Flux

I've been using this word to describe my life at the moment. I like the picture that conjures up in my mind of coloured dyes mixing in a liquid medium, or watching the continuous fragrant wisp of smoke that rises from a burning incense stick. Suddenly glimpsing the state of molecules as they really are - moving, twisting, dancing to an invisible momentum.

It's kind of not a good thing, or a bad thing. My ego grasps and the habitual anxiety ensues, and then after a while I wonder, why? Voices talk over each other in my head: "I need to know!" "But why do you need to know?" "Everything in its own time." "Are you sure?" I can't decide, and give in.

Sometimes I think about what I do in a day, and shake my head. Sitting on my couch now in the new rental with a wonderful view, I can't decide whether to count my blessings, or to somehow make changes to my life. An emotional day it had been today, and it comes back to the final of a series of conversations with one of my patients at the very beginning of the day. Sometimes small events like that just sets the tone for the whole day.

It was meant to be a bit of a chat to convince the patient to go home, even though we have brought him into hospital for a week to investigate a new cancer that was found. An elderly man, living alone, drinks out of boredom, and physically separated from his daughters.

The previous days I had urged him to tell his daughters of the diagnosis on the telephone, even though we don't know what the prognosis holds out for him in the future, and whether any treatments the specialists offer would help him or make him feel more ill than he does now. I'd been the bystander in the conversations that my seniors had had with him. They talk about what they can do, what they can offer.

But he is a smart and rational man. He askes the important things: how much longer will I have? will I feel more sick? if we can't cure it then what if it comes back again in six months and we have to go through the whole thing again? He goes on further, he says life isn't great, and he knows his body is failing. He is not a stranger to the hospitals and hears a great deal of stories and experiences from his fellow room mates.

My seniors side-step the questions. They talk again about what the specialists can offer potentially, holding out false hope. The patient turns to me and says, what do you think, doctor? I answer diplomatically, "I think you should make the choice that would give you the best quality of life." He hears me and relents. We shift focus onto the minor details to help him manage better at home, before the specialist appointment in a week's time.

Today he asks me the same questions. I tell him honestly I have no answers. He sighs a little, and says I seem to be the only one who understands where he's coming from. I nod, silently cursing the hypocrisy of professionalism and the provision of false hope. He goes on to tell me he will go home, wash his sheets and buy apple pie from the supermarket, with lots of cream, and bless his cotton socks, asks for my permission to drink a couple of light beers. I agree, and he says, alright I will go home, but I'm better looked after here. I nod, sigh and give the same old poor excuse of an imperfect public health system in an imperfect world.

I have learnt to be candid with my patients. Afterall, they are real people with real problems, and it easily gets drowned out. Sometimes, the reality is cruel. And sometimes, I don't know if my pessimism should serve me better or worse as a clinician, or as a human being.

Back at the Orifice

This is it. The time I've been simultaneously dreading and anticipating - I'm back at the emergency department, orifice of the hospital.

Second time round, the perspective is different. I have a bit less fear on board and begin to see sicker patients, and spend less time on the well patients who don't need to be there in the first place. Bosses call me by name, and I bager my seniors for advice when I am uncertain of what to do next. I enjoy the variety of problems more, and try when I can to listen and communicate with the patient.

I recall my first shift back. A woman in her forties is working herself hysterical with a pain in her belly, whilst the nurses look on with obvious distaste. I approach her and she starts unloads the story about her chronic abdominal pain with spurts of tears and cries, seen and rejected by many specialists with no solution or answer. I place my hand on her body, and just listen for what seemed like a long time, but maybe only ten minutes. For some odd reason I don't give her any pain medications and just encouraged her to breath deeply.

She eventually calms enough for me to do an examination. I wanted to test if her appendix was inflammed, and pulled her leg backwards to stretch out her psoas muscle. To both our surprise, her pain lessened, and I stayed there, holding and stretching her psoas. Then the nurse came in, and gave her an injection. I then worked with the theme and taught her how to stretch other muscles to lessen the tension in the area.

I am no physiotherapist, but I did spend a few years in body-based therapy, and in that moment, it clicked, courtesy of this woman, how it may be to integrate my diverse learning into clinical practice. Her pain, as seen by the nurse, is not a true pain, therefore not deserving of quick alleviation with pain relief. Her pain, as seen by me, had a heavy emotional element, courtesy of my O&G exposure that taught me about a lot about hysteria.

Her pain had not disappeared completely, or even halved, by the time she left the department. But her relationship to it had changed significantly. She became curious to this interpretation of her muscle spasms causing further spiralling of pain, and with stretching exercises she was once again in control rather than the other way round. Her eyes were bright when she thanked me, and I felt glad. Glad that she did not need further medications, glad that she was less likely to return to us for pain management, glad that my contributions made a difference, even for a brief moment, and glad that my journey in the therapies did not go to waste.

