The PAC day.
I was tired. That day I was rostered to be on-call at PAC (Patient asessement Centre) which is the ’emergency department’ for Obs N Gynae patient.
Just like in casualty, we quickly (as quick as housemen can be laaa) assess all patients that come in, to decide whether we can discharge them home /put them into the ward for observation/ put them in CMR/ put them straight into labour room/ or put them straight into OT for emergency surgical intervention.
For a new houseman who has never been in-charge at PAC, to be put on-call at PAC during weekend (when the admission rate is skyrocket high) is a scary thing. Luckily, I was rostered with someone more experienced and senior than me. She helped a lot!
That night in PAC, there was only the two of us. And a very garang MO, named Dr.W to consult with. We tried not to bother her too much by managing the patients by ourselves as much as possible.
We prayed for all the patients who arrive after 1 a.m to be straightforward ‘labour room cases with os dilatation of 4 cm’ without any need for MO consultation.
It was 5.00 a.m already….only two hours left until the oncall would be over. I thought that we would be able to go through the two hours without bothering the MO. Frankly speaking, the scary part about the PAC that night was the MO who was on call on that day. Not the cases.
I had wished with all my heart that the 2 hours would pass easily and swiftly.
Apparently, I never learned the wisdom of having a realistic wish. No wonder many of my wishes did not come true.
2 days Before PAC
“Doctor, the patient who was admitted for missed miscarriage at bed 5 is bleeding.” The staff nurse informed me.
That was in the ward. Supposedly, all patients in the ward are stabilized patients under observation,only awaiting approval for discharge. (Yeah, right.)
WHY, of all cubicles in the ward that the bleeding patient could occupy,did she end up in mine?
This patient was a 38 year old female, who was admitted for ERPOC (evacuation of retained product of conception) for missed miscarriage. But because she was thrombocytopenic on the day of admission, we delayed the procedure until her platelet count could improve. On that day, her platelet count had already risen up to an acceptable level for ERPOC. So I had booked her for ERPOC in OT on that very day. Unfortunately, the OT was so ‘lembap tahap kura-kura cacat’ that they haven’t called her up yet even though it was already 1 pm!
And of all the days that she could bleed spontaneously, she chose to bleed on the very day she was scheduled for ERPOC.
I hate bleeding cases. I really do. Apparently, I was never good with bleeding cases. I got scolded many times when it comes to bleeding cases. There was one case in which I quickly called my MO to come stat because the patient was bleeding vaginally; she was hypotensive with pulse rate of 100…to me, she looked pale. When the MO came, she said, “Is this pale, to you?”
Another time, I was scolded for the case of post-partum haemorrhage…apparently the bleeding was not as bad as I made it out to be.
You got the idea, right? My threshold of what rates as emergency bleeding is very low compared to that of the MOs. I always call them up for something that they expect me to manage on my own. Maybe they have no idea that I graduated from a country who basically expect the intern to be able to be a good clerk, for the most part.
With dread, I got up from my seat, and told the nurse, “Ok, saya pi tengok.”
I knew I was going to have to inform the MO, Dr. C, about this case. But I dreaded it. Other than Dr.W, this Dr.C is the most ‘bengis’ MO in the whole department. I got scolded by her sooo many times, I have lost count of the number of times I’d wanted to resign for feeling like I am too dumb to be a doctor.
So imagine the situation I was in. The patient was bleeding…lots of fresh bleeding and clots. The clots might also be the product of conception. Since I had never handled a case of missed miscarriage, I had no idee how POC looked like. I was fresh from labour room, for God’s sake. I have only seen obstetrics cases, not gynae! Was it blood clot? Or was it POC?
The patient kept on bleeding. And I was still undecided as to how to manage this patient, and whether or not I should inform the MO.
I did manual evacuation of blood clots. Insert my two fingers inside her vagina and kept removing the clots. Lots of clots were removed…and there were times when it looked like the bleeding might stop. But just when I was hopeful enough that she might stop bleeding until the OT can call her up for ERPOC (and therefore, I wouldn’t have to inform the MO), she bled again. And again.
