistic extremists in long flowing robes and unsightly goaties can champion all they want the creation of a theocratic state and religious government but the fact remains that the fact remains where there is temptation, there will be fallen souls.

Temptation comes from Satan and also from the UMNO politicians who opened the floodgates to welcome these aliens into the country with no political will to curb their growing numbers. Had the BN government been more serious and sincere in reducing the number of illegals in this country, they would not proliferated and produced the current second generation of illegals who themselves are in the process of giving birth to a third generation.

There is no such lame reason as a coastal border too long and too wide for vigilant monitoring. There is no such acceptable as an outnumbered police force. They had time to detain Raja Petra Kamarudin and Nathaniel Tan and innocent Cheras residents, so what stupid reason do they have not to raid illegal settlements intruding upon the locals’ land and property.

It all boils down to political will.

The BN government has proven itself to be incapable of seeing eye to eye in terms of the citizens’ best interests, and young children and helpless wives wrecked by husband disloyalty are very much Malaysian citizens.

I am not a pro-choice activist in any way but to put it very bluntly, had it not been for the brazen general practitioners and unabashed gynaecologists conducting so-called underground fetal abortions, the population of Malaysia would be easily a hundred million by now with Filipinos, China Chinese, Indonesians and Pakistanis comprising half of this figure by rough estimation. The church and mosques and religious bigots can condemn these doctors and the ‘dirty money’ they earn all they want, but they are the ones preventing Malaysia from having an unprecedented population explosion. In the absence of preventive medicine, a curative approach albeit being tainted with questions of morality and ethics will have to suffice for now.

I just had another patient that left an impression of sorts on me today. At nine years old going on ten, Flora Su Ying (not her real name) came to the clinic with her twenty-year-old Filipino mother. She was only 12 kilograms and severely wasted. Sores and boils were all over her body. Too weak to walk, she must have been ill for a whole year before finally coming to the clinic today complaining of vomiting worms. Her father was a Sabahan Chinese who left faster than one could say ‘jerk’ upon discovering that he had impregnated the gullible Filipino teenager.

There are thousands of children like Flora around. The children’s ward in Hospital Likas is always overflowing with these neglected children.

One can point the finger at many quarters for the current quandary that Sabah and to a similar extent, Malaysia is in. Still, we come back to asking why these foreign people are even in the country in the first place with full freedom to feed, sleep, copulate and breastfeed.

I think the answer is obvious.

Our horny old men are an ominuous omen that Malaysia is headed for ultimate self-destruction, unless of course there is a change of federal leadership.
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Monday, May 12, 2008

For One More Day

Memories are intangible and ethereal, but memories will remain the only entity we can effectively hold on to after life, after death, and in life after death.

For One More Day With My Girl

September 1991 was a season of despair and destitute. Mother’s illness had once again relapsed, not that she ever recovered from the previous relapsed at all. Disease progression is perhaps a more apt term, but it implies a step forward when in fact the person has suffered yet another setback in life. Mother was already bed-ridden by now after four years of multiple sclerosis and frequent focal seizures. She was losing the use of her right arm as well. While previously she was still able to read the newspapers independently, she now required help turning the pages of paper and the cover of a plastic container.

It was a weather that matched my emotions when I found my Girl that rainy, gloomy Saturday evening. I was a little kid cycling rigorously on my way to church.

The high-pitched cries of an unwanted kitten broke through the forceful whistling winds that fateful evening. An arrogant storm was about to make its way into the neighbourhood and had appointed the winds to be its loyal messenger. Girl was perched at the top of a typical smoldering rubbish pile one can find all over the city. She was tiny, so tiny that despite her shrieks for attention, it took some time before I finally noticed her. Her umbilical cord was still attached, mostly dried and ready to fall of anytime. She could not have been more than a week old.

To whoever that left her in the center of burning garbage, she was herself regarded as trash and merely one of the many litters of kittens abandoned and left for dead all over the country every hour of the day.

To me, she was an angel manifested in a very eccentric form, or at least that was what she turned out to be eventually.

Father was the least happy to receive her presence at home. He never welcomed anything we brought back anyway, but somehow he’ll end up warming up to them and being a responsible caretaker.

Like a human kid, Girl grew up fast, so fast sometimes I wonder where all the years went.

She was feeding from a milk bottle one month and chomping down fried fish the next. She was a curious innocent feline amazed by all and sundry, exploring all nooks and corners as though they held priceless treasures with handsome rewards. She was pretty and flirtatious and an instant hit with the neighbourhood tabbies. She caught lizards and cockroaches, birds and beetles, but the idea of catching a rodent somehow never appealed to her. She basked in the sunshine and camouflaged in the dark, waiting stealthily to pounce on any passing human feet. She was gentle and neurotic, nosy and nonchalant, hungry and fussy. It made her all the more extraordinary and vibrant.

In silent observation and hushed understanding, my Girl bore witness to all that the family went through.

Through it all, she was there.