After that day, I feel increasingly confident about being a GP. I am happy with small successes like suturing a man's big toe back to a semblance of normal anatomy after partial amputation by a fridge, lancing and expressing pus from a child's blistered wound, and applying plaster casts on broken arms and legs.

There are also not so satisfactory days where there are unwell elderly people with a multitude of problems that I can't piece together, or yesterday, twisting my back in awkward positions inside the ambulance trying to replace IV access and doing an ECG on a patient transferred from a smaller hospital with a heart attack. Indeed, as my wise medico neighbour said, when we are treating heart attacks in the hospital car park, something is definitely not right.

In the Realm of Hysteria VI

Time for departure.

Leaving O&G gives me mixed feelings. The doctors in the department are lovely, and I've grown to like and enjoy them as individuals, just as they take the effort to get to know each of us transient juniors in the brief time that we're there. Even throwing us a special 'chicken wings and blue-cheese sauce' night as a send-off. (However my meal of wedges and blue cheese sauce woke me in the middle of the night with a complaining gallbladder).

I didn't think we were that wonderful in our clinical performance, but perhaps just by not creating more work, it was sufficient to qualify for excellence. I've always thought that was the bare minimum, being plagued by low confidence, that is, until I met the new cohort of interns. Were we really so naive and clueless only 12 months ago?

I find it perplexing, and a shift away from the usual self-absorbed anxiety during internship. Somehow, my perspective has changed. I start to be asked by unfamiliar nursing staff if I were the registrar (specialty trainee), receive friendly greetings from consultants and engage in interested conversations about my career path.

The work itself, I would safely say I'd never be an O&G specialist. I may come back in a few years and do a professional development year as part of an advanced skill of a rural GP. But that's definitely not top on my priorities. I'd much rather learn how to anaesthetise someone for operations, or manage chronic pain or terminal illness.

O&G brings to the fore too many realities about life and death. About how a person takes on essentially a parasitic life form in the depth of their being, and morphs their body chemistry, physiology and physical properties dramatically. There are no promises for a safe passage, little prediction, and a lot of the time we just make do with what we have in any given situation. Maybe that's why O&G specialists are kinder than the surgeons, and more open than the medics.

I am also surprised that despite the knowledge and experience, O&G doctors still fall pregnant and bear children. But then again I am also surprised that people can continue to eat meat after anatomy dissection classes. Maybe that's how we survive psychologically, with our blinkers on.

I've never been good at farewells, but then again that's life. Once we know there is an endpoint, mabye it becomes easier to appreciate what we have the present.

In the Realm of Hysteria V

So it seems, I've almost made it to the end of ten weeks. And grown a new skin in tolerating blood and gore. "You haven't seen bleeding until you've seen obstetric bleeding" a young aspiring O&G doc shares her insight after being in the thick of it for almost a year.

Nowadays, I automatically tackfully step out of the way of the spray of amniotic fluid and blood at Caesarean sections and don my glasses at work, just for a bit of protection (though not particularly evidence-based).

I stand behind the sterile-gowned midwife, and wait with abated breath until the baby emerges, head first, then one arm after the other, then in one big fell swoop the rest of the body and thick cord, out of a gaping red hole in the abdomen. I wait for the first cry to pierce the cold theatre atmosphere, lying there between the mother's numb and sterile draped legs, waiting for the cord to be clamped and cut.

We bring the baby to the prepared resusitator, and relax into the calm of expectant space whilst wiping off the slippery stickiness of amionic fluid and waxy white curds of vernix from the newborn's skin, under the warmth of its heat lamp. I silently greet and welcome this little one into this imperfect world. I think with a light sigh, now that you're here, may you be well and happy.

We go through the motions of counting heart rate, deciding on Apgar scores (initial assessment of baby's general wellbeing), giving vitamin k injections, and wrap baby tightly in layers of cloth and towels into a well padded parcel for mum and dad to hold and behold until the surgery is complete. By this point, the new creature often tries to open his or her eyes in the bright new unpleasant environment, and gazing into its rheumy depth, I realise I am the first person to be seen in the life of this new little person.

The midwife and I examine the placenta, its heavy heady smell of blood, a meaty plate of solid tissue, not unlike the surface of a cauliflower, the thin translucent membranes, and the calamari-like finger-thick umbilical cord that once sustained the baby's not unparasitic existence inside the mother's body.

I go on to helping the midwife weigh and record the baby's length and head circumference and putting on a nappy for good measure. Having observed the baby for fifteen to twenty minutes by then, I am satisfied and take leave to return to the chores of the ward.