So, I had no choice. I took the phone and informed Dr. C.
On the phone:
“Doctor, I am calling with regards to the patient in Bed 5 who is bleeding per vagina. You saw the patient today, she was supposed to go to ERPOC today, but the OT haven’t called her up yet. At the moment, she is hypotensive, tachycardic and symptomatic of anaemia. She claims of feeling dizzy. She looks pale.”
When Dr. C came, again I was told off for saying that the patient looked pale. (Look, I really thought she looked pale. I compared her hands to mine. I looked at her eyes…she was pale! She was also hypotensive and tachycardic. What else was I to think. She was feeling dizzy some more!). Apparently, it wasn’t pale enough by the standard of the MO. But I rather got scolded than risk the patient being dead just because I was too scared of being scolded.
I called blood bank to convert her GSH to GXM and prepare 2 pints of whole blood for her. But Dr. C scolded me and said “Ey, she didn’t need blood la. Go and cancel!”
Ya Allah! But the blood bank already prepared the blood for her. So 2 pints whole blood got wasted! Of course, I was then asked to write a ‘show cause’ letter as to why I did not use the blood that I ordered.
Anyway, Dr. C taught me how I was supposed to handle a bleeding missed miscarriage patient.
1)Do a PSE (per speculum examination). “Not just a bloody VE with manual evacuation of blood clots, idiot!”
2)See whether you can visualize POC at the os.
3)Use the sponge forcep to take out the POC, if it is there.
4)After you have removed the POC, do an ultrasound scan. If ultrasound scan shows that you have removed all POC, then this is diagnosed as complete miscarriage…there is no need for ERPOC anymore. If ultrasound scan shows that there’s still some retained product of conception in the uterus, then we have to do ERPOC procedure on her.
Once Dr. C had removed the POC at the os, the patient stopped bleeding.
So, the take home message is: when you suspect someone as having a miscarriage and she is having active bleeding per vagina, always think that POC might be at the os. If you don’t remove the POC at the os, the bleeding will never stop!
I got scolded. But I’ll remember how to manage a bleeding missed miscarriage forever, insha Allah.
It turned out that there was some ‘hikmah’ behind my being scolded in the ward. It was to prepare me for what was to come during my PAC on-call.
Back to PAC on-call.
It was 5.00 am, for God’s sake.
And then suddenly this patient came…18 years old lady, referred from casualty, diagnosed with varicella zoster infection.
My MO had said earlier, “There will be one patient with VZV infection referred from casualty. Make sure you isolate her from the other pregnant ladies. Clerk the case properly, and once you have finished, consult the case with me over the phone.” And then she was gone, leaving me confused.
Why would a pregnant varicella zoster-infected lady got referred to PAC? It’s no indication for referral. If you are pregnant and you have VZV (Varicella Zoster Virus) infection, you just go to your local Klinik Kesihatan (KK) and they will treat you with acyclovir. Straightforward, no need to come to PAC or even emergency.
I was so confused.
I took her file and started the consultation. “Dik, demam campak ni sejak bila?”
“Seminggu lebih dah.” she told me. Her face was drawn into a grimace as though she was having some sort of severe pain.
I was even more perplexed. Is VZV infection so very painful? I have seen so many pregnant ladies with VZV infection; other than facial crusting and blistering ‘polka-dots’, they all looked fine.
I plowed on. “Macam mana boleh dapat demam campak ni, dik? waktu kecik-kecik dulu tak pernah demam campak ek?”
“Saya jaga anak sepupu saya. Dia demam campak. Habih berjangkit kat saya.” She said, grimacing again.
What is going on, I wondered. I could not focus on her answers because I was busy wondering why a simple case of VZV infection got referred into PAC and that particular patient looked like she was in pain.
I just didn’t know what else to ask. Obviously, the next step is to discharge her home with acyclovir…something the doctors in emergency department could have easily done. Why is she here? Am I missing something? Aiyo brain, wake up!
“Adik, awat nampak sakit sangat ni? Kulit sakit ka?” I couldn’t think of what else could be paining her?
“Tak, kak. Saya sakit perut.”