She was there when her teenage father started grappling with peer pressure. While I was bothered myself trying to buy that Converse skateboard shoes and a torn blue jeans to match, Girl kept her calm, patiently waiting for the day I’d returned to her again.

She was there when Mother passed away and hung around throughout the final rites and funeral service. While all of the family was downstairs hanging to each other for strength and comfort, she grieved alone in my sister’s bedroom. Lying whole day in silent contemplation she appeared briefly for a quick snack, said hi and withdrew to her little corner till I was ready to share some time with her. A silent companion is sometimes the best counselor in times of loss and mourning. My Girl rose to the occasion and fitted perfectly well into that role.

She was there when I stacked up my STPM textbooks and wondered worriedly how I would ever be able to score straight As. I closed my eyes those long dreary nights and mumbled an impromptu, unrehearsed prayer to heaven. I opened my eyes and more often than note, Girl was there with a smug kitty look upon her face. Much to my disgust and irritation back then, Girl emulated what other cats have practiced for centuries and generations – she leaped onto my table and nested upon my books at the first opportunity. It was usually when I was just beginning my start of a very long night. She was demanding her share of my attention after Brother had received his. I would like to lie and claimed that I welcomed her with open arms each time she pulled that stunt but the truth is there were just too many times when I chased her away and vented my anger at her. If I had known then what I do now, I would have reacted very differently.

She was there on the day I came home with my STPM results and when the acceptance letter from University Malaya arrived. I gave her a warm, strangling hug, and picked up a day of rhinitis in return. I d moved on in life soon after. On semester breaks and long holiday weekends, I returned home whenever possible to find my Girl curled up like a yarn ball on my sister’s bed in a state of surreal tranquility and a tinge of pensive contemplation. We spent those balmy lazy days lying idly next to each other, saying little but in full comprehension of our unspoken thoughts and appreciation of the times that have been.

We had come a long way since the days of torn jeans, dyed hair and stupid skateboard sneakers. We had passed that period of peer pressure and adverse circumstances. My Girl and I had reached a more secure chapter of life where we can just enjoy each other’s company, if only for a moment. I groomed her shiny coat and rubbed her rounded contented belly. I smile to myself at the thought of how far we had come in life, thanking her for placing her trust and belief in me all those years I was wandering in search of acceptance and friendship. I was totally oblivious to the fact that I already had a faithful companion in my life all those times.

I detected the lump in Girl’s belly during one of those fine, happy moments. I gazed into her green, idyllic crystal eyes and found myself in a state of disbelief and denial. It was as if she had known it all along. Girl looked away in an apparent attempt to avoid any further discussion of the cancer growing within her. She inched her way from me and headed for my sister’s bedroom again. The sun upon her cast a forlorn figure as she shied away for the rest of the afternoon.

Visits to the vet did not help. As sure as I was that Girl had a malignant growth waiting to make its presence felt, there was nothing a medical student could do to convince the so-called professionals of the suspected diagnosis.

I returned to university for my final examinations. It was the final hurdle in a medical student’s life but not necessarily the most important in one’s lifetime. Father’s call came at 8.00 pm that January 10th. Girl had fallen really ill and had become worse despite all the veterinarian’s medications.

I rushed back at 140 km/hr, reaching home to find my Girl too weak to cry but not too ill to recognize. She was a pale picture of the bouncy bundle of energy she used to be. It was too late to heal but not to late to love. I held her frail body close to mine and in between tears and sobs whispered words of affirmation and promises of a reunion. There was no sparkle in her eyes that night, no flamboyant wagging tail, no pompous display of a cat’s beauty.

Yet at that point, in that moment, her immense beauty was embalmed in loving memory forevermore.

Girl died at 4 a.m. Cradled in my arms like the baby she once was, it took a while to digest the fact that I had spent fourteen years with her. A sense of loss and grief set in slowly, as real and as strong as the day I lost my mother. Only this time, I was grieving alone as the rest of the world passed by making snide remarks over what they deemed an unjustified reaction to the loss of a cat.

People will always be people. To them, Girl was a cat. Period.

To me, Girl was a cat that was given a shot at life and entrusted with the task of teaching a young boy how to live his.

Through it all, she waited. She waited for me to play rope and strings with her, and I’ve always wondered whether I was entertaining her or the other way around. She waited for me to grow up and understand that life really wasn’t that complicated. She waited for me to be done with my seemingly endlessly hectic life and to realize that the sweetest moments in life are not necessarily times when we conquered the world. She waited for me to see beauty in the sight of two friends lying close to each other. She waited for the day I’d discover pleasure in the rough licks of a feline’s tongue. And yes, she waited for me to return in time to send her off on an eternal voyage.

For one more day and one more hour, there is nothing I wouldn’t give up. Just one more game and one more stroke of her back, one more meow and one more hiss, one more claw and one more bite, just one more day of cat fur rhinitis.