Occasionally I am taken aback, surprised by the strength of the baby's grasp on my forearm, fighting my efforts to dry and wrap him. I find myself having thoughts I read in the Red Tent, like a midwife from a time and land faraway, acknowledging his strength and vigor, and foretelling a life to be lived on the salt of the earth.

I think about the pure joy I saw emanating from a week-old infant, over the shoulder of the passerby mother. An infectious feeling, you can't help but smile back in response. I think about Thich Nhat Hanh's description of a pureland, a place where you can't help but be joyful, because every being there beams it, and you are struck by brilliant beams of light everywhere, until you, too, are full of light.

In the Realm of Hysteria IV

After surviving a mind-numbing weekend full of post-delivery "mum checks" - those repeated enquiries about bowels movements, pain, bleeding and contraceptive choice - it was with a sigh of relief that I returned to an afterhours floating shift following the directions of a more senior doc in confronting what comes through the door in any moment.

"They almost always throw up..."

We were scrubbed in, doing an emergency Caesearean section on a young indigenous woman obstructed in labour. The woman is awake with an epidural in her back, and she had told me with a fresh open face earlier whilst I held onto her hands during the epidural insertion that she already has three sons, one in her brother's care and two at home. She smiles shyly with liquid brown eyes and tells me she hoped this would be a girl, and that having a Caesearean was a new experience for her.

Her labour had progressed unexpectedly slow, especially for someone whose uterus was well trained in delivering babies, and the decision was made to proceed to a C-section because the tracing of the baby's heart rate was beginning to show signs of distress.

I played first assistant to the friendly senior doctor, and we were going well until she began to frown and remarked: "This is a really thick lower segment (of uterus)..." and asked for the more senior O&G trainee (scrubbed and sitting in the background) to step in. The next few moments saw him take hold of scissors, snipping away at the sides of the thick, pregnant uterus, adjacent to the yet-unborn baby's face, in order to make more room. And then with both gloved hands he reached in deep within the uterus.

I've always cringed at this part of the ordeal. Guts and gore I can generally tolerate, but fishing slightly (normally) blue looking babies out of a small hole in an internal organ, with the various twists and angles to assist in maneuvering its exit, is another matter altogether.

Somehow, the baby's head was stuck and not without difficulty and a lot of force for what seemed like frozen moments in time, the head was finally disimpacted and delivered, and the rest of the body slurped out of the uterus, as if nothing had ever happened. I had the honours of cutting the umbilical cord, relieved that the baby was safe, for now.

That was the cue for the anaesthetist, who gave the uterus-contracting medication, an intervention that has saved the lives of many women from the Grim Reaper's post-partum haemorrhage, a phenomenon that claimed numerous lives throughout history. Next the cauliflower-like placenta was delivered, uneventfully.

"...when the uterus comes out."

The senior doc swiftly dug his hands again deep inside the woman's body, and brought out with him, the now contracted down uterus which he placed on top of her abdomen. Fully one-inch thick in each wall, the strongest muscle of a woman's body now appeared like the body of a huge, firm octopus. Now my job was to hold it in position whilst they repaired the ragged bleeding edges. It was clear to see how good the blood supply to the uterus is, as more and more blood came from nowhere and oozed and filled the pelvis, frequently blocking the view for suturing.

And then she started vomiting on the other side of the curtain. Her belly heaved and heaved beneath the green coverings of the surgical drapes, the same long coverings that disguised her as an anonymous pregnant uterus that contained a baby that needed to be rescued, and took away her humanity, an individual with feelings, a past and a future.

My hand rode up and down with her uterus beneath a sterile cloth, and more blood spurt forth with each vomit. I feel uneasy and snuck a peek at the suction bottle, and it now contained a litre of blood lost. If she does not stop bleeding soon despite the medication and the suturing, we would be running out of options. My mind drifts admist the senior doctor's efforts, only to find my own discomfort at knowing that things weren't going well, that I felt helpless and unhelpful, and that the patient was awake and could hear exactly what was going on and our discouraging conversation. I could feel my objectivity slipping, and in its place the suffering of distress... perhaps my own, perhaps the patient's, perhaps the senior doctors'. It didn't even cross my mind that she could be in this moment rejoicing about the arrival of her wish-fulfilling daughter.

Luckily, things took a turn for the better. Eventually she stopped vomiting, and the blood loss was much lessened. The nightmare has abated, for now. A tube was put in, just in case, to drain any further bleeding in the area and the muscle and skin closed. From the outside, you could not tell what had happened or what sort of healing will take place deep inside her in the time to come. She would not be able to strain or undertake forceful activities for six weeks, not even able to drive, and that certainly should she have more children in the future, her uterus will be too scarred to withstand a normal vaginal delivery; a C-section will be the only way.

