Semporna.... The update

Today is my birthday and I am in Semporna. Many of you would be thinking "what the heck is she doing writing her blog when she should be out there diving?" .. Exactly my sentiments but then I caught a cold yesterday... and now I am recuperating.

Hopefully, tomorrow I will be better can can join the gang to Mabul. Today's plan was Pulau Sibuan. I have never been there so it is quite a dissapointment!

I have been here since last week. Merman joined me for the trip here last Saturday and we went diving on Sunday... Mabul and Kapalai. Apparently the permits for Sipadan is all out! He left on Monday and I started my two week dive medice course. It is called 'International Dive Medical Officer' (IDMO) Course. It teaches doctors about the not so well known field of diving medicine, illnesses related to it and also how to determine if a person is certified to dive. It is definately an eye-opener. We were never taught this in medical school. And what the intructors, the Dive Industry tell the public is definately skewed!

I have known this (logically) but a lot of people argue that it is not true. DIVING IS A DENGEROUS SPORT!!!! It has a mortality of about 17 percent in 100 000 per year. It doesn't mean I will stop diving but generally it tells us that we have to take precautions when diving and to promote safe diving. Reckless behaviour is not acceptable! Hahaha.... half of the divers I know are idiots, gung-ho asses who if I tell them this would go into an arguement on how I am wrong.

Well, that is not my mission. I am attending this course because I dive a lot and the ones I love also dive a lot. Not a lot of doctors have the knowledge and I plan to equip myself to keep my family, friends and myself safe.

I hope I can dive tomorrow.... I am off to bed now (it is 1 pm and outside is so damn hot!)

p.s. I will post photos of Semporna when I get back. The pc is full of viruses!

Dying wish

"What ever they do, please do not allow them to cut my leg"

That is a dying man's wish. He has been suffering for the past 3 weeks that started with a wound over his heel. Initially he brushed it off, "ah...it will heal by itself" but then gradually it got worse,; painful, foul smelling and discharging pus. He was too scared to go to the hospital, he has heard so much about the doctors there; the fearsome ones, the ones so happy to chop off people's legs.

For the past 5 years he had suffered from diabetes, he has not been taking his medications regularly. He figured, he should not be dependent on drugs; so if he felt weak he'll take a tablet or two but usually he felt fine. "Ah, the doctor must be mistaken, I am not like any other patients, I am not sick,"; that was what he had told himself over the years. And not only that, when it comes to eating he ate like there was no tomorrow.

As the years gone by his health slowly turned bad. His sight was not as good as before, the ophthalmologist told him that he had retinopathy, complications of the long standing chemical abuse of his body. The sugars have caused all this. And about 6 months ago his physician warned him, without proper diet and medications his kidneys may soon shutdown and he would require regular dialysis.

With all this warning signs he still continued as he wishes. His wife and children tried to help him adhere to the no sugar diet but then he gets absolutely pissed off and angry with them. To him, they are becoming an agent of the doctors to stop him from enjoying what is good in life.

Back the present day, his leg do not seemed so good. It has become more smelly and he can see the patchy bluish discoloration of the skin. And, the pain is unbearable. He has not been able to sleep the past three nights.

His wife is so worried. He is not well, very not well. She sees the change in him. He is so weak and at times, she felt he is not coherent. His fever has been persistent this past two days and his appetite is poor. She tried coaxing him to go to the hospital but he has been adamant. But today, finally, he agreed. She guessed that the pain is now so unbearable.

She took him to the ER. The medical assistant took his pressure and temperature. Immediately he was whisked into the Red Zone, the critical zone. Then what she saw was a flurry of movements. He was rested on the trolley, a doctor came and aked a brief summary of events, his medical illness....ah she can't remember. Blood was taken from his left arm and then after a few minutes lines were dangling from his arms.

Another doctor came, he looked more senior and respectful; he had this worried look on his face. The doctor summoned the wife and explained to her and the patient that he has gas gangrene of the leg. He explained that the infection is very severe and that it is causing 'blood poisoning' or sepsis. Without prompt and proper care he may die. The doctors will do the best for him but they need to sort out and eradicate the source of infection.

He heard the dreaded words coming out of the doctor's mouth, "sir, we have to amputate your leg to save your life". He felt his world spinning, he should not have come. Bravely he said no. Not in a million years, and not if his life depended on it.

She was standing by his side when the frenzy of movements around them started. The nurses and doctors asked her to step aside. More fluids and drugs are being pumped into him. He looked more dazed. Someone came by and told her that his pressure is very weak, it is due to the overwheming sepsis. The doctors need to support his body, they need to put him on a ventilator while the infection is being sorted out. He was then wheeled to the ICU.

She had to wait outside, it was a long wait. She prayed and prayed. Hopefully he will be all right. After half an hour an aide called her to inside the ICU. She was escorted to his bedside. There he laid, a tube sticking out his mouth connected to a machine. He was asleep.

The doctors came and talked to her. Explained that his life is in a precarious position. He may die. They are going to do their best to support his bodily functions, to stabilise him. However, once he is stable they need to remove the source of the infection; without surgery, without amputation, they fear that they can't do anything much to save his life.

Now since he can't make the decision and consent to the surgery she has to. She has to make the decision. But then, how much she loves him, how much she fears losing him she still remembers what he said. His wish. His wish to be whole, and life and in death. Painfully she decides, no!

As his wife, she is the guardian of his wish of his will. And painfully she watches him slip away.

In the physician we trust

The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease. ~Thomas Edison

A doctor in the family is not necessarily a good thing. It may or not be good for the family but definitely not good for the doctor. A lot of people take it for granted that once they have a relative as a physician they can do whatever they want. The physician will in the end take care of the ailing health of the relative. Usually, they (the relative) are not interested in prevention nor taking care of themselves.