We take life for granted. We take the people around us for granted, thinking that they’ll be around for eternity. We take our parents for granted, assuming they’ll never grow old and age with time. We take our spouses for granted, preferring to work and earn and waiting for that elusive day to finally enjoy the fruits of our labor. We think family sticks around and will be around forever and ever, until the day sickness and mishaps seize them from us. We take our animal friends for granted, making them wait for a time as when it is convenient for us to pat, feed and talk to them.

Grief is a potent human emotion. Grief does not permit anyone to pass by without changing a part of the person. Despite the vain attempt of psychoanalysts to categorise and stage grief, it remains a complex passage in anyone’s life that one emerges seeing the world in a different light and angle. Humans grieve and so do animals. Humans grieve over animals and vice versa.

Some people say I should forget and move on. Can’t I move on without forgetting? I refuse to forget and insist on moving on at the same time. We don’t live in an oasis with eternal sunshine of a spotless mind.

Memories are intangible and ethereal, but memories will remain the only entity we can effectively hold on to after life, after death, and in life after death.

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Sunday, May 11, 2008

Patience, Patients

Too many a time, the role of a patient conjures images of a wasted and bent little old lady struggling to take her steps due to the incessant pain of severe osteoarthritis. Patients are humans and humans are mortals capable of much unthinkable and downright mind-boggling train of thoughts.

Patience, Patients

The internet is a blessing for souls like me who are no scholars in etymology.

The term ‘doctor’ originated way back in 1303 and was originally used to refer to religious teachers and advisers to denote a person capable of providing lawful teachings and right the wrongs in society. It wasn’t until almost 40 years later in 1377 when healing men (and women, if there were any back then) were also referred to as ‘doctors’.

As early as 1320, someone who ‘bears or endures without complaint’ is considered to be patient. It is regarded as a virtue, an admirable quality to be quiet in one’s despair. The origin of the term ‘patient’ in reference to someone who is ill and in need of a doctor’s services is less well-defined.

It’s quite an irony then that patients are referred to as patients because if they were really patient, then they would not be complaining about their suffering but endure it in silence. Maybe the term ‘patient’ as a noun was employed to remind doctors seeing ill persons to be patient in their conduct and mannerism and endure their patients’ idiosyncrasies in silence and solitude.

It can be so easy, so effortless and even fun in fact to go on a doctor-bashing spree just as how political analysts and foreign commentators and blog owners appear to be so merciless and unruly in their condemnation of those in the political thrones.

Let’s do something different for a change. Let’s go on a patient-bashing spree. After all, we are all patients at one time or another and will become ill come a certain point of our lives.

The Stupid Patient
A 22-year-old Chinese guy came knocking insanely on the clinic’s door. He created a small commotion at the counter, demanding the clinic nurse for immediate medical attention. I checked out the chaos unfolding within my earshot. He was a chap with fair skin, hardly a pimple scar on his cheeks. His hair took on a golden-blond hue and towards the scalp, revealed the underlying original black hair. His royal yellow Timberland tee shirt had droplets of blood scattered all over. His right elbow was held flexed in place by his left hand. Blood was dripping from his right hand onto the clinic floor, but not without staining his oversized khakis hanging an inch or two below his pelvic bone. There were multiple cuts on his fingers, each wound oozing a constant but small amount of blood.

“Hi Doc. Good evening, how are you?” he bid me in perfect, accented English upon my appearance.

“Obviously better than you,” I replied. If he can be so cheerful and casual with all the blood that was trickling away, he was in no dire emergency or drunk or most probably both.

I said him down to dress his wounds. In the government hospitals, it’s usually a nurse’s job, but when one is doing locum, everything falls into the locum doctor’s purview. I could see that he has had previous injuries before. He had lost all shape and contour of his knuckles over his middle, ring and little fingers of the same hand.

The young man clarified that he celebrated a futsal goal three weeks ago. In his jubilation and ectasy, he had punched the turf with all his might and soul. His right hand had remained swollen and numb ever since then but he was so sure that it would recover he didn’t see a doctor for it. That night when he came rushing into the clinic, he had punched the glass mirror in his bedroom out of sheer frustration over what he though was an underprivileged life. Ah Beng had also taken a few drinks before he decided to vent his anger at his mirror, and I am not referring to Vico but Vodka.

The patient was formerly a law student, sent on a family scholarship to a high end university in the United States. He was happy there, or so he thought – so much so that every hour is a happy hour to booze and get laid. It wasn’t exactly breaking news or the greatest surprise of the century that he failed to make the cut in his annual exams. That, it seemed was why he was furious and mad about life.

I completed the dressing and advised him to get an x-ray done for his futsal injuries, knowing pretty well it might not make a difference. He had fractured metacarpal bones from his joyous celebration over a goal that didn’t change the world. By now, it was too late for any orthopaedic intervention. He just might have lost the use of three of his five fingers forever.