As I said earlier, I am frightened by Obstetrics. A place where the margin between life and death seems so unnervingly narrow, not just for one, but for two.

In the Realm of Hysteria III

Another shift started as per usual. Wandering aimlessly into Birth Suite and seen and ignored loudly by the nameless midwives. As if they were able to sus out who would be useful to them in a glance. To them I'm a nameless young medico with questionable aptitude.

I do not want to be like the med student, also wandering and being actively ignored. I do not want to elicit the same distaste she conjures up by overcompensating with aggressiveness and requests being involved in patient care.

I think, like nursing staff elsewhere, you have to prove your worth or willingness to listen to experience by sticking around, by being polite, by cooperation. Midwives are just a little more territorial, that's all, being more independent than other nursing specialities, and have strong beliefs about the whole childbirth experience.

I was asked by one of the bosses today how I'm doing whilst in the above state. I responded honestly: "Lost," I said. He seemed surprised and probably took pity and invited me to participate in theatre time. Instead of "providing entertainment" as he had planned, my suturing skills, though shaky, were better than he had expected. He seemed pleasantly surprised at my one-hand tying technique that we learnt a couple of weeks ago, on (defrosted) chicken rumps.

Despite more involvement, I just still don't "get" Obstetrics. Not only that each Casearian section I see scares me, and the heavy smell of blood and gore linger in my nostrils. I hold my breath and pray during each baby delivery (I think that's an euphemism for "extraction," as akin to "dental extraction"). I just keep on missing a puzzle piece of the whole complicated system. It's just a whole different world to everywhere else.

However, as I retire to bed, only to rise to a weekend of more work, I thank goodness for bored clinicians who occasionally remember that what bores them is still uncharted learning territory for others.

In the Realm of Hysteria II

There is something that frightens me about Obstetrics.

It is almost expectant in the course of life that women somehow naturally go through childbirth. Perhaps a rite of passage into womanhood. Perhaps the joy and responsibility that accompany bring a new life to earth. But from what I've seen, I would describe it as a trial by fire, through tempting and dancing with fate and death.

And almost certainly, we are talking about two lives simultaneously, mother and child. No one can predict the exact outcome.

At my first afterhours shift, the Birth Suite is ghostly quiet.

"Oh I don't like the feel," says more than one midwife and doctor, "it's like the calm before the storm."

"Let's not worry about later, here," I proffered chocolate that has become public property lying about on the station desk, "have an easter egg."

As we munch on the generosity of perhaps the hospital, perhaps some staff member, perhaps some patient, sure enough we catch wind of a lady coming in with preterm labour. The new senior doctor responds to my naiive questioning and looks up clinical protocols and guidelines on the computer.

Within ten minutes, the ambos arrive with a stretcher bearing a woman in emotional distress. Always dramatic, always effective. Not always delivers, though. You can never tell the severity of a problem when people arrive via ambulance. Well, perhaps if they had someone jumping on their chest, yes, that would be barn-door. Yet that almost never happens.

The woman is in her mid-thirties, with a wild look in her eyes. She pants and grimaces, and occasionally a cry erupts. By dates she is only half-way through her pregnancy, bearing twins through in-vitro fertilisation. She is angry at the situation and wants to keep her babies desperately. We reassure her we will try to stop the labour by giving her medications, but we may not be able to stop it, and she will deliver two extremely premature babies. Babies, unfortunately, have a very low survival rate at 24 weeks, and hers are only 22 weeks old.

The next half hour saw me fail a cannulation amongst her agitated continual questioning of "is there a chance...?" "what if...?" and negotiations of private versus public care. In the meantime, the medications have failed to stop the contractions, and the first examination revealed bulging membranes and outline of the first twin's hair and scalp, even I could see it standing in the back of the room. The babies were coming, despite our efforts, despite our hopes, despite their grim survival.

The boss on call arrived, and attempted a conversation to the woman's unlistening ears. Her husband held onto her hand, hovered in the background, with pain in his eyes and a flushed face. The paediatricians arrived and waited patiently in the corridor with the warmed resusitation cubicles. The private obstetrician arrived, knowing the inevitable, and reinstated what we already said.

"Noooo!" She yelled, "Wait! Don't come now!" Holding her legs and buttocks tight. She was doing everything to fight the contractions. "Nooo!" She yelled with every tightening. There was now a small crowd that gathered in the corridor beyond her door.

"But there is a 5% chance of them surviving, right?" She pleaded to the air in between grunts and yells now, the contractions were becoming closer and closer.

