The MMA Pahang Second Annual Scientific Meeting: Handout

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Negative Psychology

Human... A very difficult subject to study. Half the time, I do not know what I am dealing with.

Having busy myself to prepare the upcoming scientific meeting in my area, makes me realized one thing. You need a lot of negative psychology to deal with people. The program was heavily sponsored, safe to say, participants pay only a quarter of the actual amount. Yet, the respond for the participation had been underwhelmed, with only a handful of early adopters, the rest were 'dragged' into the program. I spent 1 whole evening calling every possible places, all the nearby health clinics and hospital, even rang up the health centres in nearby university, just to plea for participants. However, the past conferences that I attended to, which we have to fork out between RM 400 to RM 800 each, it was a full house, and I was actually being rejected for admission to one of the conference held in Penang! Probably, when people pay, they will actually feels the pinch and think it is a very important thing instead!

Same with patients that I see day in and out. The healthcare cost is pretty much covered by taxpayers' money when one admitted to the ward or visits the clinics. However, a person I knew was diagnosed with lung malignancy. He refused treatment in general hospital for the sake that it is free and free means it is no good or second class. He rather fork out hard earned money to get chemotherapy in Singapore instead. Currently, he is in Beijing getting some novel 'cold' therapy for his cancer. Same as generic versus labeled medicine. I have a colleague who encountered this type of patient that we labelled as 'fussy'(not uncommon, certainly seen in daily practice). She was seen by other doctors for her diabetes and hypertension. First line medications were given to her and explanations made. However, she wasn't satisfied because she received the generic medications and made a big fuss to complaint if we do not change her medications to the box type that has fancy colours. Probably its a good idea that the generic pharmaceutical company made their medication in better packaging and interesting colours instead!

Human... When can I finish learning this subject? Probably never.

Sakit Jantung Is Not Heart Ache

Malaysia is a multiracial and diverse culture nation. So the language evolve considerably between ethnic. Explanation for medical jargon can be a very confusing business. For once I cannot understand what my specialist explanation to his patient while doing his round. Below are the examples:



English: Sir, you had a heart attack. Coronary angiogram showed 3 vessels block and you need coronary bypass operation done early.
Malay: Pakcik, kamu kena serangan jantung. Angiogram menunjukkan 3 salur darah sumbat. Pakcik perlu buat operation untuk bypass pada masa yang terdekat.
Chinese: Pakcik, lu punya paip dalam jantung ada sikit masalah. 3 paip sudah sumbat. Lu kena kasi operate itu jantung kasi buat itu bypass cepat-cepat.
Indian: Ane itu jam hati manyak mati. 3 itu jalan darah sudah block. Manyak susah. Kena bukak itu jantung kasi baiki itu jalan.
Aborigine: Pakcik jantung ada masalah. Kena potong, tau?



English: The risk for angiogram is contrast related renal impairment, risk of stroke and myocardial infarction
Malay: Risiko untuk buat angiogram termasuk masalah buah pinggang, strok, dan serangan jantung.
Chinese: Itu angiogram boleh buat lu punya pinggang losak, otak jam dan itu jantung losak juga
Indian: Itu jam u buat angiogram, boleh bikin itu buah pinggang ada masalah, itu otak boleh strok, dan itu jantung boleh block.
Aborigine: Pakcik jantung ada masalah. Kena angiogram, tau?



English: Sir, your heart function is worsening, please mind your fluid intake and take your medication regularly.
Malay: Pakcik, jantung pakcik sudah lemah, kena jaga-jaga minuman dan ingat makan ubat.
Chinese: Lu punya jantung sudah lemah. Itu air kena control betul-betul, ubat kena makan betul-betul
Indian: aiyo, itu hati manyak lemah. Itu air jangan kasi minum manyak-manyak. Itu ubat makan ikut itu jam. Jangan lupa-lupa
Aborigine: pakcik, jantung ada masalah. Kena makan ubat. Air ikut ini (hand pointing to the mineral water bottle)



There is more to learn in this life than medicine itself. Don't you agree?