These are patients that I deem really stoopid with a capital S. Stupid because they think they were smart. Stupid because they do dumb things that bring harm to themselves. Stupid because they will never learn and will do it again. Stupid because they are spoiled, ungrateful brats with a mirror as their worldview. Lastly, stupid because they take much pride in doing the things they do and thinking the doctor is actually interested to hear their story and impressed by their fitting rage.

Patients are allowed even expected to be ignorant about their conditions and illnesses. It is exactly a doctor’s job to educate and teach patients about disease prevention and treatment. A doctor can never however, bring change to stoopid patients like the aforementioned Ah Beng.

The Know-It-All Patient
It is commonplace for doctors to ask patients “What’s wrong?” when we see one. It’s certainly better than asking the patient what brought him/her to the hospital to which the right answer would be a car or an ambulance.

When asked “what’s wrong”, most folks would just go on to describe their cough, cold, sore throat, pain and headache. The more cheeky ones would reply that if they knew what was wrong, they wouldn’t have come to see a doctor in the first place. Such replies usually trigger a chuckle or a natural smile unless the doctor is depressed or simply devoid of any sense of humor.

Then there are those who would jump in right into their supposed diagnosis and start demanding some state-of-the-art treatment, even when such modalities are not yet available or proven in clinical trials. These are usually the Engrish-speaking, educated urban folks who just might have a friend or two who happen to be a doctor too.

Such patients are usually the most unrewarding to treat.

They are obstinate and so full of themselves that any additional education is practically impossible. They are convinced that the fungal infection is eczema and proceed to treat themselves to a course of steroids. I applaud them when they turn up with a severe and generalised fungal dermatophytoses. They are certain that their blood pressure is high only because they just walked two metres from their seat into the clinic, although the records say that their blood pressure has been high for almost three years now.

Mr Know-it-all even recruits medical jargon like adenocarcinoma, myocardial infarction and benign nodular hyperplasia of the prostate.

Among all patients, these really stretch a doctor’s patience to its limits.

The Fake Patient
There are times when I feel like giving up on studying and further training out of frustration and a pinch of desperation and settle for general practice. Don’t get me wrong, general practice and family medicine is truly noble and rewarding in its own right. It’s just that not everyone can practice family medicine. Those who dislike gynaecology and paediatrics like me for instance, will never make an effective family physician.

At times when I feel like resigning and opening up my own humble clinic, there will always be some angels sent from heaven in the disguise of patients.

A young man saunters into the clinic and requests medical attention. He wears a Manchester United cap with a matching red jersey. His blue jeans looked neatly pressed, held firmly in place by a Harley Davidson leather belt. The ends of his jeans spread out in a bell-bottom cover over his leather boots.

Hardly the painting of an ill person…

He makes himself comfortable, raising one leg across the other as he rattles off his presenting complaint. His symptoms were vague like lethargy and headache. His story was inconsistent, flip-flopping between duration from two weeks to two days. His descriptions were nonsensical and did not match any specific disease category. He had normal temperature but claims to have a high fever.

The truth emerges when he is asked about his occupation. He is a university student on a Yayasan Sabah scholarship in his final year of accountancy. He has skipped one class too many and is barred from his final examinations. He is a fake patient, just like the cop looking for a medical certificate to avoid tomorrow’s major drug bust or that young executive suffering from a hangover on Monday mornings.

It remains to be seen whether these are angels disguised as patients or the other way around.

Their existence will never cease while their desperate ways of obtaining a doctor’s letter will always evolve. They waste their employers’ money and betray the trust of that state scholarship. They add to the doctor’s coffers and subtract the available consultation time available for other patients.

Fake patients have no respect for themselves or the intellectual value of the medications they are prescribed, most of which end up untouched.

Regardless, fake patients do an excellent task in keeping me determined not to pursue general practice as a long term career. If that’s the only good they do, then they are doing it pretty well.

The Serve-You-Right Patient
The pot-bellied, bespectacled Chinese man moved with a swagger as he slowly marched into the consultation room. His collared t-shirt was tugged neatly into his three-quarter khakis and a piece of folded paper was mounted under his right armpit. He took a seat and explained he wished to enquire about being a hepatitis B carrier.

I was curious. I asked for the report just as he was about to unfold the laboratory results for me.

The father of two and grandfather of three had hepatitis B all right. The only thing is that he was not a mere carrier of the virus but one with the disease and all its possible complications. He also had syphilis which he most probably contracted from the Filipino ‘guest relations officer’ at the karaoke he regularly frequents.

There is one thing peculiar about Kota Kinabalu whenever I think about karaokes, which is not too often, if at all. Entertainment outlets like karaokes and pubs and discos easily outnumber mobile phone outlets. In a land so endowed with the beauty of nature, it’s amazing why anyone would opt for karaokes and clubs for enjoyment.

I explained in detail the possible complication of chronic hepatitis B and syphilis and the need for further tests to exclude other sexually transmitted diseases. He nodded in comprehension but declined further investigation and treatment. He was comfortable with his lifestyle and has no intention of turning over a new leaf.

