Breaching professional limits ?

I seldom get very friendly with my patients, probably because they weren't sure if I were the buddy-buddy type. Most times I am not.

But Rz was a tad different. A 39-year old who came in for abdominal surgery, he speaks English like his mother tongue & with a sense of humour, too, both a rare coincidence these days. What clinched the deal was that he supports Arsenal as well.

Then the floodgates opened. He seemed a little cheery when I do my clinical rounds & we spent a good few minutes dissecting life in general. He seemed keen to cut down some weight (20kg, no less, I advised him!!) so I suggested to him to slow-hike up the neighbourhood hill. We parted on that optimistic mood.

I'll know if he's serious about the hill climb if I meet him on the slopes. Otherwise, all bets are off.

One good turn deserves another

As a follow-up to the Help!Help! post,  on the following day, it was I who needed help & it was the same colleague who provided assistance and advice during a critical event.

This patient developed a severe allergic reaction near the end of an operation, resulting in a drastic drop in blood pressure & oxygen content in the body. And because we took immediate measures to counter the reaction, the patient recovered without any ill effects.

This truly lent credence to the practice that two heads are better than one and that many hands make light work.

And I forget, no man is an island.

Help! Help!

I was called out of the OT by a nurse who said my colleague needed help in an adjacent OT. When I got over, he was furiously performing CPR & barking orders to the nurses. He told me the patient just had a cardiac arrest. After a few more life-saving injections, the patient miraculously came around - he actually opened his eyes & cough & spluttered.

My colleague thanked me although I didn't contribute much but I guess, sometines, one's mere presence is comfort enough.

And let us not grow weary of doing good, for in due season we will reap, if we do not give up. So then, as we have opportunity, let us do good for everyone. (Gal 6: 9,10)

Giving

The general perception of giving is that, by doing so, you actually lose something, with the exception of unsolicited advice, which people often give freely & generously.  :)  And conversely, that by receiving, you have gained something. 

Giving is integral in the fabric of the Hippocratic oath. What the unwritten understanding is that when a fellow physician seeks your professional service, you are duty-bound not to charge professional fees. Giving, remember?

Yesterday, I spent 6 hours in OT with a patient who is also a fellow doctor but whom I do not know personally or professionally. The surgery was labour intensive, and sometimes energy sapping. At the end of it, to conform with the spirit of professional courtesy, I do not expect any remuneration for this effort. It did feel unsettling initially, given the nature & duration of the surgery, but what did I actually lose? Nah....just exchanged 6 hours of my time for professional social responsibility, a notion I gradually warmed up to.

The good doctor (the patient, I meant :P) survived the surgery, so let's not sweat the small stuff.

final destination

If you have seen the movie, you'll be convinced you can't escape death. The movie makers & movie-goers alike must also believe it because there were another 4 sequels after that.

I have seen three of my late colleagues in the obituary page - one from a stroke, another from a delibitating disease & the 3rd from a ravaging cancer. Then I look at myself in context & wonder whether mine will be cut short like in the movie.

If my number had been up, it would have happened years ago.

When I was about 12, I tried to mimic a pole vaulter at the home garden. Strung a rope across & used a stick to jump over. Fell awkwardly facedown & felt excruciating pain over the whole abdomen. On hindsight, I could have ruptured the liver or spleen.

When I was 14, I opened the fridge at home during a thunderstorm & felt a sharp slap-like pain at the back of my calf. Was that a teeny-weeny electrocution?

When I was 27, before I could afford a car, I rode the motorbike to do part-time locum at a clinic along Jalan Jelutong, Penang. Many times, I had to stop in the middle of the road while waiting to turn right. If you live in Penang, you will know it's a very busy road & I had to depend on the goodwill of vehicles passing behind me to keep a safe distance.

When I was 29, while driving down from Penang to KL, I drifted off to the left of the main trunk road (before the NSE was opened) & as a reflex, turned the steering wheel excessively to the right & the car jumped up the kerb & veered sharply to the opposite lane. I lived to tell the tale because there was no oncoming traffic.

