THE FIVE STAGES OF GRIEF

As a (former) medical student, I used to learn about the stages of grief. It was in the study guide as part of our professional development. The purpose is so that we doctors will be able to be as empathic as possible with patients or relatives who are in their stages of grief. 

Those patients who have just been told that they are suspected to have appendicitis which will be cured after an appendicectomy, a simple daily most common surgical procedure, or those patients who have just been diagnosed with a stage 4 malignancy with only few months to live. Those parents who were told that their children have just died following motor vehicle accidents, or those wives whose husbands just presented with heart attacks and that CPR is ongoing, then asked if CPR should be continued for another 30 minutes or otherwise stopped if no signs of life present soon enough. Let it be benign nor malignant, let alone the patients themselves or their relatives. All of them will eventually face these stages of grief.

What we sometimes overlook is how this teaching actually applies to many other situations that may occur to anyone, any day. Sad things happen everyday. Unpredictable things happen everyday. Sometimes they occur in your lives, some other days they befall upon me, and some other days they happen in some other people's lives. So everyday there must be certain someone who is at these different stages of grief. 

The five different stages of grief. Denial, anger, bargaining. The first three stages that may bring you so many unanswered questions; that you would do many impossible ridiculous things you would regret later on just to have these questions answered. 

Then there is depression. When you would ridiculously torture your own selves for something you should not, be it either you have no appetite for food causing you loss of weight despite busy occupying yourselves with baking new recipes just to get rid of those memories that brought you to your grief; or be it you have no energy to smile that your colleagues would query and whisper among them why have you become someone different; or be it you cannot sleep, only you are so lucky to know some medications that have their sedative effects then wrongly use them to help you sleep rather than for their own indications; but even with this abuse you would still have interrupted sleeps that is most definitely unhealthy; or worse, at this point of grief some people with no faith would just succumb to ending their own lives a a shortcut to end the misery and pain they were going through. And this is where I think the challenge is for the psychiatrists - to differentiate whether the depression is pathological and needs treatment, or whether it is just a physiological stage of grief which is completely normal and needs only time to heal, hence treating this with medications would only cause a disaster and is inappropriately necessary.

And then, comes the final stage. Acceptance. Only if you handle the depression well enough to come to this stage. And you will never know how long to go until you come to this stage. 

I used to read a really wise book entitled Don't Be Sad, or rather known with its arabic title, La Tahzan; which also has its Indonesian translation - Jangan Bersedih. I used to read it halfway through, never did I finish it, had you known me, you would know I like to read, but I always stop halfway through. I know it definitely is not a good thing, but reading it the second time at time, I will try to finish it and hopefully not only to finish reading it, but also will be able to take in and hold firmly all the advice close to my heart.

I am no where near to the middle pages, I cannot promise that I will finish reading the whole book cover to cover (it's an old habit that is hard to change of course, and promise is not something you should play with), but I can promise that reading the first few chapters would have given those in grief (or not) soothing words of wisdom and hope. Hope that should only be leaned to Him, as to Him alone do we all return. The words that bring you closer to Him, that hopefully will lead you to be able to deal with the griefs or tests in the best possible way.

Every word written is so true. Reading too much into the past is a waste of the present. Sometimes, you want answer for things that happened, but maybe not knowing the answers is the only way you can live better, you never know, but He knows. Enough with all the ridiculous things you have done in the past; denying, being angry, bargaining. Former days are gone and done with, and you benefit nothing by carrying out an autopsy over them, by turning back the wheels of history. 

Depression brings you to idleness and idleness would furthermore brings you to depression - as nicely written in the book; When you find yourself to be idle, prepare for depression and despair, because idleness allows your mind to wander in the past, the present and the future, with all their difficulties. Idleness is an expert thief and your mind is its victim.  It says ' Get up now and say a prayer or read a book; praise your Lord, study, write, organise ... and loads more, so that you can put and end to your inactivaty.' Tossing and turning around your bed, thinking too much about the past would bring nothing other than torments. ...and hence the writing after one year of silence =)

And these are my favourite quotes from the book so far: 

"The pen has dried, the pages have been lifted: all events that shall come to pass have already been written. Whatever has befallen you was not meant to escape you, and whatever has escaped you was not meant to befall you."

As a weak human being going through difficulties, those awful feeling will always haunt you and put you in sorrow and trouble, and studies have extract out this common stages of grief which should be a normal reaction towards letting go. As those who believe, we will never completely feel at ease until we firmly believe that Allah has preordained all matters. It is the 6th pillar of faith anyway. Easier said than done of course, and once in a while even if you agree and are comforted by the preordainment, those things that happen to you will always haunt you because it is your past. Just wish that it will not haunt you too much and be thankful that your life is much better than some other people.

So yes, every day some certain people are at grief. Sad things happen every day. Unpredictable things happen every day. But good things also happen every day. And unpredictable things can happen in good ways. Grief is a normal process, just pray that it will not take too long to destroy you  apart. 

I pray that my faith, our faith will always lead us to the betterment. No, I pray that we always have faith, as once we have the true faith and we believe, this will always lead to betterment =) So my friends, (and a very sincere advice to my own self of course), HAVE FAITH because He is The All-knowing.

HATING YOUR LIFE?

I have just finished updating another week's shift rota and my eyelids are so heavy already. It was a tiring AM shift especially at the beginning. Enough to say that I and my lovely MO oncall today had to standby at OT for a triplet emergency delivery - not to mention that there is a DIL patient in NICU, also another one with PPHN on HFOV. But still, I'd prefer neonates than general paediatrics.

