Nothing personal!

Doctor in The Dock (2022)
Author: Ariza Mohamed 

I have known Staff Nurse (SN) Theresa since 1988. She embodies what I perceive as a true manifestation of the lady with the lamp. Though she may not be the social reformer and statistician that Florence Nightingale was or her contemporary, the flamboyant Mrs Mary Seacole, the nurse who nursed convalescing Crimean War soldiers to health, she did her own share of saving lives.

Growing up in an orphanage, Theresa felt a need to repay society. She did not see the need for a family of her own.

"The world already has enough children and enough broken families!" She commented once.

Outside her regular busy duties at the Maternity Ward of a public hospital, she managed to squeeze time for inmates of an orphanage, old folks' home and church.

Her dedication at work was exemplary, earning the best employee award many times over. She would go out of the line of duty to help her parturient patients, even teaching them the minor points about breastfeeding during the graveyard duty.

I was reminded of her while reading this book. An Obstetrician was sued for negligence 16 years after the event. The Obstetrician, the author, had seen a mother who presented in an advanced stage of labour at 26 weeks of pregnancy. The mother was in the process of being transferred to a tertiary centre that could handle premature babies when delivery ensued. The baby later developed cerebral palsy. 16 years after the delivery, the Obstetrician was sued for not suppressing labour when the mother presented at her practice. The plaintiffs' (the baby and parents) bone of contention was that delivery could have been averted or delayed if labour had been suppressed.

Four long, harrowing years later, after reaching the stage of the Court of Appeals, the doctor was relieved of her negligence. Still, the complainant was awarded the most enormous compensation in a Malaysia medical negligence case, RM 8.9 million.

The author describes her experience dealing with the bureaucracy of the legal system. The emotional and economic turmoils that the doctor endured are indescribable. Her whole life appears in front of her as a wasted one, serving, helping the needy, forgetting food and sleeping, all just to be assessed condescendingly. All her academic laurels appeared pale in her current position. Netizens, with a crystal clear vision of hindsight, were quite brutal with their opinion and caustic with their remarks. Even before the courts had set the hearing, these armchair judges, jury and executioners had already crucified the accused.

Leaving the fate of the future of a person of science to be determined by the learned who could not differentiate between ECG and CTG seems unfair. No matter what they may say about practising being an art, ultimately, it is science that decides what this or that modality of treatment is appropriate. Assessment by members of the medical fraternity is more relevant. But, in reality, are the men in robes and sharks really going up their chunk in the game of medico-legal interplay? That is bad for business.

Coming back to the case of SN Theresa. It happened during one of the nights she was on duty. A mother had just delivered a few hours previously. Theresa, after helping her out with breastfeeding and settling her with her baby, continued with other duties. A colleague saw the patient sprawled awkwardly on her bed. She alerted others, and soon, a code blue was initiated.

The patient had collapsed due to a non-obstetric reason. An aberrant splenic artery had ruptured, and she bled in her abdomen. Surgery was prompt and successful, but the patient succumbed to lung complications two weeks after the episode.

The family sued the hospital for medical negligence. During the trial, Theresa was called in to give testimony. So when the Plaintiff's lawyers inquired about the events before the collapse, Theresa narrated what actually happened. She was taken aback by what the learned lawyer had to say.

"You mean to tell me that a government hospital teaching and guiding a recently delivered mother through breastfeeding at 1.30 in the early morning, and you want me to believe that," he went on all four barrels. "I put to you that your whole nursing team neglected the patient and only discovered to be out cold."

It had come this. An armchair critic, a lawyer who makes a living out of others' misery, who taught himself medicine through the clinical practice guidelines online minus the pressure of peer assessment telling a dedicated nurse who answered her calling she must be doing her work. I do not know the trial's outcome, but as was narrated, that incident got stuck in my mind.

Seacole and Nightingale

The author left clinical practice for a teaching career. The last time I heard, Theresa had retired from Government services. She divides her time between extending her much-needed services to her private patients, orphanage and old folks home.

The era of a paternalistic attitude of the medical staff towards poor, helpless patients is long gone. A medical personnel is just a spoke in the machinery of modern society. Health is a commodified product sold to individuals who demand perfect health as an undeniable right with no margin for error. Then, a small fraction of people gain from falling sick. Sometimes, unaffected parties have nothing personal against the medical workers. They are grateful to them, but they see a lot of money, if unclaimed, going to waste, but it could come in handy to ease the pain of falling sick or being debilitated.

