kenapa anak saya takut doktor? (based on real-life events)

Scenario 1:
I meet an old frend/relative with his/her cute kid. Kid starts coming to me arms outstretched to salam or mintak dukung. I stretch my arms too, ready to receive the incoming bundle of cuteness and affection.
Kid's mom/dad: "Adik, acik ni doktor tau. Adik takut doktor kan?"
Kid: *patah balik* tak jadi kawan
Me: Dengki la. Kau memang nak anak kau benci aku ke apa?
What really bugs me: *Dahle le kau panggil aku acik!*

Scenario 2 (this happens ALL the time, but I especially hate it when it happens when I am just about to examine a kid):
Kid's mom/dad: "Haa, cucuk dia doktor, cucuk dia ni. Dia nakal sangat!"
Kid: *looks at me with those big eyes, lips tremble, mouth opens and .. *CRYYYY (as loudly as a kid can cry)
There are multiple reactions to this one ..
Me: *Acute deafness*
or ..
Me: Olololo ..tak cucuk la.. *dan ayat2 pujuk seerti dengannya*
or ..
Me: Dengki la uols. Kan dah nangis. (mood still good, laugh with parents)
or ..
Me : Donkey la korang  #@**!!^&;^%$#! (mood out, temper in, what I really wanna say, but dont say la of course, dalam hati only)

tak menjawab soalan (based on real-life events) part 3

Q = Question asked by me.
A = Answer I get.. or rather did not get.

Sometimes it may be due to hearing (wrongly heard) and sometimes maybe because the questions are not specific enough.

Scenario 1
Q : Aku tak pernah jumpa lah si polan binti polan tu? Orangnya baik tak?
A : Oh, aku selalu jumpa dia. Orangnya ..badan besar-besar.
Q : ..erk.. so baik ke tak baik tu?

Scenario 2
Q : Anak you tengah demam ni, makan minum semua ok?
A : Ok doktor.
Q : Bagus. Jadi tak ada muntah2?
A: Muntah2 ada.
Q : Oh, ada muntah. Jadi minumnya cukup ke tak tu?
A : Minumnya kurang doktor. Makan pun sikit.
Q : Baiklah. Kencing berak semua ok?
A : Ok doktor.
Q : Tak ada cirit birit?
A : Cirit birit start pagi ni doktor.
Q : .... Anak you tak sihat ni dah ada bagi apa2 ubat?
A : Tak ada bagi ubat lagi doktor.
      Kecuali ubat demam.
Q : (doktor pun rasa cam nak demam mak oii)

discharge please

"Tak boleh discaj ke doktor? Doktor saja je kan nak tahan anak saya lama2 kat wad ni,"
"Cucuk sana cucuk sini. Doktor nak buat anak saya bahan ujikaji/eksperimen ke?"

These are comments that my colleagues and I are quite familiar with receiving.
My short and immediate response?

"Tak."

Honestly, as a paediatrician working in a busy government hospital, I definitely do NOT want my ward to be full with patients. I prefer to have zero admissions. If patients do need to be admitted, I will try my best to make sure that they don't have to stay more than they have to. In paediatrics, patients are babies, infants, toddlers, children. So lagi la orang kata "Kasihaaann. Budak kecik."
So yes, the less veins we need to prick, the less pain we need to inflict, the better.
Believe me, even though pricking patients for blood or IV cannulation will help junior doctors to master this skill, no house or medical officer ever groans at me when I tell them "no need to take blood" or "no need to insert IV line". Lagi diorang happy adala.
For us, the less work the better.

So why do we still admit patients to the ward? Why do we keep some of them longer in the ward compared to others? Why do we send multiple investigations, not just blood, but also, urine, stools, sputum and even the often "feared" spinal fluid sometimes?

Well, why are the children brought to the clinic/hospital in the first place?

Children don't bring themselves to the clinic/hospital.
I do not go to your house or look around town for ill children to take with me to hospital.
YOU bring them, you the parents and caregivers.
Because you are worried that something is not right with them. They may be sick. Ill. Unwell. Not their usual self. Have a toy stuck up their nose. Breathing funny. Whatever.
If they are okay, we reassure you and send you home. If they are unwell, but we think you can just treat them at home, we send you home. But if we think otherwise, we ask to admit the child.

Various reasons.
The child is too ill.
We don't know what's going on so we need to investigate.
We think we know a little bit but we need to make sure.
We do know what's going on, but the treatment needs to be given in the ward/hospital, not at home.