Happy Valentine

  

Sorry sweetheart, 

I may not be the BEST person in your life, 

but I will be the ONLY person you need in this life.

Happy Valentine's.

Thirty and Wasted

This is a true story. 

This is a story of a boy. He is 30 years old, and paralyzed. A freak accident 6 years ago took away not only his limbs and his freedom, but also his dreams and his life. A boy that has plenty of future, ended up lying on bed more than 20 hours a day.

We pass urine without even break a sweat. He needs to self catheterized. "Or else I will have retained urine." He said. Passing motion is a automatic response. Moving around means a lot of work transferring himself to wheelchair and back, involving many helps and energy-consuming. He and caretakers resorted to the simple way out, that is not moving at all. He has a loving wife, staying beside him, answering to whatever his needs are and tend all his errands. Whenever he is admitted, she will stay beside him, like a shadow.

But he is not always a good boy, to start with. He has issues. He can't get over the fact that his life has changed. He did drugs. And he had complications from it. The heart fails as we witnessed that he has worsening oedema all over his body. He is breathless at rest. He is tired all the time. And he makes his wife suffers. The newly gained weight caused him more disability. As a result, there were multiple pressure sores over the buttock and the prominence of the hips. And it sure smells bad too.

With good medications and nursing care, we bring him out of the disaster.  His failure symptoms resolving. His infections under control. Proper rehabilitation goes a long way to restore his function and self esteem. Last I saw him, there is a shine in his eyes that were absent previously. The smile that he and his wife gave us tells us a lot.

This is not only Malaysian dilemma, I believe it is rampant all over the world. Illicit drug is a very serious problem, both in term of healthcare burden and social aspects. Most of the drugsters are of the young and so call productive group. The country lose out the brilliant assets when these people getting high in some dark alleys. They are prone for blood-borne illness, as well as creating sense of insecurities in the neighbourhood. Many ended up in correctional facilities or prison, some even to the hang rope. 

I don't despise these people. I felt sorry for them. I will try to help them, if it is within my ability. I don't deny that many treat them as a nuisance, a self-inflicted illness, 'high risk' for infection transmission case, and difficult vascular access case. But I sincerely hope it will change. It start from within your. Please...

MM Kills the Doctors

No. It is not Marilyn Monroe. And it is certainly not your M&M sweets (although some might argue that the high sugar content will cause harm). No, I am not talking about multiple myeloma either.

Its maternal mortality.

Just mention this term among your colleague, it will certainly bring chills to their spine. Some had nightmares of going through the painstaking process of being interrogated. Months of sleepless nights, loss of appetites, anhedonia, and suffers in term of performance at work. Some even loss their money and worse case scenario, losing jobs. 

I want to share a personal experience of my recent encounter with MM:

Mdm Z was a 24 years old expecting mother. She enjoys good health previously. She had a loving husband, and a caring family. This was her first pregnancy, and she had lots of hope for it. The first trimester of pregnancy passed through like a breeze.

During her second trimester, she had fever for a week. To cut short the stories, she was found to have infective endocarditis of the native valve. She was told of the problem and treatment commenced. As she was pregnant, many drugs were contraindicated, so the choice of antibiotics were limited. After about a week, she developed heart failure, probably because the infections cause valvular insufficiency. However, as of many Malaysian, they have predominating mindsets that alternative medicines works, and refused the trial-proven therapy. So the family brought a Shaman at midnight to her cubicle (without our prior consent), chanting spells for 2 hours, spraying water all over (nevertheless, causing massive rain inside ward and disturbed the other patients). You know what, the fetus died the next day!

Couple of days later, she delivered. Treatment was continued (and many 'I told you so, yet you don't want to listen'). Finally she was discharged well after weeks of antibiotics and planned for operative management in near future. Just a week after discharge,  patient condition deteriorated at home yet family refused to bring her to hospital. When we rang up to follow up her condition, that's when we knew she had met her maker.