Patient’s autonomy, right? So be it then.

This Chinaman has chosen to spread his viruses around and one day die from it. The law does not provide doctors with the power to overrule patients’ decisions and choices. He may and may not contract HIV one day, but he’ll die a horrible death nonetheless from complications of hepatitis B.

His family might remember his as a loyal father and a reliable provider, and maybe blame the doctors for failing to save the patriarch of the family.

Someone somewhere, a doctor seated in a clinic knows better.

This is not an article to belittle patients and their rights in modern medicine. Too many a time, the role of a patient conjures images of a wasted and bent little old lady struggling to take her steps due to the incessant pain of severe osteoarthritis. Patients are humans and humans are mortals capable of much unthinkable and downright mind-boggling train of thoughts. There are many more types of patients that really test one’s patience.

To write any more is to test your patience.

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Friday, May 9, 2008

Murderers In Our Midst

There are multiple first degree murders that are currently taking place this very moment of our dreary Malaysian existence. These merit a whistlestop discussion at the very least.

Murderers In Our Midst

May 13 is just around the corner, another four days from the date of this article, in fact. Malaya and now Malaysia has never really gotten over the racial riots of May 13 1969. It’s nearing 39 years since the date Kuala Lumpur literally went up in smoke and still Malaysians are talking about this dark spot in Malaysian history as though it only happened last week.

Declassified documents and exclusive articles, new allegations and counter allegations still surface every once in a while, and usually after the UMNO general assembly. Kua Kia Soong’s account and analysis of May 13 1969 provides an insightful look and an alternative view of the events leading up to the massacre that claimed an underestimated 194 lives as per official government statistics.

To summarise Kua’s findings and analysis in one sentence, the May 13 incident was unlike other state of emergencies in the world. Far from being a string of unfortunate events, the carnage that enveloped the newborn nation of Malaya was in every sense a well-orchestrated social meltdown.

Despite the damages and deaths that occurred between May 13 and July 31 1969, the aggressors throughout the whole episode were never fully penalized, procecuted and brought to justice. Many who participated in the slaughter, plundering, rape and arson are currently still roaming about us as apparently innocent citizens. They are as faceless and nameless as those who were murdered and violated. These assailants could be anybody – the well-dressed CEO of that public listed company, the goat-bearded, skull-capped seditious state imam or that chest-thumping, keris-wielding unruly UMNO politician.

People believe that we should stop harping on the past and instead look ahead in order to progress in life. The discussion on May 13 shall therefore end abruptly here in this web log. I am after all no expert in Malaysian history and I certainly do not fancy the idea of being charged for sedition for stating the obvious.

There are multiple first degree murders that are currently taking place this very moment of our dreary Malaysian existence. These merit a whistlestop discussion at the very least.

The National Service Program is currently into its fourth year of instalment. It has recently claimed its 24th victim recently. The young lady, Too Hui Min suffered a ‘stomach upset’ together with 177 other National Service participants, was sent to the hospital, discharged and soon after readmitted for a worsening condition. She died nine hours after the onset of her symptoms. The NS program is easily the most corrupted, stupid and lethal Barisan Nasional project in history. It costs close to RM 450 milllion annually to run the program. Until an imminent change of federal government, that annual half a million ringgit will be spent till eternity or when Jesus comes back, whichever is sooner.

Mention National Service and one expects our young men and women to be bigger, leaner, stronger and older upon completion of a National Service stint. They end up instead in crowded camps eating unhygienic food cooked by dirty UMNO cronies and spend weeks held up in rooms listening to wearisome UMNO humdrum. We might as well sponsor these young souls for a holiday in the sun, building sand castles and watch Iron Man en masse.

The deaths occurring at National Service camps and program are anything but justified. Those who have lost their lives rarely ended up so not because of any advance weapons training or brutal martial arts sparring. These young men and women ended up dead at a premature age because of simple ailments that were potentially treatable and downright preventable to begin with. The very fact that the National Service Training Department director-general Datuk Abdul Hadi Awang Kechil employed the term ‘stomach upset’ is a clear demonstration of his blatant ignorance about simple health conditions. The presence of qualified medical personnel as opposed to paramedics could have given the young lady her fair chance at growing up and be a useful person in society, much unlike the esteemed Datuk himself.

Malaysians make a big hoo-ha about snatch thieves and armed robbers, and make boisterous claims that they want to protect their family and children from all hurt and harm. They have no qualms however, sending their pampered, home-grown children into the abattoirs of the Ministry of Defense.

Healthcare in Malaysia is easily among the most assessable in the world. Heck, even foreigners with no identification, no passport and no visa are receiving equal healthcare as bona fide Malaysian citizens. I am done whining endlessly about how foreigners are accorded full medical treatment at the expense of our taxes.

I shall dwell on foreigners on the other side of the mirror this time.