Why do we keep them long in the ward?
Various reasons as well.
The child is too ill.
The treatment needs to be given a long time.
The treatment is not working. We need to try another way/treatment.
We still do not know what's going on.

Definitely NOT because we like or saja-saja.
We may "try" different treatments, especially if one is not working, but we're definitely NOT doing "experiments" or treating your child as a lab rat. We may not have all the answers but we can't and won't just give up that easily.

In the end, we want the same things as you. For your child to get better, so we can discharge you.
Less patients in the ward/clinic, means less work for us.
We do like having less work.
Don't take it personally.
We assume when there is less work for us, there are also less sick children out there. And that's always good.

Ah. But there are people that say to me "But that's how you make money whaaat."

Again, I reiterate, I work in a government hospital.
Ada patient ka, tak ada patient ka, gaji aku sama whaaaaat.

it's okay to cry

In practicing medicine, doctors generally cringe at the term "breaking bad news". Bad news in medicine can either be finding out that you have an incurable disease, or that you can never have children of your own, or that you will never walk again, or that you or your loved one is dying, or finally, that your loved one is already dead.

Back when I just started in medicine, and was a jovial, enthusiastic young woman who was proud to be a doctor albeit totally naive of what was expected to come, I used to believe that it is not okay for a medical staff, especially a doctor, to cry in front of a family or a patient when you are breaking the bad news to them (or "informing DIL" as what is commonly used in Malaysian hospitals today).
I felt that it is okay to show a sad face, but not to the point of tearing up or crying. I felt that crying in front of them made me appear unprofessional, that instead of showing sympathy/empathy, I would be showing too much emotion, and probably a sign of weakness too. I was even proud to be able to do all of my "inform DIL" orders without shedding a tear all all through my housemanship and into the early years of being an MO. Until one day, and I remember this vividly, I was an MO in charge of NICU, and we had this one particular baby girl that died.
The baby had been critical for many days from a severe infection, and we already had to actively resuscitate and perform CPR on her multiple times.  I had repeatedly explained to the parents that their baby was really ill and that the next time we have to do a CPR again, we might not be able to revive her anymore, and that she might die at anytime; standard "informing DIL" stuff.
Every time I told them the news, the mother would sob and cry.
The father would repeatedly mutter "Yelah, baiklah doktor," hands on his wife's shoulders, his own eyes red.
The nurse sometimes too can be seen wiping off her tears as she stood behind the parents.
And I would stand there and look at them, pausing my explanation for a moment of respectful silence, solemn look on my face, eyes dry, and in my head thinking "ok don't you dare cry too emie. ok how long is this gonna take, I have other babies to see". For me, in order to dissociate myself from the atmosphere of engulfing sadness and tears, I turned the baby into another job task, just a checklist on my long list of work to-do list.
On the day that the baby finally died, the parents have not reached the hospital and by the time they arrived, we had pronounced the death and I was already writing up all the necessary paperwork. So I went to see the mother as she stood by her baby's body and was ready to explain to her what happened; how she had continued to deteriorate and how we tried to resuscitate her. Again, standard stuff, when the mother turned to me and actually smiled. I was a bit puzzled seeing her smile at that moment so all I ended up saying was "Takziah ye mak" (I'm sorry) and she nodded and actually said "Thank you doctor."
Before I could say anything else, she said "Saya nampak setiap hari, pagi petang siang malam, bagaimana doktor dan nurse menjaga anak saya dan anak2 orang lain dalam icu ni. Saya tahu doktor dan nurse2 semua bekerja keras untuk cuba pastikan anak saya dapat baik dan hidup lebih lama. . Tapi Tuhan lebih sayangkan dia. Saya harap doktor dan nurse2 semua jangan putus asa ye. Dan jangan sedih. Saya amat2 menghargai segala apa yang doktor dah cuba buat untuk anak saya ni. Saya redha dia pergi."
(I know how hard you and the nurses work all day and night to help by child and the other children in this icu. I know how all of you have tried to keep my child alive, but God loves her more. Please don't be discouraged and don' be sad. I am truly grateful for all that you have done for my baby. I accept her death.)
And for the first time ever in my medical career, I let my tears roll down my cheeks right there in front of the mother. I couldn't stop them even if I wanted to. And I didn't dare open my mouth to say anything for fear that all that would come out are loud ugly sobs.
It was like a huge slap on my face. I was not sad at the time but the mother thought I was. Because I could be sad, and perhaps should be too. Because of her unexpected gratitude and encouragement, in the wake of her baby's death, I was woken up instead. That in being a doctor, it wasn't JUST work that I'm doing, that it wasn't JUST a job. A patient is a human being. A patient is somebody's mother/father/daughter/son/sibling/spouse/friend. He/She is somebody's loved one. Even if you don't know the family or the friends or the loved ones. A patient who has been under your care, whom you have looked after, whom you have tried to treat, who was your responsibility, of course you can be sad too if they die. You don't need any permission.You don't have to suppress your sadness. You can definitely cry if you want to. You don't have to of course, but it's okay if you do. (Hopefully not to the point of the patient's family having to console you instead of you them, but you get what I mean.) There's no need to be ashamed.
Because doctors are humans too. And we all need to remember that.