Sudaah! Sejak bila VZV infection jadi sakit perut ni? Is it double diagnosis….VZV infection with gastroenteritis? Not bloody likely. I knew I was missing something!
“Sakit perut? Sejak bila sakit perut?”
“Baru malam tadi.”
“Oh ok. Hmm. Sakit macam mana tu? Kat bahagian mana? Tunjuk kat doktor.”
She pointed at her suprapubic area. And then she told me, “Kak, kenapa saya berdarah ni? Gugur ka?”
I slapped my forehead in frustration. Why in God’s name did I spend almost 15 minutes on her bloody VZV infection when she was bloody bleeding! I remember thinking that maybe my MO was purposefully trying to mislead me by not mentioning that the VZV infected case that was referred from ED also had PV bleeding! Which I think, should be the first thing she should have told me., right?
“Laaa…awat adik tak habaq awal-awal adik berdarah ni? Pacak kaki, mai akak check kat bawah. Banyak ka bleeding? sejak bila?” I had to take the bloody history all over again.
After awhile, she told me quietly. “Akak kalau tak gugur, jangan habaq kat mak saya tau. Biar dia ingat dah gugur.”
I knew then what had happened. “Adik mengandung ni, mak dengan ayah tak tau ka?”
“Ayah tak tau. Mak baru tau tadi. Kalau tak gugur pun, biar lah mak ingat dah gugur. Senang sikit.”
I swallowed the pain. “Adik mengandung anak siapa? Anak boyfriend ke?” I was almost at the verge of being sarcastic. My excuse was: I haven’t had enough rest, I have just wasted precious time asking irrelevant questions about VZV when I should have focused on the bleeding, and now I have to manage a bleeding case again. What pained me the most was that this patient was a Muslim lady who should have known better.
But then I bit my tongue from being spiteful. I reminded myself that she was a patient. She needed me. She needed me to stop her bleeding; she needed me to assess her as to whether she was in a state of threatened miscarriage or missed miscarriage or incomplete miscarriage. She didn’t need me to pierce her heart with unhelpful snide remarks just because I was tired. In fact, this was my chance to give her some good support and advice.
Yes, I had seen so many unmarried post-partum ladies in the ward. But none of them had confessed to me or confided in me, or asked me to help her in anyway. Most of them were patients in other cubicles that I did not look after. Therefore, even when I was inclined, I was not able to offer them any good advice. (I simply let the psychiatry team do that).
“Adik…saya tak pasti adik gugur atau tak. Mungkin hanya berdarah tapi tak gugur. Kalau gugur, mungkin Allah nak lindung keaiban adik. Saya check dulu. Nanti kita tengok macam mana.”
I put the speculum into her vagina. And sure enough, the POC was stuck at the os. No wonder she was bleeding. So, she definitely miscarried. But I did not tell her straightaway what I knew she wished to hear. I simply took out the POC slowly, and carefully removing it with the sponge forcep.
“Adik, kenapa tak kahwin dengan boyfriend adik? Tak kisah la adik gugur ke tak. Lepas ni, kalau dah sayang, ajaklah boyfriend kahwin.”
“Kak senang la cakap. Bukan senang macam tu.” She said, weakly.
“Awat? Boyfriend tahu tak adik mengandung ni?” I was getting annoyed with the unknown guy.
“Habis? Dia tak nak bertanggungjawab la ni?” I was getting pissed off now.
“Bukan. Dia nak bertanggungjawab. Tapi keluarga saya tak suka dia.”
In the way that she answered my question, it was obvious that she absolved all guilt from her bf; like it was not her bf’s fault. As though her family not liking her bf was the reason that she ended up in this situation. When you think about it, if your family doesn’t like your boyfriend, you should be even more careful about your decision to get sexual!
“Dik…kalau dah jadi macam ni, kahwin sajalah. Ajak dia kahwin. Kalau dia tak nak kahwin, tak apa lah. Mungkin dia bukan lelaki yang baik untuk adik. Insya Allah ada lelaki yang lagi baik untuk adik di masa depan. Sekarang ni akak tengok memang adik dah gugur. Dah habis keluar darah nanti, buat solat taubat. Janji dengan tuhan, takkan buat lagi. Insya Allah, Tuhan terima kalau adik ikhlas.”