The Malaysian Ministry of Health employs a great number of foreign doctors. These expatriates hail mostly from Burma, Pakistan, India and the Middle Eastern nations. It remains a mystery why the Health Ministry look to these nations for a supply of medical manpower. Anyway, these doctors are employed as clinical specialists to fill the void left behind by the exodus of local clinicians. While a few of these foreign contract doctors are well-trained and qualified to heal and treat, the majority of them have failed to demonstrate adequate clinical competency that inspires confidence. By any standards, their level of knowledge, skills and clinical assessment are dubious at best.

Sabah appears to be a favorite dumping ground for foreign doctors. This is especially so in the districts.

An Indian orthopaedician who can’t fix bones, a Burmese anaesthetist who can’t gas patients, a Middle-Eastern surgeon who can’t cut, – these are among the rewards the Barisan Nasional government has presented to Sabahans for their undying loyalty over the last half century. I am not convinced things are very much better over in Peninsular Malaysia.

Patients have suffered a wide range of morbidity directly and indirectly under the care of these expatriates These doctors were not screened or assessed prior to their employment. Non-union fractures, intraoperative heart attacks, leaking peptic ulcers, wrong psychiatric diagnosis, and unnecessary deaths have all occurred and conveniently forgotten.

Our local doctors are in no way perfect, faultless and unblemished. It is simply a fact that medical errors are more prevalent among foreign contract doctors. It is all the more shocking and incredulous that these foreigners are paid more than our local clinicians despite the fact that the amorous Chua Soi Lek himself once admitted that even paramedics are more skilful and experienced than the expatriate doctors.

In short, the Malaysian Ministry of Health is vicariously employing hired killers to go on a slaying spree masked as medical treatment. Murderers are murderes, even if they carry a doctor’s title before their names.

Most folks think that the ingenious Project IC/Project M has done little harm apart from keeping UMNO in power for eternity in Sabah which, in itself is already a grave insult. The mass immigration of Filipinos, Indonesians, Timorese, and to a lesser extent Pakistanis has brought not only a change in the demographics of Sabah, but also in the prevalence and incidence of infectious diseases. UMNO’s desired citizens have brought with them more than their family and baggages. As they entered Sabah en masse, they brought with them tuberculosis, HIV, Hepatitis B and C, syphilis and other sexually transmitted diseases and are more than keen to share these conditions with the local Sabahans. It appears that they too have adopted the muhibbah concept.

The foreigners and ‘other bumiputeras’ have increased their representation from 8% to 34& of Sabah’s population in less than one generation. For this, the appreciation goes out to the strong endorsement provided by the Immigration and Registration Departments.

Unlike the quick, fast kill adopted by the foreign doctors, Project IC citizens prefer to murder Sabahans in a slow, painful and sadistic manner. Patients with tuberculosis cough their lungs out for years, enduring episodes of high fever, chills and night sweats and finally succumb to their acquired ailment when the tuberculosis bug has spread to the whole body system. The process of dying from HIV and hepatitis is not any more comforting.

Once in a while, say every other day, the Poject IC citizens emulate their doctor counterparts by getting it over swiftly. Their involvement in rape, robbery, abduction and murder are testified by the local Sabah papers. It’s not to say that local Sabahans do not commit crime, it’s just that when crime is committed by persons who are not even supposed to be in the country in the first place, the crime becomes all the more heinous and deplorable.

Once again, it makes me wonder how many murderers and pillagers are lurking behind the veil of a hardworking butcher and a sweaty labourer.

Speaking of butchers, perhaps there will be no butcher more distinguished than the tyrant who served as Malaysian Prime Minister from 1981-2003. The mighty Mahathir was the mastermind behind many a grandiose national project. While they were hailed to be farsighted and revolutionary twenty years ago, many of his pet projects have since proved costly, ill-conceived and ultimately fatal.

His introduction of the approved permits made foreign vehicles too expensive and beyond the means of an average Malaysian drawing an above average income. Proton cars came into being and market conditions were manipulated to favor Mahathir’s prized legacy. Made of metal more suited for Milo tin cans and ketchup sardines, countless of individual Malaysians and their families have met their Maker driving substandard Proton cars along our treacherous trunk roads.

Admittedly, road ethics play a major role in traffic safety and in this sense, the Mat Rempits losing their lives and limbs every day deserve it all. It will remain mere hypothesis whether the outcome of road mishap victims could have been better had they been traveling in foreign-made vehicles. I am no statistician or physicist, but the mangled states of Proton cars after a mid-impact accident seem to support my hypothesis. Mahathir should indeed be held fully accountable for placing blind nationalism over citizen safety.

Mahathir has been a bold and vocal critic of his successor, accusing Abdullah Ahmad Badawi among other things, of turning Malaysia into a police state. He seems to have forgotten how Malaysia was just as repressive under him when he was in power. While Mahathir will be revered as the prime minister who curbed the previous immunity of ‘royal families’ from any legal repercussions, Mahathir will also go down in memory as the one who ruled the nation with an iron fist with little discernible separation of powers between the legislative, executive and judiciary branches of government.