The picture above was posted by a friend in my facebook - it is a wise reminder for me at time because I am so not looking forward to be responsible for HO in my department - but it's a duty I cannot run away from and I think it is failing me - I have never been a good leader, I suppose. God, help me. I should have been more grateful.

THE SHIFT SYSTEM: PRO AND CONS

About a month ago, the head of HO in my hospital asked me to send him opinions from paeds HOs regarding the HO shift system. These were the feedbacks I managed to gather from the team, at time with the assumption that the shift system planned for implementation is a similar one to the one used in A&E posting:

PRO:

1. Enough rest in between work

More energetic housemen and presumably less mistake. Hence, shift system is probably good with departments with expectedly non stop works, and with not much of continuation of care which need brief passing over– for example, in casualty and labour room, but not in wards where continuation of care is essential

2. No oncall allowance for housemen (*definite cons for housemen though)

A huge reduction in the money spent on the health sector by government – good as money can be spent on other healthcare needs, for example hypoallegenic gloves (as part of right and welfare of the employees with sensitive skin) or to get better equipments for treating patients

3. Working time not adhered to regular office hours might be beneficial

Ability to run any errands that need being done during office hours eg going to the bank

CONS:

1. Number of housemen in each department is labile and not fixed (due to possibility of extension)

Not enough numbers to be divided into shift hence difficulties in coordinating the shift duties

2. Limitations which makes hectic morning shift – and might lead to major dissatisfaction if shifts are not properly assigned

Morning shift will be particularly busy – with the specialist ward round, blood takings needed being done during office hours, attending clinics. Surgical based posting with elective surgeries in the morning makes it rather difficult to organise the shift system. Few housemen might be left in ward, leaving jobs passed over to the next shift, but unlikely to be done on the same day if those jobs are limited by office hours only – hence the unnecessary delay

3. Less teaching

Teaching done during office hours, some might miss the teaching

4. The pass-over tradition which in itself is time consuming and might not work well in all departments especially in ward

Those who are less responsible will become more complacent, passing over the jobs to the hardworking/more responsible ones.Either the hardworking ones will continue to suffer or a viscious circle to happen where jobs might be passed over on and on before being noticed, which might compromise the patients’ care. Also, jobs might be missed if passing over sessions are not properly conducted so, effective hand over session is very important, and a clear guideline is required. Having said that, a proper pass over can be very time consuming, hence more time spent for passing over, less work done in time, less care and time for patient

5. No oncall allowance for housemen

This is probably not too bad, providing the working hours is much less than the current oncall system. However, it is of no guarantees, and the working hours might end up with mere minute difference. These extra hours should be entitled to some compensation too

6. No more weekends or public holidays

Difficulties in arrangement of holidays as everyday is a working day, hence ending up with less rest throughout the month even if there will probably be enough rest in between shift. Cumulatively, working shifts might be more tiring

----------------------------------------------------------------

In conclusion at that time, consensus I think was NO, DO NOT implement it until we are all ready. Or at least that was the consensus among me and my colleagues in the same hospital.

Good grief. I can still picture myself standing up in front of all housemen and DG in my earlier days of working, asking about whether or not the shift system is soon going to be implemented. And why on earth did I ever have the nerve to ask that question?

And now having been in the system for around 10 days, I can see the pitfalls here and there which I will try to conclude in another entry after having a post mortem with other colleagues of the department. Enough to say, I need daily motivation to go to work now....

THE NEW LAYOUT

Today marks a one month away to completing housemanship. Loads of experience gained, with happy and sad times, with encouraging and upsetting moments, together with old and new friends. I am still in Paediatrics department, and since I am too busy with making the shift timetable for the housemen, this leaves me with headache. I just created a blog for the HO in my department to put up updated timetables which I am really sick with - I will comment about it later - and after creating a new blog, I made a change to mine as well.

So TARAAAAA...here is the new layout. It looks weird, but sometimes change can be good. I need to accustom myself to new changes all the time anyway. I am sorry that there were previous posts that will come out without previous comments, or with white font colour which won't appear upon your eyes because to change it all will take me ages.

A few more things in mind before I keep myself busy next week for another rota:
1. Summary of my thought on shift system so far
2. Nice write up on HIS system - can I go on with petition?
3. Viva!!

Too much but too short and I still have not decided yet of my field of interest, huh

HILARIOUSLY IRRITATING

I was reading this one article that I accidentally found upon googling for articles on the yet to implement shift system for all housemen in Malaysia. Hilariously irritable. I repeat, irritable.

No offence to the nurses, my near 2 years experience have exposed me those who are unexpectedly of cannot-make-it calibre, as what the blogger named it. Go on, have a read:

DOCTOR, DOCTOR! by Home of the Manx (I think the blogger is a psychiatrist)

The head nurse of my main ward was slightly upset when I told her my opinion that some nurses of certain wards are of cannot-make-it calibre. But it’s true. The ones in my main ward are generally OK despite being relative greenhorns. They have an acceptable average level of intelligence, integrity and diligence, with an outstanding one here and there. On the other hand, some staff in other wards really make me want to bang my head against the wall. I tell myself that there is no point in sacrificing my noggin like that. If I used their heads to smack the wall instead, the building would crumble.

Example.

(Phone rings)

Me: Hello.