N.B. Florence Nightingale OM RRC DStJ was an English social reformer, statistician and the founder of modern nursing. Nightingale came to prominence while serving as a manager and trainer of nurses during the Crimean War, in which she organised care for wounded soldiers. Mrs Mary Jane Seacole was a black 'doctress' who did her style of treating weary battle-fatigued soldiers, which involved spirits of the beverage kind. A British born in Jamaica to a Creole mother, she ran a boarding house and dabbled with herbs. In 2004, she was voted as the greatest black Briton

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More to hide under the robe!

George Bernard Shaw is said to have said, "whenever you wish to do anything against the law, always consult a good solicitor first." At a time when the law is often called upon to decide the appropriateness of the action of one in power, doing the right thing in the eyes of the law is more important than ever.

It used to be that wars were planned by generals and executed by soldiers with the national leaders as their chief commander. Not anymore now. Over the years, it is increasingly evident that members of the legal fraternity play an ever-important central role in the targeting and other military operations. They are known as war lawyers.

Since after World War 2, the world started looking at how badly humans treat each other in the name of defence of ideology. They realised the dire need to dictate how to act 'humanely' in the face of conflict; how to behave with civility looking at the mouth of impending death! Law was applied for this purpose.

The War Lawyers interpreted and examined the laws of war in and out. They applied these laws in aerial targeting operations carried out by the US military in Iraq and Afghanistan, and the Israel military in Gaza. They justified their attacks, quoting prevailing laws to plan carnage whilst escaping subsequent legal scrutiny or percussions. They define who legitimate targets are. War is no longer confined to combatant. It legitimised violence against civilians. The net effect of all these is the progressive rise in the number of civilians being caught in the line of fire. They are given names like plain-clothes combatants, human shields and decoy to cover their faux pas. Sometimes we wonder whether there is any truth in these allegations of the contrary as the machines of destruction become increasingly precise to the dot.

I did come into a friendly conversation with a senior lawyer friend about defending a person who had actually committed a particular crime. In some many words that he had explained, my understanding was that it was the onus of the prosecuting officer to prove his client's guilt. It was not up to him to expose his client's misdeed. He was mentioning things like solicitor-client confidentiality and the need for everyone to have adequate representation, but not once was the question of morality or doing the right thing did come up.

I guess the purpose of the court is to uphold the law, not mete justice. Money can buy watertight defence and maybe witnesses too. To add on to Shaw's proposition, one should get the right solicitor when one is accused of a crime. It does not matter whether he actually carried the act. The adage that 'the truth will prevail' is outdated.

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The lost invisible touch!

Sir Robert Hutchison
Father of clinical methods

A friend, during our stint as house officers, told me about an incident that happened during his medical student days when he was studying in Manipal, India. An American elective medical student had joined the group's ward rounds. The old Professor of Medicine was showing them the correct technique of examining the respiratory system. He laboriously punctuated the teaching rounds by asking basic science questions and snarling occasional sarcastic remarks, for not understanding the basics. He was showing the green medical students the art of inspection, palpation, percussion and auscultation.

The American student, failing to see the point of such a laborious examination of a single patient, raised his hand.

"Professor, wouldn't it be better if we just send the patient for a chest X-ray?" he quipped.

That is the state of medicine now. We have lost the art of practising medicine. It is just about diagnostic procedures and laboratory results. Clinicians no longer use clinical methods to diagnose. If it used to be that laboratory and auxiliary tests were used to confirm or disprove our differential diagnoses, now it is the primary modality of the approach of a patient. 

Pretty early in my training, I did an attachment in a Gynaecological Oncology unit. Its head, an old-timer Professor, once was in a dilemma. As part of the staging of cancer in his patients, he would perform a CT scan. This, he would do after carefully performing a complete clinical examination. The outcome of the scan would enable him to decide on the operability of cases. There was this particular cases where he was in limbo. He was unsure of the stage of cancer. After much discussion, argument and reevaluation, he was convinced that that individual patient had an early operable cancer even though scans were reported as otherwise. After much deliberation, he went ahead and assessed the patient under anaesthesia on the operation theatre. It turned out that the old Professor was correct after all. He proceeded with the surgery, and final histopathological specimen confirmed his clinical findings too.

That was how it used to be. Clinical acumen took precedence over laboratory and auxiliary investigations. Now, lab tests take precedence even over a good history taking. The recent Covid-19 pandemic is evidence of the above. Do the swab test first, then the clinician (or perhaps the technician) would decide the next course of action; whether to operate, treat conservatively or even see the patient. Just quarantine and see the outcome later - If he pulls through what was perceived as a death warrant. 