I admired the senior doctor, a general practitioner, in his gentle yet firm manner as he continued to guide her during delivery. The membranes were ruptured, and pale yellow amniotic fluid gushed onto the bed, mostly caught by the midwife's skilled placement of a kidney-shaped dish and slight turn of the face to avoid splash injury. "I'm sorry, I'm sorry, I'm sorry," she said to her partner, who holds her head and shoulders and turns his head away in visible tears.

Eventually, the first baby was delivered. Size of a small kitten, skin so thin and tightly stretched that it appeared a deep pink, tiny configured features, waving his arms and legs in the air in the unfamiliar environment. The cord was cut and baby quickly swathed in warm towels and shipped outside to the waiting clinicians.

And so the second baby came, also a boy, this time feet first. Breathing, animate, just like his brother as he emerged. And then the injection for the uterus to contract down again and the placenta delivered uneventfully. A warm, fleshy, bloodied mass, not unlike soft coral.

By now, the new mother has relented, and asks only that we try everything for the babies to survive. We nod and say they are in good hands, but that she does not keep her hopes too high.

I depart from the room, to look for her blood type on the computer, and lingered to listen in on corridor conversations from the bosses. The event is now over for the obstetric side, it is now a fight on the paediatric side. And perhaps a lifetime, for these two eager parents.

I take my leave as it was now at the end of my shift, having done little aside from feeling overwhelmed by the whole episode. I tried to reflect and cannot conjure up a better solution or communication effort for the night's events. I go to the adjacent ward, where the paediatric special care unit is, and assist the doctor there in placing miniature lines into the baby's umbilical cord, until I was truly tired, and long overdue for rest.

It's a difficult world, and one difficult to navigate in, emotionally and clinically. I used to think that transparency was the only patient communication that was needed. But now it appears so cruel, that we do not allow a shred of hope, even though the reality is a tough one.

Is Hope the only medicine? If so, what are we hoping for?

In the Realm of Hysteria I

Hysteria: \his-ˈter-ē-ə\ noun

From the Greek notion that hysteria was peculiar to women and caused by disturbances of the uterus 1 : a psychoneurosis marked by emotional excitability and disturbances of the psychic, sensory, vasomotor, and visceral functions 2 : behavior exhibiting overwhelming or unmanageable fear or emotional excess


The tribe of women gather in the mornings. Discussing other women who are in the process of giving birth, the various obstacles, or suffer from a pregnancy related illness. The elder's responsibility is rotated on a daily basis, but always present at the meetings: guiding, teaching, challenging decisions made for the sake of self-reflection. The men are token attendees in the secret business of women.

We disperse and go forth in the day's activities. Waiting for us in the ward are two women. Commonly these women were sent in by their family doctor for definitive management of their miscarriages. Starved and thirsty from midnight the night before, their anxiety and emotional fears simmer just beneath the surface.

I went to review one of these young women, holding at bay my own insecurities and palpable sense of lack. I only hoped I did not appear as ghostly white as the woman in front of me. With her pale long blonde hair and lacklustre eyes, she was an apparition, linked vaguely to earth by her partner holding her hand.

We had had several phone conversations on the previous day. She wanted to delay her review as she could not get someone to replace her at work. The only information I had was her doctor's urgent referral letter for a more serious condition and adviced her it would best to come in at the arranged time. Then she told me her doctor had called her and said it was just a miscarriage, and nothing more serious. I told her I had no records but I will chase it up and ask for senior advice. Then she called again and said she wanted to come in on the arranged day, but in the afternoon. By then I had sufficient information available to me and I adviced her it would not be more advantageous, and that it was easier the next day, as she had desired in the first place. But of course, I added, if she was feeling feverish, unwell and bleeding a lot that she should present herself to Emergency. Oh, she added, but if she were to have a procedure done, would she be able to go to her daughter's dance performance that night. Yes, I reassured her, it is a straightforward day procedure.

And so the following day, she presented at the original time, apparently after waiting for four hours at the Emergency department overnight, when she was obviously not an emergency, and left to go home. Apparently our circuitous discussion had not worked out as I had planned. And here she was, driven mad by anxiety and fears. Nevertheless she was here, and I went on to prepare her for the procedure.

It's hard to get away with being in hospital without at least a blood test. And especially with pregnant women, the risk of bleeding copiously is always there. She mentioned her needle-phobia, amongst various other random thoughts that I had ceased to pay attention to and I grit my teeth internally.