Nurse: Hello, Dr. Katie. This is staff from Long-Stay Ward Pee-A-Lot. Do you think you could come and conduct an urgent multidisciplinary ward round with the medical officer, nursing staff and pharmacist? This afternoon?

Me: (thinks: that would be the equivalent of chartering an emergency jet plane to buy groceries for tonight’s dinner) Huh? Why?

Nurse: We want to convert all the patients on Valiant tablets to Valiant syrup.

Me: Huh? Why?

Nurse: Because we had one patient who nearly choked on a Valiant tablet.

Me: Oh? When? No one told me.

Nurse: Last year, before this ward came under you…

Me: (moment of disorientation – this is late July, right?) Okayyyy…

Nurse: … so there was an enquiry, and now we have to think of ways to prevent further near-choking incidents, so I thought we should change his Valiant tablets to syrup form. Then I thought we should also convert everybody on Valiant tablets to syrup. That’s fifteen patients. That’s why we need you to do a multidisciplinary round for everyone to institute the changes.

Me: Whoa, wait wait. This patient who nearly choked – was he only on Valiant tablets?

Nurse: No, he’s also on Fluent tablets, Hallucinate tablets, Chlorophyll tablets, Di…

Me: Uhhh… so you’re telling me that putting him on Valiant syrup plus ten other tablets will prevent him from choking on tablets?

Nurse: Well, it was Valiant that he nearly choked on.

Me: And the other fourteen patients? I suppose they’re on lots of other meds too? For which there is no syrup form?

Nurse: Yeah…

Me: So how does converting them to Valiant syrup make sense?

Nurse: Well, true, it doesn’t… but there was an enquiry. We have to do something!

Me: (sighs) OK, fine. If there HAS to be a change, I have no objection to this one patient being converted to syrup form. Leave the other patients alone. No multidisciplinary round. Just get the medical officer to convert the Valiant to syrup form at the same dose.

Then came the clincher.

Nurse: But Dr. Katie, Valiant syrup is very expensive, you know. Are you sure you want this patient to be on syrup instead of tablets?

Good grief. No amount of bonus is gonna compensate me for the brain cells that died during this conversation.

My very shallow experience so far has enlightened me of how unbelievable nurses could be and of how much the nurses' works has shifted to become part of the junior doctors' jobs, because we (junior doctors) have apparently become the glut.

One example of mine:

One hectic night in a surgical based ward, a patient was having a problem to pass out urine post op (which is not uncommon) and another patient who has low GCS due to intracranial haemorrhage ran amok in ward. Not to mention there were another few cases who I had not yet fully clerked after seeing them shortly with my MO - at least the diagnoses and plans were already there. I was left alone in ward as another HO oncall in the ward had long gone into the OT to assist the surgeries.

Before handling the latter patient, I have requested the nurses who were chatting at the counter (and was probably finishing off their very important report which copied every plans by doctors) to prepare the catheter set for the former patient.

After the amok patient been taken care of, I upsettingly found that the set were not ready yet. To make it quick, I prepared it myself and pushed the trolley to the patient's bed myself, passing through the nurses who were too busy chatting or probably gossiping. Then I had to pull the at least 2 screens to secure the patient to his own privacy - there were no curtains in the ward you see.

And to make it worse, it was a male ward and I was completely aware that I was much in need of a chaperone for those kinds of procedures - but like that ever happened in this hospital anyway. Surprisingly in Malaysia or maybe just in this hospital where the chaperone appears in every single introductory papers to be signed off by new doctors entering a new ward, having a chaperone practically were made compulsory only if you are a male doctor having intimate procedure done on a female patient. Other than that, it is definitely not widely practised here.

So I shouted out that I needed a chaperone, in which later on as expected, nobody came to chaperone - let alone if I asked them to assist me. Again to make it quick, I just proceeded with the procedure but it was not as easy as expected. I needed a smaller sized catheter and hence shouted for another help.

Me (shouting): Akak, tolong bowok cbd size 12 se (nurse, can I have a size 12 catheter please?)

After twice or thrice shout out, a nurse came with the wanted catheter and she placed it on the trolley next to me who were all sterile.

Me: Thanks... (before I could finish off with asking for another favour to open the catheter packing up into the sterile set, off she went to the other two nurses at counter)

SPEECHLESS. That was all I remember. I was completely speechless! Hello, it was a only a common sense for you to open it up, d*** you.

Luckily my MO (who was quite new in this hospital at time) passed by and he nicely helped with the favour I was about to ask and chaperoned me until I finished off my procedure, asking during that while 'what are the nurses doing leaving you alone here?'

Exactly. So what do they do? Obviously we need more doctors to compensate for those jobs that previously not done by doctors. So why complain of the glut?

Anyway, having said that, there are some nurses who I love so much and I think these are the nurses that achieve the same standard as those in the UK. If there are awards I can give to the best nurses, I will definitely pass them to these two nurses I have met in my career so far - 1st one in renal male ward who would call you to clerk a new patient who needed a peritoneal dialysis at 3am in the morning and by the time you reach the ward, everything has already been prepared, and when you were doing the procedure she was closed to you so you do not have to shout to ask for favours (I know nurses have tasks to do too, not that I always wanted her to be on my side even though that is what u get in the UK), and when you finished off the procedure she would take care of the other sets after you thrown away the sharps as she knew your phone just cannot go silence for a while and there were other patients you need to see and take care of.