My personal belief, and I stress personal, is that my time is not yet up because in the grand scheme of things, there must be a role I still need to play, the reason for my very existence, as is for everyone else who is still alive.

It is my wish that all of us do whatever we can, while we still can, for the betterment of mankind.

Ten ten

Some one took the trouble to create such a day. I wouldn't have known about it had not someone posted on FB.

Not sure how to celebrate it, if at all. For me, all I want is for the patient to leave the operating room alive and healed.

That alone is reward enough.

Amen.

primum non nocere

that, in latin, means 1st, do no harm.

i've not always adhered to that principle - blame it on immaturity, anger, or just plain callousness. i recalled an incident very early in my training when the senior consultant of the department ( aka The Boss) hauled me into his office to give me a mouthful.

on that morning, i had a dispute with a consultant of another department over the management of a child. in anger, i walked out on the child, to whom i had just given some sedation. that consultant rightly complained to my Boss about what i just did (the argument & subsequent abandonment of the child) & that was just 1 of many reprimands for wrongdoing in my career. yeah, i was a serial offender - bad, bad doctor!

however, i learned valuable lessons that day....

1st, my patient becomes my responsibility, no matter what i had for breakfast, how miserable i felt or who i fought with. his well-being is my priority.

2nd, to err is human, to forgive is divine. my Boss censured me in the privacy of his office, thereby sparing me the humiliation of a public flogging. that, IMHO, constituted a pardon in itself, & till this day, i appreciated that magnanimous gesture. therefore, it was with much sadness when i read last year that he had passed away from cancer.

so, it's ok to be human - to resent, to antagonise, to show displeasure. were we not from the fallen beings of eden? paul has this valuable counsel:

"in your anger do not sin. do not let the sun go down while you are still angry, and do not give the devil a foothold." ephesians 4 : 26,27

** this post is a saved draft from 2007. I don't remember why I didn't post it then, but here it is...a reminder to myself that it's OK to start badly but must finish strong **

Double whammy

As if having an allergy is not enough, how about having an allergy to the medication used to treat the initial allergy??

40 year old woman admitted for nose surgery. In the OT, just before commencement, she developed an allergic reaction to the anti-vomiting injection. We treated the severe coughing and breathlessness with alternative medications, for fear of triggering another allergic reaction should the standard anti-allergic injection be used. The surgery was subsequently postponed for safety sake.

The allergic reaction subsided the next day & surgery proceeded with no further untoward incident, with administration of alternative anti-vomiting injection.

We really have no idea what we are allergic to until we develop it. Some  are mild, e.g. to prawns, while other maybe severe or even life-threatening, e.g. to peanuts. As doctors, we were taught how to treat it, but it is safest to avoid the offending food or medication, if we are aware of it. Patients should communicate these previous incidents to their doctors, too.

Saved by the ECG

33yr old male doctor admitted for nose surgery. Overweight 100kg with high cholesterol 8.7 (normal upper limit 5.2). No known medical problem.

On the operating table, it is routine to attach wires to patients for monitoring the heart & respiratory functions. This patient's ECG showed a bizarre pattern, even after adjustments were made to rule out artifacts.

When I asked him what his previous ECGs were like, he said he never had one done, understandably since he is only 33. so, I decided to postpone surgery till the cardiologist has given him the full workout.

In what I do, the patients who enters the OT alive should similarly emerge likewise.

I want to keep it that way.

**contrast this**

1st time on a plane

I was a houseman in the medical ward when this middle-aged Sarawakian gentleman, visiting Pesta Pulau Pinang with his family, suffered a massive heart attack. Although he made good recovery, he was apprehensive about returning home, so his family requested for a doctor to accompany. Guess who was given the free trip responsibility to transfer the patient home? Unrecorded leave, some more, yayy!

The journey (Penang-KL-Kucing-Sibu-Kapit) was largely uneventful. Truth be told, if anything should happen, there's not much besides CPR that I can offer but I suppose my presence was all that is required.

