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.

‘Doctor…”

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.

“Doctor…”

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?

7 comments:

nyp said...

Did he get his liver biopsied ?

dak1ller said...

tinge of arrogance i sense in your post... no doubt though u did good for Valrus, but the end can never justify the means...

Product of the System said...

NYP,

Didn't ask him whether he got the liver biopsy in the end. It didn't cross my mind when i met him so unexpectedly.

Anyhow, there were sufficient indications to support anti-HCV therapy so maybe the liver biopsy was not really necessary.

Unless you still think he has other hidden issues, which is totally possible.

Kong said...

dak1ller. What can you expect? POTS was full of idealism just like many young man just out of college, probably you and me included. For hot blooded young man, "the end do justify the means" is pretty common thinking.

Now I am not saying that's a bad thing and one of the reason why we always need fresh blood in any field. To me, the most important thing is; POTS started out with good intention. And that's a value that will serve our community well.

jj said...

you have done justice.
may Allah bless you and your family.
Amen.

sojourner said...

how is forging signature for ultrasound any different from making own decision for emergency laparotomy?

dak1ller said...

dear kong,
if the end justifies the means, both u and i can do alot for the society, we can go rob rich ppl (yeah, just like robin hood) and help the poor (konon), we can inject some potassium chloride into a rapist/ prisoner whom was admitted to our ward for viral fever... sojourner put it quite into our context, we even forge signatures for laparotomy, no big deal...

we are profesionals, and our line of work is governed by ethics and conscience... if the end always justifies the means, the world goes upside down, dude...good intention can kills... good intention only is not enough.. good intention is a lousy excuse to be lawless...