So there we were, alone sitting in the waiting room, glass panes and all, her partner holding her in a tight embrace while I tried to utter soothing sounds as I first inserted a cannula into her vein. And when the blood did not flow freely, due to her much starved and dehydrated state for too many hours, I regrettably informed her that another needle was needed. Only to be met by further hysterical tears and cries. And I felt hardened in my heart in that moment, doing what was necessary, in an imperfect world.

That was my first taste of hysteria.

Pump Class in the OT

After moonlighting in the ICU for a couple of weeks, it's time to go back to the refridgerator otherwise known as operating theatres for a bit of anaesthetic exposure.

I don't know why, but the white walls always looks sterile in the bland sense of the word, but not necessarily sparkling clean. We all wander around in our variably stained, variably washed-out blue scrubs. Recently they've even introduced disposable scrubs that have all the tactile pleasures of no-frills paper towels. I think they are more for our own protection than for the patient's, however whether it leaves integrity intact is another matter.

But somehow despite the far-from-ideal physical environment, they managed to breed a different type of medicos... the Anaesthetists. Freed from dealing with all-day ward rounds, extended conversations with patients and families, unsolvable social issues and disadvantage, they emerge with a dry sense of humour, generosity with teaching, and clear and sharp-minded about the fundamentals: physiology, anatomy and how to tinker with drugs to achieve what you want. Alas almost complete control.

It is Day 5, and I'm lucky enough to be in the same theatre with just one other senior doctor. She allows me to draw up medications from little glass ampoules before trusting me to attempt looking after a patient's airway whilst deeply asleep. I grapple with an obese middle-aged woman's overflowing neck to get a good seal with the oxygen mask and frown at my small hands and desperately weak pinkies. I break out a sweat and soon my arms are tremulous with the effort.

"I'm going to make you hold on for a bit longer..." my supervisor said with the air of a personal trainer, and that small hint of sadistic glee. I am now tensing and using my shoulders, neck and legs in un-ergonomic ways just keep that chin up and mask tight. "When I was training, we'd had to hold on for the entire case..." she adds, obviously enjoying the moment.

"I've been told I snore," I faintly recalled those dreaded words that the patient uttered in the anaesthetic bay, as I lift up those very obstructing structures with a strange instrument with my left hand, in an odd position using muscles I've never used before. Eureka, the vocal cords are seen and I insert the breathing tube down. Phew, what a narrow shave. My arms were just about to give up.

That adds another surprising impression (and respect) of the quiet anaesthetist in the background. Explains the massive biceps (twice that of mine) of the bosses, and my physical inadequacy to fill the shoes required for training.

My arms still ache at the memory...

First Encounter with Death

Is it taboo to talk about death and dying? Nobody seems to take an interest. You could almost hear the unspoke thoughts in the silence: 'He's fading' 'We can't offer anything else' 'It is awful, watching someone (die on us)'

It is awful, indeed.

I struggle with my guilty feelings. Sometimes it seems easier to think about someone dying, an endpoint, closure, rather than to think or witness them suffering in prolonged disability. All or nothing, no grey areas in between. My world is solid again.

The first time I saw death outside of the anatomy class, it was with the a senior doctor than I, though younger in years than I. His proper English upbringing gives a palpable air around him.

Today he was teaching me about death. We had been called to certify a man who has passed away due to his fulminant cancerous state. We went into his single room. It was quiet - no distracting machines beeping at irregular intervals. No accessory lines, probes, blood pressure cuffs that restrain his body to the physicality of the room. There were no wailing or distressed relatives. There were no get-well cards or flowers from the gift shop. There was just him, an empty husk of a man lying beneath the thin sheets that no longer gave him warmth, but only serve to offer a fleeting modesty.

The colour of his skin was a bright yellow, as if someone had painted food colouring on him, except it had a sickly tinge, beyond his obvious jaundice. His skin appeared waxy and taut, stretched tight over the normally animated eyes, nostrils and cheekbones. His mouth was shrunken, yet fixated in that ominous 'O' sign.

'They nearly always look like this,' my mentor said, in his usual detached tone, so that his emotions were not betrayed. 'Do you know what to look for?' He asked. I gave him an anxious glance and started to utter a few words that floated to me from fragments of my clinical experience, almost six years past. Without hesitating, he started to teach me systematically a way to fulfil the legal requirement of death certification.

Artificially, the first step was to call out the person's name. Then checking a response to pain. I rub my knuckles over the patch of tightly stretched skin on the centre of the chest that no longer shifted air. 'It's easier when they've had a bit of time,' my mentor said, encouraging my efforts.

I pry open the plasticine lids and shine the ungraceful Energiser torch at his pupils. No movement can be seen in the laxity of those eye balls. I made a mental note to myself to buy a penlight so that no person at the end of their life should have their dignity lessened by their signs of life being checked by a big red ungainly torch.