And another one I met in ortho ward who would call you to clerk a case and by the time you need sedation and analgesic for a close manual reduction, he said it was already prepared as he already anticipated it. Prepared as in already diluted, mind you.

Seriously, thinking about these two particular nurses made me want to cry, thanking God for still making them exist in my current world. How I wish things are different, but who am I to change things?

OF WIZARDRY AND ITS WELFARE

It was one fine day where everything ran smoothly. But it was Monday, the day all the young wizards were gathered at a new building called the Cedric Hall to learn more about magic. A female young wizard had finished off all the works required in the main magical infirmary that morning. Off she went to the dining hall with another female wizard to fill her stomach up then to a room to commit herself to God, the One she believes in, before going to the lessons of magics.

The sign on the heavy, bulky door reads ‘staff room’. They very rarely went there before but it was one of the nice rooms in the hall for a prayer.

Suddenly the head of the fairies named Bathilda looked at them in a suspicious way, asking “which department are you in?”

“The art of human carpentry”, the young wizard gave her a short and honest answer.

“There is a room just outside here if you would like to do your prayer, you know”, said Bathilda, pointing towards a general room, probably at the back of the room they were in, where anyone with the same beliefs who came to the magical infirmary would perform their prayers there, as the main means of submitting themselves to God.

Of course, the young wizard already knew where the room was. And, of course she understood what Bathilda was trying to hint them both.

“But this one is more comfortable. It has the restroom inside here, you see”, again, the young wizard tried to reason herself. ‘After all, we are still staffs, are we not?’, she whispered.

“Even when we were treating the humans with potions out there, we still go to the outdoor restrooms”, replied Bathilda with a mean look, and as she was on her way out of that so labelled as ‘staff’ room, she took out her wand for a jinx to switch off the room cooler, making the room warmer than it had already been – that was after Bathilda started talking.

Speechless, the young wizard was reminded of Hogwarts. She used to study magics in Hogwarts before being awarded to become a wizard. In Hogwarts, things were very different. The welfare of the wizards in Beauxbatons, her birth country was comparatively horrible.

In Hogwarts, let alone the young wizards, even the students who were not considered staffs were being treated nicely. Tea was pouring endlessly in their cups during the hand-overs, a session where the switching team of wizards, witches and fairies gained information about the humans retained in the infirmary, their illnesses and the potions that worked well for them. Again, let alone the young wizards, those students of magics – mind you, who were not the staffs – were given a small cupboard where they can use a unique enchantments to lock up their valuables so they were not lost to the abusing power of black magic. And these students of magics were entitled to use the big, huge staff room that was equipped with a magical entertainment box that enabled them to watch news from all over the world, nice and comfortable seating and many more.

The young wizard never had these advantages of being a staff in Beauxbatons. At least, that small cupboards for wizards would do, coz all fairies had them, but not the wizards. And they even had them placed in wizard's rooms. What more can you say of a wizard being chased out of a staff room (which I supposed was meant for any staff) when a fairy could have their belongings in the WIZARDS' room?

Even though there were not many people who shared the same belief in Hogwarts, most of the people there would respect the young wizard when she had to excuse herself to a room – any room – so that she can perform her prayer wholeheartedly. Some of them kindly showed the way to the nearest quiet room where any believer from different religions were welcomed to perform their prayers. If there were no quiet room, the fairies, and sometimes the head of fairies would put an unlock charm to a locked room for her so she can submit herself wholely to God without any distraction. And these people did not share the same belief in the same God as she did.As Bathilda did.

And rumours say that the Beauxbatonians who used to study magics in Hogwarts not coming back to to serve their own people because of the higher rewards they gained in lthe atter. Nonsense! Well, it was true indeed that they gained extra galleons there – but that was only the benefits of staying in Hogwarts, not the reason. The young wizard can clearly see now that welfare might be one of the issues.

Not that she wanted the endless cups of tea or coffee, no. Not that she was so arrogant, being a wizard, who supposedly by hierarchy was higher up than the fairies, wanting to be respected too much like she had been a staff for long and knew everything about magic already. No, not that. (But sometimes even those higher up in hierarchy, the witches were outruled by the fairies in the infirmary, let alone the level 2, 3 or young wizards). On the other hand, of course those fairies were mostly more experienced and hence, the same respect that the wizards deserved for should be given to them too, no. So in the end, it was not a question of who should be respected by whom, but a matter of respecting each other even if you were just a house elves who served diets to the humans.

The young wizard was helpless and hopeless. She could create a parchment of complaints to King Arthur or Lancelot or even the witches - she might, but this might well get back to her as witches sometimes like to compare the way the were being treated when they once were the young wizards – those times where she assumed the welfare were never thought for or fought off. Time has evolved and people are more educated about their rights and it was never fair for people to let you being treated as they were before. If this still occured, then why use the apparation, the latest means of transportation, and not the old conventional broomstick?

As for Bathilda, the young wizard thanked her for finally triggered her to do something about the welfare of the wizards. A parchment of news would do, maybe? It might be the time to start fighting for the right. And hey, wizards are staff too, they do work for the infirmary!

*original idea taken from OF WITCHCRAFT AND WIZARDRY

THE LAST HOLIDAY

Considering the quite regular basis of blogging I did over the first month in casualty, it seems like ages that I have not been updating anything on the blog. I have been quite sick - no, really sick with keyboards I guess, I wish there are devices which detect whatever I say verbally and turn them into the soft copy. No doubt there will be, in years if not too soon. The computerised system at the hospital is killing me, especially when there are way too many patients to be served. Now that we are moving forward to the second phase, I wonder if my eyes can endure looking at the computer screen too much. I hope it is the best for all.