She listened. She nodded her head. I wasn’t sure how much she took in whatever I said. But I had given it with my voice caught on my throat because I was that sad. Sedih tengok orang Islam macam ni. Aku sedih, pukul 5 pagi aku kena remove POC from a young, innocent-looking but unmarried Muslim lady.
I did not raise my voice at her the way some nurses did with unmarried patients. Because as an often-scolded houseman, I knew that your heart will be resistant to anger-driven nagging and instruction. It will only harden her heart if I was harsh on her.
I don’t know how to say this without sounding holier-than-thou.
The young generation has forgotten – they could not compute- what love is all about. They have never been acquainted with real love. Never recognize what it is all about. They could not differentiate the difference between ‘desire’ (nafs) and love.
Let’s try a philosophical question in the manner that we learn TOK (Tehory of Knowledge). Let’s ask ourselves, what is love? Is this thing that you feel for your boyfriend is love?
Love cannot exist when you have not tested it with responsibility. If you haven’t been responsible to one another in any way other than exchanging phone calls and text messages and going out on dates with each other, then whatever it is you are feeling CANNOT be called love. Does that make sense?
Ok, I will give you an example.
Sekarang aku ada anak kucing. Aku balik kerja saja, aku mesti cari anak kucing aku tu. I want to hold her, pet her. Call her names. It was fun, something different than stressful hospital work. It was fun sebab aku boleh main dengan kucing tanpa aku perlu kutip tahi dia, basuh bekas makanan dia, basuh kandang dia, cuci telinga dia, bagi mandi dan shampoo bulu dia. All I did was play with her.
My maid took care of everything else.
See? Memang la fun! Mungkin la aku boleh cakap aku sayang kat kucing aku tu. Tapi katakanlah one day my maid is gone..and suddenly I have to take care of her toiletting, her food container, the washing up and the cleaning….will I love her still?
But maybe not!
Isn’t that why marriage fails? You are so used to having fun while coupling…suddenly you get married expecting that you can still continue being lovey-dovey as freely as before. Suddenly the wife realizes that she has to cook, iron his clothes, clean the house, make up the bed, scrub the toilet….satu habuk pun husband tak tolong. Suddenly the husband realizes that…Oh My GOd, all my salary is gone…to pay for the house, to pay for the car, to pay for household expenses, to pay for his wife’s clothes, her shopping habits, etc etc. And then, they fight saying…..”You dah tak macam dulu.”
Babe, memang lah tak sama! What you felt when you were coupling was false, untested so-called love. Our ancestors first-hand experience of love was one that comes hand-in-hand with responsibility; they did not know any other ‘love’ other than the one that comes only after they declare to be responsible.
Look at those who claim that they HAVE ALWAYS WANTED to be a doctor. That they LOVE this job. Now that they knew the hardship that comes with what they claimed as love, they quit the bloody job.
So, don’t mistake your pre-marital desire as love. It’s not love if there’s no responsibility in it.
Just because you always think of him, doesn’t mean you love him. I always think of food. I always think of my pillow and my bed. I am not in love with my food or my pillow or my bed…it was only to fulfill the needs of my nafs. Nothing more.
I may think of food every time I am seeing patients, but if you give me the RESPONSIBILITY to cook the food first before I can eat it, maybe you will find that I much rather not eat at all. I much rather switch my thoughts to my pillow or my bed first. And if the pillow and the bed are not available…then I can go to any sofa available to satisfy my nafs.
That’s exactly what this generation’s love is all about; devoid of responsibility and switchable depending upon whoever that is easy and available. Now, start recognizing that type of pattern as NOT LOVE…but nafs. Regardless of how many times you think that you are thinking of him, remember that your thought of him is no different than your thought of food, your pillow, your bed or the handbags in the shopping complex, or the books at the shelves in Borders.
Does that make sense?
Please God, I really don’t want to remove another POC from the opened os of an unmarried Muslim lady.