I place my fingers over the major arteries of the neck. I feel nothing apart from the fine tremor of my own fingers and the weak rapid pulse contained within it. I place my stethoscope over the area of his heart, and contrary to what I hear 99.9% of the other times it is used, I heard an emptiness. Not completely devoid of sound, but a hollowness, as if the rustling of the sheets and the brush of the stethoscope were transmitted inside the empty cavity of his chest. A loneliness of sound.

We listen to this loneliness for a few minutes together, then silently lift our stethoscopes off his body, readjusting it into the comfortable nooks on our shoulders. There is no dramatic flare as we walk out of the room and nod gravely at the nurse so that she may begin the preparations down to the morgue. We find the medical chart and write down those fateful words:

"ATSP (asked to see patient) re: signs of life
No response to voice or painful stimuli. Pupils fixed and dilated, unreactive to light. No breath sounds or heart sounds heard. I pronounce xxx deceased as of time/date. May him rest in peace."

Beggers and Choosers

I sit inside the "fishbowl" - the nursing station that has glass panes separating the healthy from the sick. I twiddle my thumbs mentally as I glance at the screens that show changing numbers and squiggles. Numbers that show the heart is beating: how fast, how slow, how hard, how irregular. Numbers that show the lungs are breathing: how fast, how slow, how deep, how shallow, how effective. Here, the human being is reduced to a series of numbers and lines.

I am in the Intensive Care unit.

Where patients are asleep, bound to their surrounding machines and monitors by tubes and lines. Watched over by their assigned nurse with a hovering pen, ready to record the new numbers. Ready to adjust another knob to crank up the breathing support, the blood pressure support.

I am in a living physiology lab.

Challengers earn their entry inside the arena with the failure of more than two organ systems. Armed with antibiotics, IV fluids, painkillers and pump pushers, they wrestle and tackle their nemesis: Sepsis, Kidney Failure, Lung Failure. Retreated into the ever-expanding fluid-filled physical body, the tug of war of life and death takes place in an unseen realm. Some are winners, and go on to battle smaller enemies, like boredom, anxiety, lethargy, adjusting to leglessness. Some are not so lucky, and run on borrowed time.

Like Mr D.

Everyday he seems more gaunt. His hollow, sallow cheeks and semi-closed eyelids over softened eyeballs speak louder than the surprisingly good numbers his machines generate. The moisture in his body does not rise and fill his skin but somehow fall dejectedly, surrendering to gravity, to the dependent areas of his body. It's not that he was in a great condition before the illness either, with decades of alcoholism and smoking eating away and ageing him beyond his years. But I feel he is leaving, even though nothing else seems to have changed.

A wise person once told me, that initially people noticeably age in the space of ten years, then five, then three, then one, then by the matter of months, weeks, and when they are towards the end, in the units of mere days, hours, minutes.

If that is the case, then I pray for you, Mr D. I pray that you go to a good place, a good life, and catch a glimpse of your true nature unrestricted by this physical shell. May you be well and happy, and free from suffering.

May you go in peace.

Holistic Medicine vs Quackery

Whilst habitually clearing out my inbox one day, during a post-waking pre-caffeinated state, I came across an forwarded email entitled "fringe medicine." I thought, odd, especially coming from a holistic doctor's mailing list.

Scrolling past the various replies, I read the first email, from someone I did not know, but was adamant about the public attack on the NZ medical council's newsletter. It went something like this:

"... the fear of death as a sequel to illness is a powerful and not always helpful emotion. In the cloud of serious illness, the unwell human believes any number of claims to 'cure'. Most patients simply do not have the training nor the knowledge to make valid judgements..."

Then the author started to list the ways in which doctors practising alternative therapies were turning against their training in logical, scientific rationality and embracing financial gain and satisfaction in making diagnoses and inventing treatments for many conditions that conventional medicine do not treat.

And simply concluded:

"... Fringe medicine has been around for a very long time. There was hope that the modern scientific method would rid us of dodgy practices. This has not happened. None-the-less a doctor’s role is clear. That role is to protect the patient from false claims and from futile or harmful treatments."

And so, the sentence is clear, any non-conventional doctor is a shady character of questionable ethical standing. Thus, by encouraging segregating and rejecting these people, the author is ultimately protecting masses of innocent unsuspecting patients.

Or so it seemed.

I have to agree with the fact that there are a lot of charlatans about, and in my experience there are a lot of well-meaning but somewhat ignorant therapists, and that there are also a number of skilled but incredibly poverty-stricken healers... but what about doctors?