Kinabalu Mountain; 16 December 2010 [Credits to Faizal]

I spent half of my holidays for this rotation climbing up Kinabalu, too much stories behind it that I refuse to type in, enough to share that I still have bilateral subcuticular haematomas on both my big toes, they are still black after one month coming down from there. Today, is my last day off in casualty that I am entitled to. Will be finishing off my rotation at casualty by 11th of February, provided I pass my viva of course. And the thickest logbook of all... Great, now these sound dreadful.

Three months being here, I have to say it is the best posting of all, despite the same moaning of unfairness and insatisfaction, it is a nice posting indeed. I still hate green zone as much as I used to at the beginning of the rotation, and I still love reds. Adrenaline rush...

Honestly, I do not mind staying at casualty for another 8months to complete my housemanship, swapping it with orthopaedic and paediatrics posting which coming up. New posting means new environment, new staff and superiors you need to be dealing with and get used to, new knowledge (which is good) and new everything. If only there is a way for me not to do the other two postings...

TRIBUTE: THE LOSS OF A FIGHTER

I was totally shocked upon hearing the news of the death of a good friend, Mas Afzal Masaruddin. Not that I was one of the closest person to him, but him and my other good friends; we surely are bonded by one tie that is strong enough to say that yes, indeed we are good friends who walk the same path.

I first met him at KMYS, the college where I did my A Level. We were never in the same groups but I remember going for the bronze award of D.O.E which involved climbing up to Cameron Highland. He was one of those few who joined - he was so nice he carried my 10kg rucksack when I was too tired to push my body up with the heavy rucksack on (which made it probably more than 20kg total of rucksacks he was carrying).

I was despatched to Newcastle whereas he went to Sheffield. I met him every now and then back in the UK. He was constantly giving good words, inviting people to what he believes in, Islam. He was then diagnosed to have Hodgkin's Lymphoma - but I was not that close to him, to personally say how sorry I was to hear his condition.

Yet, he was a true fighter. He never failed to amaze me. Having been diagnosed with such cancer, with bouts of coughing and side effects of chemotherapy that he had to succumbed to, he still passed his final year medicine and graduated as a doctor. The last time I read his blog was quite a few months ago, then I never really heard of him and how he was doing again.... until today. I feel ashamed and speechless, to have been so busy with my own life and nonsense worries, when he was fighting endlessly in his own world - and never did I try to contact him.

Truly, he was indeed a fighter. He fought to the end. My deepest condolences to all close to him. His presence once will be remembered. May all his doings bring him to the Paradise.

Innalillahi wa inna ilaihi raji'un.
Al-Fatihah.

DOCTORING THE DOCTOR

I was planning for at least a decent day off during the 'week off' for raya haji, but due to shortage of H.O. that was not made possible. But my wish was finally granted, after I got this horrible self diagnosed AGE (acute gastroenteritis).

I actually went to hospital for my morning shift on Friday, only to find out that I was too dizzy to stand up (I even get my brother to send me to the hospital), probably due to the loss of fluid via vomiting and diarrhoea. I hesitated before decided to finally take the two days of MC that the Big Boss offered me. My hydration was actually fair (a very bias judgement I have to say, as I was assessing myself), so I refused IV drip in the first place, but after two bouts of vomiting I succumbed to the correct decision of having a cannula inside my vein - and it did feel painful when the Hartmann solution ran through the small pink cannula into my left radial vein (is there?) to compensate for my loss.

Diarrhoea became worse when I got home that I literally did nothing just because I was incapable of doing things or to think, because I was too tired and dizzy running from bed to toilet, and vice versa. The next morning I woke up, pulse rate was still tachycardic, but I was feeling much better - then only I could think up straight - I was probably already in second stage of hypovolaemic shock. I called my friend, and let her brought me in anohter couple of IV drips. Today I feel much better, and ready for works, and surely in a much more empathic mode.

*Left - modified IV drip stand at home; Right - adik Aqil my doctor*

The Big Boss asked me why did I refuse admission, which I didn't because on Friday morning there was exactly no indication for admission (Friday night's condition was a good enough inditation though) - but so true, the worse patients to serve are the staff, simply because we know how it works.

I might as well sign an A.O.R anyway should I require admission, why should I be warded when the rest of the family is at home? Still the granted two days off at home was not that meaningful because all I did was sleeping and sleeping, all day long. And I miss a day out with friends who came around from Kelantan, as well as a friend's wedding. The least bit that made it worth it was that I managed to read almost five chapters of Harry Potter and The Deathly Hallows after feeling a bit better, after completing those IVD and tolerating orally.

The sad thing is, I am left with only 6 days off for another 3months in this posting, and that is only if it is permitted. Yes, for us H.O, MC is deducted. Counted in. Exactly why we bother so much about getting ones. Explains the reason why we still work despite having a one week suffering of unresolved fever, seeing those who came with a few hours fever without taking antipyretics.

The good thing is, now it reminds me how bad an IV line could torture your nerves, I will try to be more empathy as I used to once upon a time when I was a medical student.

EID MUBARAK

THE BIG BOSS

Some people missing in action in working time, is not a peculiar subject for me anymore. People coming in late for the ward rounds in the morning, or go back so early and leave the burden of the ward works to the others, also sounds so familiar. I can go on and put in complaints, and the list will be endless. Including things about my own self, like how I feel how slow I can be at times. But complaining alone won't achieve anything. Feedback like those in today's handovers is more likely to cause improvements, complaints won't.