Reached Kapit after a nite in Sibu & a boat ride on the Rejang. Found out that the guy owned a coffee shop. Looking back, they really took care of me throughout the whole trip. Funny thing, I can't remember his name or his shop, but the name of the hotel he checked me into remained in the backburner all these years. Mahligai Kapit.....and I was treated like a king.

Thanks for the memory, Towkay.

Kapit, Jan 1985

PS. I met an old flame on the flight from Kucing to Sibu, but that's a story for another day. :P

Houseman

 16th July 1984

1st day as a houseman, posted to the Paediatrics ward at Penang Hospital. I must confessed that I was disappointed that I didn't get my 1st choice posting to Johor Baru Hosp. Having lived away for 5 years in med school, I thought I 'd rather enjoy staying at home for a change.

As it turned out, Penang was a game changer for me. Chance for me to live fully independent in a place I am not totally unfamiliar with. I spent a week here in 1975 for a national level chess tournament and another 2 weeks in 1983 for a community health survey as part of the medical curriculum.

So, what happened in the 4 years in Penang?

Earned my 1st paycheck, found out I can date Penang girls on a motorbike, owned my 1st car, started post-grad training, spent a memorable 08-08-88 with a few close buddies and met the girl I was to marry.

(And others events I can't mentioned without getting indecent. Heh, heh!)

A game changer.

Right time, right place.

It's often proclaimed that wherever we are, whatever we do, it's for a reason. Like if we had not gone there, then ...... or, If we hadn't done that, then...........

If you are religious, you'd feel it's even like a divine decree.

Last Wednesday, I was at such a place and time. My scheduled case didn't not take place & at 4pm, I was just walking pass the surgical ward, getting ready to change & go off.

I got an urgent call from that ward that one of the patients I had anaesthesied earlier that morning was having a convulsion & was not conscious.

I was by the bedside before you could say Code Blue. With the help of the nurses, we proceeded to do CPR. Although the heart momentarily stopped beating, we managed to restart it because  prompt action was instituted early, which is the essence of CPR anyway.

The stay in ICU was quite stormy, and we weren't sure if the patient has suffered brain damage because he remained unconscious for 2 days after that. But on the 3rd day, as we scheduled him for  CT scan of the brain, he suddenly opened his eyes & started to respond to instructions.

All I could say was Hallelujah. It felt like a religious decree that I was at that place at that time.

The patient was discharged very much alive from hospital today.

Falling below expectation

In a way, looking back, I felt I was indifferent at best & negligent at worst.

The nurse called me last night about a late admission. This patient was supposed to have surgery this afternoon & I would usually see & assess on the morning of the surgery. Not knowing any detail of this patient, I refrained from giving any medical advice over the phone, lest it was inappropriate. Besides, once I start getting involved, I know the nurses will call me for every discomfort the patient may complain of throughout the night.

Therein lies my predicament. I am a doctor and yet I want a good nite of uninterrupted sleep, because I am not on call.

At my age, I dislike, & try to avoid, on-call duties, because I am on my worst behaviour without sleep.

Cholangiocarcinoma

This is a malignant growth of the ducts that connect the liver and gallbladder to the small bowel. These ducts deliver bile to aid digestion of fatty food. Diagnosis is often late & the downward course is often rapid.

My colleague's brother had it & he just passed away today. This condition struck a resonant chord with me because the very 1st patient I had as a medical student in the surgical ward (circa 1982) was this cheerful and obese middle-aged gentleman who was admitted for jaundice.

Mah Hung was his name & how I can still remember that, I don't know  ...... maybe it was because he was my 1st surgical patient & I saw him every weekday till he finally passed away.

But I will never forget his kind words to me during one of our meetings. He advised me to work hard to be a good doctor and hoped that I will be a specialist one day.

Dear Uncle Mah, you are long gone but your kind wish did come true. I was touched then, just as I am today. Thanks for being my patient & my  teacher, for who you were, what you had & what you went through. May your soul rest in peace.