"First do no harm" - first principle of medical ethics

We are trained to be cautious, to give promises only when based on solid fact or evidence. Diagnoses are made when certain criteria are reached. And if not, "subclinical" or "prodromal" or "viral" or "nonspecific" terms are used and no treatment can be commenced. The diagnostic train grinds to a halt, and the patient is offered a reassurance that it is nothing significant. Yet.

Somehow, preaching healthy lifestyle is not popular. But, selling a health-promoting substance is. If we cannot take a drug for it, then why not a tonic, or hope? Why try to change the unhealthy habit that caused it in the first place?

What a strange world we live in.

My grandmother is admitted to hospital again, while I look after other grandmas on the other side of the world. She was found drowsy at home and brought in for treatment. She had high blood pressure and, alas, traces of amphetamines in her blood. She is now recovered and spritely following various IV infusions and nasogastric feeding, the tonics of the medical world.

Amphetamines?! I gasped when I heard on the phone. How on earth does an elderly house-bound conservative Christian woman get hold of a street drug? And then mum added nonchalantly, "she is always taking some herbal remedy."

My mind spins. No wonder any alternative therapy is guarded against. And this is in tranquil New Zealand, where so far I have not heard of any immoral tainting of "herbs" with synthetic toxins. But already so much animosity in such a public domain.

It will be interesting to be doing a practicum with my mentor during the next period of time, when the group of complementary medical practitioners will be formulating their reply, hopefully with more integrity than reactivity, so that the air can be cleared once and for all.

Another Day at the Orifice

It is almost 2am. The building is quiet and I can hear the soothing sound of soft persistent rain outside, and the occasional call of a gecko. I've lost track of how much sleep I've had in the last 48 hours, having finally finished the last night shift at the Emergency Department. I will finally be in a place to reset my biological clock, that is, if I can. All I know is, I am tired.

My mind still drifts back to the last patient I saw before emerging again into a world of bright glaring sunlight and steamy heat, from a world of variably fluoroscene-lit and variably air-conditioned environment permeated with various smells (human or otherwise) that you don't really want to know where it originates.

Somehow, everyone I see is in varying degrees of anxiety, and mostly out of proportion to their physical ailment. This particular gentleman is in his 60s, well-spoken and uses medical terminology to relay his symptoms. He is anxious, and keeps glancing at my name tag, scaring himself that I were a day 1 intern. He had woken up in the middle of the night with tingling in the left side of his body, which hadn't gone away after four hours. Obviously he is worried about having a stroke. And as it happens, he is a medical professional, which just makes the worrying so much worse. I sympathise, and at the same time trying to not let the intimidation get to me, and proceed with a mish-mash of physical examination at the end of the 10-hour shift with my already cotton-wooled brain.

He is a little reassured that there is nothing solid on my findings to indicate he's had a stroke, and that his plantar reflexes were downward pointing. He did not even have objective temperature sensation changes. But alas he is still anxious. I hand him over to the fresh day team doctor and organises his CAT scan to happen immediately (a rare feat in the public system) . And his parting words were: "Go home, Kiddo."

For the first time in a long time, I feel acutely powerless in being young, female, Asian.

I know I am still gathering experience and that my knowledge base of Neurology is limited. But I also know that the CAT scan will show very little, and he is unlikely to have bled into his head during the middle of the night. However, he will mostly likely end up being admitted to hospital and proceed to an expensive MRI scan, which is likely to be inconclusive anyway.

I think about the fear that is driving his anxiousness. The loss of control not knowing what is happening inside his brain - should he take more blood thinners, should he lower his blood pressure; could his longterm smoking have contributed to his stroke; would he lose his livelihood forcing an earlier retirement than he'd liked, due to his procedure-based medical practice. And to make things worse, he is being assessed by a glorified medical student in the relatively unsupervised early morning within a limited public hospital away from any Neurology or Neurosurgery service. He tried to protect me from the outlash of this, by being nice, by proactively giving me his history, by smiling reassuringly that I'm doing the right physical examinations, by apologising to me when he saw me being lectured by a nurse about letting him use the staff toilet, by attempting the friendliness in his farewell when I could almost see the snarl in his lips as the words came and his unlistening ears to my wellwishes.

I had felt a strange mixture of emotions since parting his bedside. The elation of having finished a long stretch of shift work and performed satisfactorily in my assessments. And the feeling of being a passive observer in another being's struggles with morbidity and mortality, unable to influence or alter the outcome. I hope he does not end up having had a bleed, or a stroke. I hope at some time in the future, he emerges from being confronted so directly with the bare essentials of life and death, and the interim hell of disability that would be for him, and rises to a new level of meaning and awareness to what life is, and what life could be.

As one of my bosses had said recently following a particularly harrowing shift during the Xmas and New Years period: "... another day at the orifice."