I like my Big Boss, he is so far the most responsible H.O.D. I have met. He has this weird 'flight of ideas' speech when we were presenting cases or during the handover sessions, but he is very thoughtful and he does take good care of the staffs and the department; about things that should be in its right place. No one is allowed to come late. Which is good. I dislike punctuality too, even though I have always been rushing to work - but to my defense, that is only so that I arrive on time. I can list up ten reasons how coming in late for ward rounds will cause your punctual colleague to suffer. Of course, there are exceptions to being a few minutes late, but if it is a habit, it is something that hardly changes.

Back to the Big Boss. He knows what is going on in the department. Absconded staffs, nonfunctioning computer system that delay things, absconded patients, issues with other departments...etc. People who were missing in action and those staffs who weren't helpful were also warned today, so hopefully things will get easier and quicker for me. I love those nurses who were so helpful and not just bossing around, scolding doctors (read: housemen) because they have to do jobs. I love the former I would bake cakes for them. If I have the time and energy =)

Anyway, feedbacks like these, discussed in today's handovers are more likely to cause improvements, complaints won't. When I said feedback, I mean complaints made to and done by people who are able to do the changes for the better, and not just merely complaint to friends, who are at the lowest position like yours.

Attempt to get help from the supervisor was to no avail the last time, and even when we ran out of the lab forms yesterday, nothing very helpful was done about it. If the Big Boss is not in his current position right now, I wonder if adrenaline will always be enough in the emergency department.

Malaysia and good feedback system, is still a long way to go. The last time I put in suggestion in a suggestion box, a few weeks (or months) later, the box was gone. When my medical boss lodged an incident reporting to improve some systems, which I seconded, he got an incident reporting attack as if he was doing that out of arrogance.

Reminds me to how Newcastle University library answers NICELY to all the suggestions sent, oh how good the system is.

Same goes with the politics. But not going into that topic tonight, too tired I need some good sleep right now. And the conclusion is I like my Big Boss. Taraa...

OF ALL THE FEELING

I feel I lack that feel that I used to have
I don't exactly know how to describe it
Maybe one day I will be able to
But for now
It is just upsetting
I want my old self back
And the gratitude I used to show
I miss my old life
This working life is just.... not working
As how I wanted it to be
As how I imagined it to be
The soul feels empty
That surely needs a refill
And all traced back to the One

THE GREEN FEVER

I was working at green zone this morning, and most of the cases I have seen today were those with fever. Here goes some conversations:


SCENE 1

Me: Bakpe mari?
Patient: Demam doktor
Me: Bile start demam?
Patient: Bangun tidur tadi
Me: (glancing at the watch which showed 1030am) Ooo...baru 4jam laa lebih kurang?
Patient: Lebih kurang gitu aa
Me: Amik panadol doh ke?
Patient: Dok pon. Buleh ke gitu?
Me: ????


SCENE 2

Me: Mokcik, bakpe mari hari ni?
Patient: Demam doktor
Me: Ooo, berape hari doh?
Patient: Lima hari doh
Me: Lagi ade masalah lain ke?
Patient: Ade...batuk-batuk doktor
Me: Ooo, berape lame doh batuk?
Patient: Lame doh doktor
Me: Ye la, berape lame?
Patient: Lame sangat doh doktor
Me: Mokcik, (again, with all the patience) lame tu, berapa lame? Seminggu, sebulan, setahun?
Patient: (sengih) Lame doh, mokcik dok pindoh rumoh anok mokcik lagi mase tuh
Me: ?????? (and how on earth would she expect me to know when did she move to other house?)


SCENE 3

Me: Bakpe mari hari ni?
Patient: Rase pening aa doktor. Hawe2 nok demam ade gok. Tadi daroh saye tinggi
Me: Ooo...kad takdok lagi ni, doktahu lok tekanan daroh awok berape (assuming it was the BP he was talking about). Saya panggil je dulu sebab takut ramai lok beratur kekgi. Berape tekanan daroh awok td?
Patient: 146 gitu aa
Me: Hok atas ke bowoh?
Patient: Hok mule2
Me: Ooo dokla tinggi sangat
Patient: Tapi memang tinggi tadi doktor!
Me: Dakpe, kekgi sapa kad kite tengok

(after noted his diastolic BP was more than 90 for four times, and him having symptoms of hypertension with a high haematocrite and viral illness symptoms, he was advised for admission)

Me: Awok kene masuk ward ni, tekanan daroh memang tinggi, apstu kite takut denggi jugok
Patient: Hah? Dok payoh la doktor, saya rehat kat rumoh je laa. Doktor wi ubat je ke saya
Me: Doh awok siap kelabu mate lagi, tu tanda2 tekanan daroh tinggi. Dohla mude lagi dapat doh. Kene cek betul2 ni. Lagi daroh awok dok comel sgt, takut denggi. Ade due sebab doh ni saye nok suruh awok masuk ward
Patient: Dok payoh laa doktor. Bagi ubat je laa
Me: ??? (tadi die jugok yg beriye kate tekanan daroh tinggi, pening dok berenti)
Lucky he finally took the advice for admission, if not I myself would go hypertensive.