tak menjawab soalan (based on real-life events part 2)

More ward round scenarios.

Scene 1
HO    : This baby is the one with the hypokalemia.
Pakar : What is the latest serum potassium level?
HO    : Err.. (flips the pages of the patient's file)..there is a half gram potassium in the drip, Doctor.
Pakar :  ?? (What'd I ask?)

Scene 2
Pakar  : (on the phone) Hello, can you tell me how many empty beds we have in the ward today?
HO      : Hello Doctor, yes lemme see..err..there are 26 patients right now in the ward, Doctor.
Pakar   : ?? (What'd I ask?)

Scene 3
Pakar   : How old is the baby today?
HO       : Err...He was born on 23rd Feb, Doctor.
Pakar    : ?? (What'd I ask?)

gosh i'm old..and fat..and old(based on real-life events part 1)

Okay, I've posted these scenarios before in facebook in a visual comic formal.
Just reposting them here mainly to keep this blog "alive", but also to practice translating them into writing.
HO = house officer/junior doctor
Pakar = specialist (in these scenarios all me)

Scene 1
HO                             : Mother is geriatric, this is her 10th baby..
Pakar                         :Geriatric?? How old is the mother?
HO (who is 25yo)     : 40yo, Doctor
Pakar (43yo, no kids): *cry*

Scene 2
HO    : Mother is obese..
Pakar: Obese? How big is the mother??
HO    : Well she's about your size, Doctor.
Pakar : *%^&**$#!*

Scene 3
HO   : We sent FBC, LFT, RFT, CRP, ABF, IEM, TORCHs, xray, urine..
Pakar: So many investigations!! Who ordered them?!
HO   : You did, Doctor.
Pakar: Oh, did I? *blush*

this is emie. she's a doctor.

there are different ways we get introduced to people.

it almost always start with your name, followed by maybe a little bit more information about you.

like, this is emie. she was my friend in college.

or she was my neighbour.

or she works in JB now.

or she's so and so's daughter/sister/cousin etc.

you get the picture.

a small polite conversation then usually follows this introduction.

but what happens after you get introduced to people and they mention your occupation instead?

like, this is emie, she's a doctor.

well, when you get introduced as a doctor, most times you get these raised, often questionable eyebrows first as a response.

at least i do. as if to say, really? she doesnt look like a doctor. 

or really? i thought she's a teacher (refer to another previous blog entry. this i take as flattery) .

or she sure isnt dressed like one. (this will make my aruah mama go i told you so. she told me so soooo many times).
or really? she's too cute to be a doctor. (okay, i made that one up).

then other questions usually follow. 

if you're a doctor, some people may ask you where you work, which hospital, is it a busy/nice place, even maybe which medical school you went to etc.

or some people will just straight up ask you a medical question, more often than not, pertaining to their own health or worries about a certain ailment that they have, rather than a general question like, how about that zika,huh?

itu okay lagi. you still try your best to answer their questions.

but it's a little awkward when this is at a funeral, or you're visiting someone ill at the hospital, and you get introduced to the person's relatives who are also visiting, like what happened to me recently. a friend's close one was critically ill and admitted to the icu, so i went to visit. the atmosphere was sombre, the person was on a ventilator, with tubes and wires running to and from his body, the machines were beeping. there was another relative there so i was introduced by my friend as emie, old friend. she's a doctor. the relative then proceeded to asking me what i initially thought was going to be with regards of the ill person that we were visiting. understandably. may be she's hoping i could help explain certain things further.

but no. she actually went on to tell me about how she was also hospitalized in the same hospital a few times already for multiple surgeries, the last one on her uterus, just last year. i just listened politely and nodded a few times, i see, i see.

she then went on to tell me she is still having some symptoms which she wasn’t sure if it was related to the surgery or the underlying condition that she had, or whether there is a new diagnosis or if it was all part of the aging process, and asked if i knew what they were.