My encounters of such has been quite minimal but there are a few. Many of my fellow colleagues suffer from 'relativitis', a not so new disease inflicted only on doctors by the family members and is mainly infested by severe headache, unnecessary worry and feeling of self-worthlessness.

Take for example myself, my auntie's husband (therefore my uncle by marriage) was a young diabetes. They were married when I was 14, my auntie 24 and uncle was 28. So I basically grew up being close to both of them. Fast forward a few years, I was in medical school and being more aware of medical illness I realise that the family was not in a healthy condition. My auntie being a great cook, was obsessed with feeding all of us, it was how she shows her love. It wouldn't have mattered much if they were also active but being a typical 'nerd' my uncle doesn't exercise nor do much heavy work. At that point, my advice did not matter as I was only a 'medic student'.

By the time I graduate, my interest in diabetic care grew as well as my love for orthpaedics. It's an interest out of frustration on how poorly Malaysian in general precieve diabetes. They always think that by taking medicine they are free to abuse their body and binge on what ever they desire. And when they come to the Orthopaedic ward they are usually in sepsis with fulminating infection of the limbs that we have no choice but to amputate the diseased limb in order to safe their lives.

Back to my family, at this point, uncle has had diabetes for nearly 12 years. The lifestyle had no improvement nor did the diet. I sat one day to have a heart to heart talk with both of them. I told that dietary control is more important plus quitting smoking and the need to exercise. I also told that with a young family he needs to take care of his health - renal failure, eye complications, neurological complications and lastly what I do the best, amputations are real risks. It went like... "yeah, yeah.... I know... don't worry, I am taking care of myself... nowadays I only take 'teh tarik kurang manis"... Uh duh?? Got me so riled up but I decided to leave things alone. I guess since they know me as a kid, I have no right to give any advice.

A year after that he was so ill that they came to see me in the hospital. He has sepsis and uncontrolled sugar level (this was way high). I admitted him to the medical ward (3rd class ward) and I gave him along lecture in 'I told you so'. His eyes and kidneys already showed some impairment. And all his stupid relatives could see was..."hey, why is he admitted to the 3rd class ward?". Still after this incident, he was unrepented and continued his 'wayward' ways. Well, both of them. And everytime I came and visit them I can only shrug my shoulders and let it be. The worse thing is, they'll ask me "Eh ok kan???....memang banyak lemak tapi uncle makan sikit aje..boleh kan???"

But the highlights of it was when we went for a fishing trip in I think was Sabak Bernam. Met somewhere at a the highway, I noticed that his face was skewed. When I inquired, apparently it occured overnight. It seemed like a stroke to me as he also had difficulty in walking. Although I inststed I was right they decided to go ahead fishing at some river and being worried I tagged along. However, as the hours passed he got weaker and weaker. I was very worried but he was as stubborn as a mule.Finally, his own uncle (who is a contractor and businessman) told him " Ekau ado angin ahmar".. and they believed what he said.....and all this while what was I saying....another Uh duh??? I guess apart from being a contractor he was also a part-time bomoh and thus is more revered and trusted than a medically trained doctor.

That was the starting of the end, my uncle had abused his body till he went into end stage renal failure (ESRF), severe retinopathy and thus vision is impaired and has numerous other complications. The ESRF was a jolt into reality but then it is too late. Now he requires thrice weekly dialysis and that is such a hassle and a lifestyle change.

As a niece, I went a did my duty. Arranged all the medical treatment, got my friends to look after him and advise the various aspects of his illness but I kept my distance in taking any part. I cannot be compassionate anymore and furthermore, I would not be taken seriously so why bother.

This is just one chapter in a few family stories but then the gist is the same. Never treat your close family nor friends. They are just using you to justify their illness and actions. 'Relativitis' and 'Friendititis' are real and makes you wonder why did you ever want to be a doctor.

How do you decide??

Life as a doctor is pretty mundane...Day in day out you will do almost the same thing, rounds at 8am, clinic at 10...blah..blah..blah But there are occasions like this past week where it has been an adrenaline rush. It is meant not in a good way. As I mentioned earlier, there has been an exodus of patients to the ER over this week... and this is not yet Raya. But what I am rambling about is not on how busy it will be etc etc etc....

I have been practicing medicine for the past 8 years.... but one thing I have never gotten the hang off is how make the decision whether to go for active resuscitation of a patient or not. Tonight I have been ask to make that call. A new admission who is elderly and has multiple medical problems was admitted with gas gangrane (a potentially fatal infection) of the leg. She has been bedridden for months and is taken care of by the daughter. Anyway, her pressure crashed tonight as she was in sepsis. My medical officer after resuscitating her called me to make the decision for active resuscitation or not.

Ah, I was in two minds. First and foremost I have no idea of the patient and her social support and thus can I make the decision there and then. I asked for active resuscitation but went myself to asses the situation. There lie a frail looking lady gasping for air.

Ah...shit.... next running through my mind is her quality of life.... can I ever improve it? Should I prolong her life in this current vegetative state? But then who am I to make the decision? Is the family accepting her very ill condition? Things like cost and quality of life is something hard for me to quantitate. 8 years never got me comfortable in making that decision. If I know the patient longer perhaps I wouldn't hesitate but this lady is 'new' to me.

We sent her to ICU. There I met her daughter who was crying away. I saw the old lady in the ICU.... we intubated her. Now I feel guilty, I should have the guts to say NO. I am making her miserable, but how can I let go. Ah I don't know, I don't know, I don't know...

And now at 1.30 I cannot sleep... I have done her wrong. If I was in her shoes I would want people to let me go and die in peace.... Ah......Life is depressing...

To comfort always

"To cure sometimes, to relieve often, to comfort always."

Hippocrates