SCENE 4

Me: Ye dik, bakpe mari ari ni?
Patient: Sakit perut doktor
Me: Sakit kat mane...bla2
Patient: Sakit kat beloh ni...bla2
Me: Ade demam dok?
Patient: Semalam rase macam ye, tapi tadi misi kat depan tu kate saye takdok demam pon
Me: Tuh hok die cek, die dokleh rase awok demam ke dok. Awok sendiri rasa hawe2 demam dok, dik?
Patient: Doktau laa saye. Takdok la kot
Me: (susoh nguh ikut ke misi pulok doh)


How I wish history taking can be much easier...

THE CUTE TOM

This is not the exact reason why I am giving my thought to having an iPhone, more specific the iphone 4. Should I, or should I not?

But seriously, the Talking Tom is so cute and funny it made me laugh.

ps: I practically did part of a chest tube insertion today, I was only assisting, but did actually managed to put a finger on top of somebody's parietal pleura. How exciting is that? Just joking =) At least next time I will have to do it on my own, I have some ideas about it.

SHIFT VS ONCALL SYSTEM

For those who would like to know our working time as houseman, this posting will enlighten you in general of how it works. It might be different with different hospitals or postings.

I am working pm shift today. We have three shifts per day at casualty. Morning or AM shift starts at 0800 and finishes at 1530. Afternoon/evening or PM shift from 1530 to 2230 and night or ON shift from 2230 until 0800 next morning. But every weekdays' morning starts at 0730 with the handovers, and usually the morning people will start the shift at 0730 then.

In general , everyday we are entitled to work for at least one shift. There are days where we will be working double shift, which means we work in the AM and ON shift. And the next day, those who worked the night shift at the red or yellow zones MAY be entitled for a night off - meaning they don't have to go to work the next day, but those in green zone, still has to come for a PM shift the next day. This is how it works here.

Even if we have a night off, we will still be coming for CME (continuous medical education) presentations for our learning purposes on the night off day, and every weekdays, regardless of us in the PM shift, still has to come sharp at 0730 just for the handovers. I don't mind that seriously, as it forces me not to prolonged my sleep too much, like today (because it's a weekend, and hence no handovers). Plus, sometimes there are so much to learn at the handovers. The HOD (head of department) really likes to ask questions, and I think that is how I learn much. Even though most of the time, I was not even close to answering the questions.

I think I'd prefer the oncall system better, but maybe it won't work well in casualty because the patients are non-stop, and you will most likely be exhausted after the formal working hours. At least with double shifts, you get to go back for a while before continue with the night shift. But still, so tiring.

For those who had no idea how oncalls work in other departments, this is how it works - your working hours starts as usual from 8am to 5pm, but you come as early as 7am or earlier for your morning rounds. If you are not oncall, you go back after 5pm only if you finish your job that are not supposed to be burdened on the oncall people. Say you have too many jobs in the ward, you might only goback after 10pm. If you are oncall, then your oncall time starts at 5pm until 8am the next day. Then you continue working, until 5pm the next day, or later if too many tasks need to be done, as mentioned before.

Let me give you the example of one of my tiring schedules with the oncall system. It was when I was in medical posting, at times where the total medical housemen was 17 and we have four main wards to cover, not to mention the clinic and other periphery wards, also the H1N1 breakout at time. I had a few EOD (every other day) calls that month. I came to work at 645am, carried on with the sleepless night with the oncall, then I only went back at 1030pm the next day after the all sorts of procedure done. Then next day I came back at 645am for the morning rounds, and was oncall again, only to be back around 10pm the next day.

Dear my beloved Damia me niece who always keep mentioning that all I do at home is sleeping, if only you could understand this, you won't blame me for coming home and sleep for sleeping is the best rest, after the long working hours with those sleepless nights. In medical. But please note that, not all days were like this anyway, especially in different posting.

Anyway, back to casualty. Only the 4th and above poster housemen are allowed to enter the department, so we won't get any new freshies here. The total of housemen in the department is reducing. Therefore, holidays are out of questions these days. Both my brothers' family are coming home for the upcoming eid (raya haji), and no holidays are allowed during the days they are back here. Now, these are the days I resent becoming a doctor.

I just pray that I will manage to apply a straight four days off I need in December, as I have already paid such a big amount for something I have long wish done. I give you a clue:

But I wonder if I had enough stamina for the much awaited event.

THE LOST COURTESY

Today I was so upset and greatly reminded of the World of Courtesy ranking, produced by Reader's Digest four years ago. According to the ranking, which might not be accurate at all, Kuala Lumpur i.e. Malaysia is ranked the third least courteous country out of 35 cities of different countries included in the RD's global courtesy test.



A sudden regret fulfilled me for a while - I am not sure whether it was a regret of being a Malaysian, or being surrounded by majority of non courteous people where you cannot make a difference. Or a regret of not staying and work in the UK , and not even applied for a job there. Whatever it is, I feel guilty for having this regret, but it surely does bring back nice memories and life back in the UK, where everything seemed so easy and approachable. And the courtesy was at its most. I have been to most of the European countries and I think UK is still the best at courtesy.

Let me go through and see the differences:

In buildings with doors

UK
I was walking 5-10 steps behind someone before reaching to a double door, and that someone I never knew would turn back to see if anyone was at the back, smile and keep the door opened until I reached the door, that sometimes I had to walk really fast to not make them wait for too long.

Here
I was walking just behind someone's bum, even worse someone that I know who realised I was right behind them, and we were just about to enter a door with him/her right in front of me, and then....'bamm'. The door shut. Right in front of my face.