errrrrrrkk…

so i said, well i'm not a gynae so maybe you can ask your gynae next time you see him/her. i looked over at my friend and saw that HE looked real apologetic.

seriously.

that's not the worst scenario though.

imagine a kenduri kawin. you are really hungry, and boy does that nasi minyak look yummy & inviting, let's quickly find a seat. a relative sees you and calls you to sit near him/her. you gladly walk over, that plate of warm nasi minyak + rendang daging + ayam masak merah also calling you to quickly grab a seat so you can quickly eat (hey that rhymes!)

another introduction of ini emie, anak so & so, dia doktor kanak-kanak by the relative to a pakcik you dont know and his family.

this pakcik you were introduced to then briefly looks at you, washes his hands (he was eating) and lifts up his shirt to show you that rash/mole/growth/something-that-looks-like-a-map-of-somewhere on his belly/chest/armpit (!), and asks you if you know what it was, he's had it for awhile now, so can it be cancer?

the nasi minyak suddenly turns cold and no longer look appetizing.

why i still haven't quit my job

i find work to be increasingly stressful and tiring recently. it isn't anything more than the ordinary of course, working as a doctor in a government hospital, it's all part of the job. but there are times when you feel really tired, both physically and mentally, to a point that, for me, i start to think about the possibility of quitting. this also isn't surprising or new, you can talk to any doctor, almost all if not everyone of us have thought of quitting more than once in our medical career. the worst for me was probably when i was doing my masters program. the pressure to perform well, pass your exams, finish your thesis, all while still providing service to the patients in the hospital and being oncall, at the same time trying to balance your personal needs and the needs of your family, was more than enough for you to think of quitting at a daily basis! it's definitely not as bad now, but from time to time, the feeling does creep up again.
so i decided to take a day off today just to unwind and "recharge" myself. i went to the bank, did a bit of groceries and some shopping and then went back home, cooked a bit and then started reading a new book-iban journey by golda mowe. by the way, i went to the bookstore just now only to buy a pen and a whatchamacallit the whiteout-liquid-paper-correction thingy, but of course i cant help from browsing the book section too, so i ended up paying about rm100 for 3 books, 3 pens and whatchamacallit the whiteout-liquid-paper-correction thingy,  . sigh. i really should have bought the pen at the grocery store.
anyway, suddenly there was a whatsapp message from the sister in my palliative care team, sharing with me a message she received from a patient of ours today. just yesterday, the patient came to the hospital for her cardiology clinic follow-up and went looking for me in the ward. she wanted to show me the tablet she got from the children's wish society (cws). she was referred to our team about one and a half year ago, because she has a congenital heart condition that is now worsening and is limiting her daily activities and eventually her lifespan too. she is a very shy and quiet girl and it took me quite an effort to get her to warm up to us, and some coaxing to get her to tell me if there was anything that she wished to have. in the end she wrote me a 2-lined letter stating that she would like a tablet.

so i referred her to the cws team who then got her the tablet she wished for just about a month ago. and so she came to the ward yesterday to show it to me, and then asked to take a photo together. and so we did, i chatted with her a bit and that was it.
who knew, after that she sent a message to the sister, sharing the photo that was taken, and inviting us to visit her at home for raya. but what blew me away was that she also said that she misses me and that she loves me like her own mother!

so what am i supposed to do, (other than cried like a baby) after reading that?

well i cant quit my job yet, that's for sure!

the death deal

all of us die. death is the only thing 100% guaranteed for us mortals.
i deal with death and tend to dying patients everyday as part of my job.
paediatric patients.
children. babies. newborns.
it isnt easy.
but as difficult as it is for me, it is more difficult for the parents and families of these children.

the expected "normal" life cycle for us start within our mothers' womb. we are born as somebody's son/daughter, and then we grow and become adults, as our parents grow older and see us becoming parents ourselves, and they get to be grandparents. and when the time comes, our parents die and leave us to continue the cycle.

but when the child dies before the parents, the life cycle gets disrupted. it creates a huge black hole in the parents' lives. there is not even a specific term designated for these parents whose children died before they do. unlike "orphans", "widows" or "widowers".
although life can and will continue on for most of these parents and families, for some of them the major event disrupts their life cycle so significantly that it just goes spiraling down from there.

i dont have children of my own.
i did have 3 pregnancies.
i had a ruptured ectopic last year that almost took my life, and i didnt even know i was pregnant at that time.the closest i had to almost feeling like an expectant mother was for the 2 weeks after finding out i was pregnant before the 2 miscarriages i had, most recently about 6 weeks ago.
even then i was quite emotionally affected, so i can only imagine how it is for the other mothers out there who carried their babies for 9 months, or have already held their babies in their arms, breastfeed them, watch them grow, worry for them, play with them, scold them, love them.. and then to watch their babies & children die.