One wonders how many unjust and wrongful verdicts have been delivered during Mahathir’s reign and constant interference with judicial appointment. How many innocent Malaysians have been wrongfully sentenced to death and incarceration while Mahathir was in power?

Malaysia started taking on a police state outlook under Mahathir as well. During the peak of Mahathir’s supremacy, the number of deaths under police custody from May 1989 to 1999 came to a total of 635, and these are merely the official, reported figures. Something ought to be gravely wrong when the very people entrusted to deliver safety and justice to society also take on the role of a self-appointed executioner and cold-blooded punisher as well. Anwar Ibrahim may survive a black eye and some cyanide poisoning, but not everybody is so lucky. It is not outrageous to reason that many cops who participated in their orgies of torture and butchery ten years ago are currently in positions of higher power and authority and giving press conferences on the latest drug bust.

Wars are not always synonymous with jet planes and missiles. Economic sanctions and the severing of foreign relations are wars in their own rights. Similarly, murder need not always involve the physical body and result in bloodshed.

Killing a child’s fertile and blossoming mind of all curiosity and creativity is just as despicable as bodily harm. For half a century now, Malaysian school children and even university scholars have been inundated with pro-Malay, pro-UMNO propaganda. They are taught a version of Malaysian history that is sanctioned, approved and filtered to UMNO’s favor. The role of all races in the independence of Malaya has been drastically watered down, and all non-Malays are taught to be grateful for their Malaysian citizenship and be content playing the role of unwanted citizens of Tanah Melayu.

Our young minds are taught not to question any form of authority, even when it reeks of tyranny. From young, we are reminded repetitively not to disagree with our teachers, not to go against all rules and regulations, not to challenge the status quo, not to rock the system in place. Since then, we have learnt to revere the religious figureheads and desendants of ‘royal families’ even when they make comments inciting hatred and disharmony.

The brainwashing and mind-numbing elements of Mahathirism and now Badawi-ism has produced the current Malaysian generation, youngsters who see talent in Akademi Fantasia and find role models in Mawi.

Our whole education system has been nothing less than a massacre of talent and potential.

I am guilty of murder as well. As a matter of fact, I am committing murder this very moment. By writing four pages of Microsoft word about the obvious murderers in our midst, I am achieving nothing and am guilty of killing time.

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Wednesday, May 7, 2008

Sleeping Away, Slipping Away

Perhaps there is some genetic link and heritage to both insomnia and a nocturnal circadian rhythm.

Deep inside, I know there is more that meets the eyes, not unlike the Transformers.

Sleeping Away, Slipping Away

I’ve been working like a dog the last two weeks, barely getting 2 hours of sleep per day. My schedule of work and locum slots this month amount to an average of 18 hours per day. It still leaves me with a theoretical six hours of sleep but the fact is we all have biological needs and physiological functions to fulfill some of which might take a big chunk of your daily life.

A low requirement of sleep is an advantage in the medical profession. I sometimes pity the doctors who had had an easy pathway to their medical careers. They are not used to sleepless nights and end up I fatique and depression. My colleagues ask me why I don’t appear exhausted despite my lack of sleep. Most exclaimed surprise that I was on call the night before but still appeared energetic. I shrug and say that’s just my body.

My father has been a self-diagnosed insomniac for as long as I can remember. He falls asleep only with the aid of midazolam and wakes up just in time to greet the newspaper vendor and catch the daily news.

Unlike him though, I have ceased trying to resist my nocturnal system and instead embrace it to my advantage.

People impress upon me that the early bird catches the worm and that many successful personalities adopt an ‘early to bed, early to rise’ approach in life. Most ‘longevity experts’ advocate adequate sleep and a regular sleep-wake pattern in order to live till a hundred years old.

Well, worms are not my delicacy and I don’t fancy living to an overripe old age in time to witness Tanah Melayu becoming Taliban-land a hundred years from now. Unless researchers can find the Methuselah gene and couple it to the Fountain of Youth, thank you very much - I’m pretty comfortable with a nocturnal lifestyle even if it means I’ll die a little younger.

Perhaps there is some genetic link and heritage to both insomnia and a nocturnal circadian rhythm.

Deep inside, I know there is more that meets the eyes, not unlike the Transformers.

I may have had nocturnal roots engrained within my system since childhood, but I nevertheless slept to my contentment back then.

I started surviving on two hours of sleep back when I was sitting for the pre-university/STPM examinations.

It was sometime around May/June of Upper Six, that time of the year when the local universities announce their student intake for the year. My Malay peers who went through Matriculation were to enter university a year earlier, while us non-Malays in secondary school outfits were still fighting one another for our share of the varsity racial quota limits.

Lest and before anyone accuses me and other nons of being kiasu and competitive, essentially STPM was just that – an intra-ethnic survival of the fittest. This is one salient feature about the New Economic Policy (NEP) that many folks don’t point out. It pits Malays against Malays, Indians against Indians and Chinese against Chinese, instead of providing for a clean contest that rewards meritocracy without regard to race and religion.