When you are in need a favour

UK
People would ask politely, with the nice "Do you mind....." or "can you help me with....." at the start and the magic word PLEASE at the end. Even when the favour asker was a specialist asking for some help from a medical student. And help is at your tip of finger, especially if the favour you are asking is totally the responsibility of the person you are asking the favour from.

Here
If you ask for a favour nicely, there is the slightest chance of you being entertained quickly and nicely. Even if sometimes it is supposed to be their job. Most of the time you have to ask them three times then either do it yourself or start shouting and complaining (then people will complain about you to the boss). Believe me, giving instructions, or telling people to do something with a raised voice gets the attention better. I have this one colleague who always give instructions instead of asking properly, and 'favour' done as instructed.

Hey, what is wrong with being courteous? Maybe they like instructions better.


At the workplace

UK
If a doctor needs to perform a procedure, a nurse will be around (we call them dirty nurse) so to help us keep sterile while they can get things for us. Even when I was a medical student, I get my own dirty nurse to insert a catheter.

Here
Me (in sterile condition needing another catheter of different size as I failed to insert two different sizes that I already prepared myself together with the catheterisation set) : Akak, boleh tak tolong amik CBD saiz 12 tak? Tolong eh kak, tengah sterile ni. Translate: Miss, can you please get me another size of catheter, size 12 please, I am currently steriled (shouting at 3am to the ***** who was gossiping at the counter, who were supposed to prepare the set after nicely being asked, twice.

***** (went to get the catheter that I asked for): Nah. Translate: Here you go (putting it on the trolley, without even bother to empty the sterile catheter into the sterile area, then went back to gossiping).

Don't I deserve a chaperone, even if you don't want to help me preapring the stuff or be my dirty nurse?

*ooops, I think this is a complaint already aye?

On the road

UK
I am not a good driver, but driving in the UK was way much easier. Imagine you were turning right at a T junction or you were changing lanes. Even if it was not too busy, they will flash their headlights to mean that "you go on. I will slow down for you".

After you give way to people, they will flash their headlight twice implying "thanks", and not enough with that, they will put up the hand, mumbling thanks, again to show their gratitude. And you will put your hand up, mumbling "you're welcome, glad to help".

Here
If somebody flashes the headlights, it means "It's my road. Don't you dare take over. I am speeding, can't you see?" I don't even dare to flash my lights to give way if I see someone is coming out of a junction I am turning into, just in case they misunderstand. So you see, there's no room to be courteous. You just cannot be humble on the road.

I was not in rush and let those from the front to pass first at the guard at entrance of my house, and I hardly get a hand showing thanks. Don't bother the lights.

And when I was grateful that people waited for me to pass the guard and put up my hand of gratitude, they just stared. Oh how I miss the courtesy of driving in the UK.


At the parking lots

UK
Disabled parking lots are really meant for the DISABLED. And the disabled people do come out and enjoy their life even if they have to use wheelchair to move. The buses are even properly designed for them so they can travel easier.

Here
SOOO many disabled people (parking for the disabled are always, always full), but I think most disabled people are usually stucked at their house and the only place they usually visit is the hospital.


And the ones below.... I cut and paste from Iris' blog, a good friend at the university, who is currently working in Selangor and just entered O&G department:

In encouraging labour
England
Midwife: Come on, push. Good girl. Push. You can do it. Push. You're doing very well. Just bear down. No, you're pushing the wrong way. Bear down. Push. Yes, gooood girl. You're doing reeeally well.
Here
MO: Push, push, push, push, PUSHHH. What are you doing? You're not pushing! You want the baby to die? If something wrong with the baby, it's on you. Push. Do you understand ar? How many times I must tell you?? EYYY, don't push to your face..see, flushed already.. haiya... DON'T LIFT UP YOUR BUTTOCKKKK!!

On the welfare of the juniors
England
During handovers amongs specialists and senior doctors, there are always cups of tea that you can have...with some biscuits..someone might bring their homemade cake to share. And I was only a medical student then. And the cups of tea flow endlessly. From 3rd year to final year. Made for you. By nurses.
Here
The Biggest Stitch: (On the suggestion to increase the number of beds for oncall house officers to sleep on) Actually I don't think housemen should sleep at all. It's good enough if you can sleep straight up in a chair. Or bring your own camping gear and camp in the parking lot. You think oncalls are for sleeping?? During my time............ etc.

Ego
England
When you gave the wrong answer to a pretty basic question:
Consultant: No, I don't think so. Try again.
Here
When you gave the right answer to a pretty basic question:
Specialist: [stare at you after your answer] Some more?
Me: Erm.. can't think anymore
Specialist: [to colleague] Read out your list of answers (prepared beforehand)
Colleagues: bla bla including the answer I gave earlier
Specialist: Why didn't you say that answer?
Me: I did!
Colleague: She did.
Others: Yeah. She did.
Specialist: No, I didn't hear it. Oh no, it's because I caught you cheating. You shouldn't be spoonfed. That's why I didn't count that answer.
Me: ????

*LOL on the labour room situation* She is in Selangor and exactly the same words are being used, I can imagine. Can you see, it is happening not only at my place, but also at other city. I bet if you go to the north, or south or West of Malaysia, in general, the situation would most likely be the same. Oh how encouraging we are!

I won't deny that I am also losing the courtesy, I wish I won't. And I blame the environment. Tell me, am I guilty for missing UK so much?