i see and talk to these mothers and fathers before and after their child's death. and that's how i know how difficult it is. i try my best to help them get though it. there is nothing i can do to bring the children back, but i try and help the parents get back on track. not by making them forget. i actually help them to remember. many dont want to be reminded. it is normal to be sad. but you should hold on to the lovely memories of your child as a way to move on. you can never forget. those who think or say they can, have merely put aside the memories of their dead child in a tightly sealed vault inside their memory bank and sooner or later the vault will explode open, and that's when you get problems.

i'm not just talking about depression, anxiety, anger management issues, alcoholism or substance abuse. these things can happen to any of us who have lost our loved ones, not just parents who lost their children.
but when it comes to parents who have lost a child .. the explosion of the bottled up feelings (that vault i mentioned earlier) can happen when the mother gets pregnant with another child and may cause problems in that pregnancy. or soon after the new baby is born ie post-partum depression/anxiety. it's one thing not being able to stand hearing about other people getting a new baby or even the sights and sounds of other people's children laughing and playing.. but what about their own children. losing one child does not mean you are no longer a parent. many of these parents still have other living children.. neglect, if not actual physical abuse, may occur to their other children, often without the parents realizing it.

even though i have been dealing with death and dying children everyday as part of my job, it doesnt get any easier. it doesnt make me "immune" or "numb" as some people may think ("emie mesti dah tak heran tengok budak2 sakit ye..dah biasa tgk budak2 sakit ye.."). some of these parents initially say to me too " doktor tak paham, doktor apa tau.."
i would be a heartless superhuman if all that was true. or the opposite. a non-human.
in paediatric palliative care, even though we know that there is no more cure for their disease, that their lifespan is now made shorter, that they are dying, and we make sure that the parents understand this, our goal is to try and make these children live as much as they can for the time that they have with us. as my palliative team and i tend to these dying children and their families, we get to know them and become close to them too. and even if it's true, that when the children die, we may not be as badly affected as the parents themselves, there's no denying that we are still affected. for the brief time that we had with them, they became our children. at least that is how i feel. but i know most of the medical staff in my team feel the same. we have debriefing sessions for ourselves from time to time to help us deal with the sadness and emotional pressure. because we also need to remember. we also cant forget.

why i am a 25 year old doctor. or at least look like one. at least to the eyes of my darling patient.

this was a conversation on whatsapp between a patient of mine and a staff nurse on my palliative team. the patient's nickname is "baby" and she is 10 years old with  congenital heart disease. initially when she was referred to us, she was so shy and i had a real hard time getting her to talk to me. her condition was slowly deteriorating, and her mom revealed to me that baby was becoming very moody and was often angry towards her mom and her older sisters. in order to get her to talk to me and gain her trust, i asked baby to come up with any questions that she may have for me. they can be about anything. i promised that i will answer all her questions or will at least try and find the answers for her. when i saw her 2 days later, she had written 6 questions for me, 3 of which were actually about her mood swings and whether they were related to her heart disease. i was happy that i managed to get straight to what had concerned her mother and  me, and i addressed the questions and explained to her the best way i could. according to her mom when we followed up on her recently, baby's mood has been much better at home now, and i'd like to think that our little q&a session helped her with that, even if a bit. 
as for the other 3 questions, well surprisingly, they were all about me.
she asked what my full name is, whether i am married, and my age. when i told her my age, she didnt believe me, stating that i look younger, and i laughed (happily, of course! i know i know.. she's only 10, what does she know about how 40 year-olds are supposed to look like, but hey.. i'm taking it in. or rather-sucking it in. get it? haha). anyway, that was more than a month ago, and at the time it was only she, her mom and myself during that meeting because she was too shy to even let my nurse in. but the nurse continued to visit her everyday while she was in ward, and later even visited her at home after she was discharged, and they have been keeping touch via whatsapp. when i had to go on leave for 2 weeks after my recent miscarriage, we had to postpone her clinic appointment with me, and that's why she asked if i was well too during the whatsapp chat. it's so amazing that even though she herself is unwell (she doesnt even go to to school anymore because she tires easily) she still thinks about my health. here's to you, your health and your happiness, darling baby. God bless you, not just for being so naive and kind for saying i look 25 ;), but for being the sweet strong thoughtful you, as a reminder for the rest of us to love life and always be thankful.