Who's at fault?

Sooner or later, there will be inquiries regarding this maternal mortality case. We have to attend countless of meeting, fired with many questions and waste many time in between.

MM also created a culture of defensive medicine where managing team will priorities the non-emergent case over others to save themselves from this MM inquiries hassle. What do you think?

Your Friendly Neighbourhood

I was going through my copy of 2010 ACLS guidelines. Something strikes me...

This is only happening to the Chinese patients. I never see it occur else where.

Whenever a person falls very ill (or collapse), we as a natural instinct will start our resuscitation effort. Secure airway, Bag-valve mask, Initiating chest compression. Orders will fired across the poor chap. Adrenaline, IV access, Oxygen...


Then a head will poke inside the curtain. "How is the condition of this patient?" He ask. Seriously, I am not joking! He is the familiar face around the hospital when you work long enough. And he is not even related to the patient or the relatives!

I will usually ignore him.

Resuscitative effort carried on, Nurses getting grumpy, junior doctors getting fatigue, and I am also exhausted. Finally I terminate the resuscitation. Break the bad news. Family cries. Some howling, Some fainted. But he will snake around to me and ask, "What is the time of death?"

The man is an undertaker. Its his business to care for the afterlife, and its a good business, where every 'customer' average from RM 3000 onwards. Beneath what we see, there are few companies doing this and  these people are fighting with each other to get more customer. There are eyes and ears in the hospital looking for potentials, and last time I heard, they are the attendants and the nurses. Tips can go up as high as RM 200 (more than an on call pay for a doctor).

What I hope is that they respect the person that we are resuscitating, as well as the family. The privacy of the patient should not be breached. One should never be a busy body around the resuscitation. You may be the obstacle for the process. On top of that, they are harassing the family members with the 'packages' and the promotions of the day. Often, critical periods like this are usually the last moment a family can spent with their loved ones and prepared mentally for the worst.

Its a good business, but please do it with some sense of responsibility.

From Bad to Worse

Medicine is a highly regarded field. The stakes are high. The demand is always overwhelming. When they tell you there is surplus of doctors, they are actually talking BS, at least in Malaysian context. This created a demand for youngsters to go into medical field. Many parent send their children to medical schools, be it local or abroad, self sponsored or scholar shipped. Many graduated. Some are knowledgeable and willing to endure the workloads. Handful are not very intelligent, but able to carry out the job. Yet a small portion are neither having the marble nor the right attitude for the task awaits.

Sometimes, I encountered a few special cases that worth mention:

The Troll

This type of people are born with a very thick skull bone. They cannot follow orders. If I give them plans of management, they will not give me results. If there are 10 plans, probably 1 or 2 were carried out. Sometimes poor time management are to be blamed.

The Escapism

These people usually less equipped. When given the task beyond their capability, they are at lost. They would not know what to do. The solution is to run away from the trouble. There are also a mixture of laziness in these people. They refused to learn up new knowledge and skills, despite how much I try to guide them.

The Fierce

Conflict of ideas are common when you are dealing with matters. Some when confronted, will over react and snapped back immediately. They take every comment as a negative thing. Some forgets their position as a junior staff. Some just forget how to respect other people. Some don't have manners.

The Fart-and-go

At times, I met some junior doctors that always looking at their watch whenever they do round with me. When given a job to do, they do it half-heartedly. The case summaries needed to be summarize again. The referral letter most of the time are plain useless. In the end, the ministry decided that these people are not up to the task of doing these things and the medical officers have to take over.


Despite all this, now they are cutting down the working hours for junior officers to 60 hours. I sincerely hope these doctors can absorb the needed knowledge or skills. It is also my duty to guide the young doctors so to make them a better person. Well, I will always teach whoever that wanted to learn.