It really doesn’t matter how well one performs objectively, all that mattered at the end of the day was how one fared in comparison to another person of the same ethnicity. This bitter fact of Malaysian life did not hinder us STPM students from helping one another though. I received loads of help from my studying partners and ultimately we all fared pretty well in the examinations.

Burning the midnight oil was not the trigger of my nocturnal state though. Most STPM students studied real diligently, except for some who was lost to cloud nine from day one of school. On my side, knowing that the NEP cloud was hovering above me at all times may have driven me to strive harder, but it certainly did not deprive me of sufficient sleep. Sleeping was very much an option still.

I was shouldering multiple positions in school because we required our extracurricular activities to propel us ahead of the others with similar academic credentials. I was determined to enter medical school, not any medical school but the Medical Faculty of University Malaya. My teachers told me to drop the idea, aim lower and even something else apart from medicine. They meant well I suppose, considering the fact that no head prefects in the preceding few years have ever came close to achieving a decent score in STPM. I appreciated their apparent belligerence and belittling of my hopes and dreams for it made me even more determined to prove them wrong.

Naysayers should never be brushed aside and ignored. They play an omnipotent role in one’s life. Ultimately, it’s our response to critics and skeptics that truly matter. We can ignore them and proceed at our own momentum. If one is has an intrinsic high level of motivation, one will do just fine, like my sister. If one is a lazybone with inherently great inertia and low drive, one ends up paying a high price for ignoring antagonism, like Abdullah Ahmad Badawi. One can also pay too much heed to cynics and end up dispirited and downcast, like Britney Spears and half of the Hollywood neigbourhood. That too is not desirable. I don’t know how and why but I’ve always liked the idea of proving detractors wrong which must not be misconstrued as discrediting every dissenting view.

That was a side track from the main topic, if there were any to begin with in the first place.

In summary, high school activities were not how I came to survive on minimal night sleep though.

Both my sisters were away from home pursuing further education during my STPM year. Essentially, only my brother and I were left in the family home. He has been at home for most of his life in fact. Don’t ask me to elaborate in detail why he was not sent to a special school for children with Down syndrome.

Suffice to say, there were multiple, intertwining factors. The UMNO/BN government did not offer decent special education to begin with. Back in 1996, I checked out this special school called Sekolah Semangat Maju literally translated as the ‘school of progressive spirit’. The windows were broken, the doors were rotting and the teachers in tudung were yelling at the top of their voices. It was an atmosphere of regression and the teachers were anything but spirited. That was then. Things may have changed a little for the better now but ultimately, the fact remains that special education in Malaysia is a farce compared to other nations, and I am not talking about Burma and Zimbabwe.

Brother was lonely. He could have well been lonely his whole life, but I’m sure he was happy and at least contented when Mother was still around to talk and listen to him. They kept each other company. Hers was a body weakened by multiple sclerosis but Mother remained strong in mind and was determined not to neglect her special child from heaven. Brother was lacking in cognition but abundant in character and he too has resolved not to be inhibited by an extra chromosome.

I don’t think I was a responsible brother all those years Mother was around. Truth be told, I was lousy. I came to this realization when I was left all alone with Brother at home. I had to learn everything about him from scratch as though I never knew him all those years we were growing up under the same roof.

We talked. We talked a lot those two years of STPM. Actually, Brother talked mostly while I did the listening. Mother had taught him well enough while she was still around and able to. She must have done an excellent job in that because Brother seemed to have endless to talk about. In between recounts of the latest episode of Kindred Spirit and a daily reminder of whose birthday was coming up soon, Brother spoke of his endless hopes and dreams. From his down-to-earth desire to have Hawaiian chicken pizza the coming Sunday evening to the far-fetched even absurd ambition of being the next new character on Kindred Spirit, the hours spent with Brother turned to weeks and months.

So while other students spent their time at home reading Chemistry and doing Mathematics, I was getting to know a brother I already had my whole life.

We usually spoke till way past midnight, after the mandatory drive around town and a game of modified racquetball in my bedroom. After supper at around 1 a.m and a drink of Daisy Hi-Low milk, my routine-obsessed Brother retires to bed.

I’m left with five hours before school the next morning, where I’ll spend one third of my time out of class chasing after Malay guys smoking in the school toilet and catching Chinese brats playing truant at the nearby snooker outlet. The dark-rings around my eyes suggested an all-out studying orgy, but only God knows that I have had less than two hours of Biology/Chemistry/Maths.

That is how I came to survive on two hours of sleep every night. The STPM examination paved the course. A racist system placed me at the starting line and a tall ambition blew the starting whistle. My brother kept me on the course, alongside my silent prayers to Jesus.

It’s 6.30 am now. The sun is shining, the birds are singing, the grass is green and you might still be sleeping. Now if you’d excuse me, I think I need to sleep too.

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