A recent case that came to my attention recently during my work made me realised that perhaps we are too dependant on lab results. Maybe it is fueled by patient expectations of wanting an instant resolution (diagnoses) and fear of litigation. The need for an instantaneous gratification in all human dealings has permeated all social activities. We do not want our results now, but yesterday.

A 30-year-old lady presented with a two weeks delay of her periods. A urinary pregnancy test showed positive findings (i.e. pregnant). The couple presented at their doctor for a pelvic ultrasound scanning. The examination did not reveal much. As she was asymptomatic, she was told to show up in two weeks for reassessment but to return earlier if she felt unwell.

Just three days later, she returned with slight discomfort over her lower belly. HCG levels revealed 2000 IU/L. This time, a vague mass was seen just right of the uterus. A diagnosis of possible ectopic pregnancy was made and referred to a tertiary centre.

Based on the above findings, at the tertiary centre, Methotrexate was administered intramuscularly to medically treat the ectopic pregnancy. 

Follow-up HCG five days later was 5000 IU/L; adnexal mass still present, uterus empty. After the first episode of pelvic discomfort, she had been symptom-free except for the anxiety caused by the turns of events. 

Another three days later, HCG was 3000; still, uterus was empty, and the adnexal swelling persisted. The patient was well otherwise. 

© George Condous

Seven apprehensive days later, i.e. three weeks after her first consultation, much to the puzzlement of everyone, a small shadow was seen in the uterine cavity of what appeared like a gestational sac with a yolk sac in-situ. A diagnosis of heterotopic pregnancy (concomitant intrauterine and extrauterine pregnancy) was considered, and laparoscopic evaluation was considered.

Being confused with the whole turn of events, the patient decided to opt for 'wait and see' policy. A day after that, she passed out blood clots. She was diagnosed as had a complete miscarriage and was monitored periodically. 

So what happened here? Did the clinicians place too much trust on biochemical results over clinical findings? Perhaps not. When the HCG levels are significant, with the presence of extrauterine shadows and an empty uterus in imaging, it would be negligent to just sit on it. Did the methotrexate cause miscarriage? Possibly not. A high HCG with an absence of visible pregnancy is itself a hallmark of abnormal pregnancy, including impending miscarriage.

In anything that the Covid-19 had taught us, it would be that everybody can be an expert. Armed with statistics and articles to support the assertions, anyone can insist on having found the elusive cure for the ailment. Clinicians, who by nature, like to err on the side of caution, had been accused of selling out the whole human race for self-interests. It seems PhD doctors got the panacea for all woes. Their data analyses and textbookish method of approaching disease make them excellent armchair critiques of what is wrong with the medical services in any country. We all know what happens in the field is not what is shown in laboratory experimentations. But still, it is a free world. Anyone can say what they want. The more one delves into a subject, the less he is cocksure about anything.

Perhaps the demand for wellbeing makes medical services a lucrative business. If before, in the Jurassic era, the doctors would call the shots in the management of patients and the running of medical facilities. The ever increasing expense and the need for state of the art medical equipment make healthcare revolve around breaking even and paying the stockholders rather than being patient-centred. Law of Attraction dictates that the smell of money draws characters of reputable character. Hence, vultures and hyenas of various ferocity started flocking around. Referring to the clinical practice guidelines as their holy grail, these creatures of the dark forces scream medical negligence or even manslaughter whenever an adverse outcome ensues. In hindsight, everyone has 20/20 vision. They think that treating patients is like cooking chicken vindaloo referring to a cookbook.

Like the 1927 movie Metropolis, everyone is just a cogwheel in the big machinery of modernisation. We are mere technicians doing our designated duties for the greater good of mankind as decided by the powers that be - the businessman. The future is not bright, either. After breaking down and digitising our individual tasks, our jobs may be assigned to artificial intelligence (AI). We will be redundant and irrelevant.

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Save lives or your skin?

Courtesy: Zee News

Stemmed a mob in Kolkatta cracked the skull of a 
doctor when his 76-year-old patient with myocardial
ischemia and arrhythmia succumbed to his ailment. 
Incidentally, the victim is from a minority group. 
That makes it difficult for politicians to make the 
'correct' decision.

There was a time when it was noble to treat the sick and downtrodden. People who had 'failed' in life, i.e., failed to live up to the expectations beset by the society, would find solace is serving the infirm. It was considered virtuous to live amongst and care for sick. Father Damien cared for lepers, contracted leprosy and was canonised. Florence Nightingale spent sleepless nights holding vigil in her ward to minimise morbidity. Mother Teresa left the comforts of her hometown to answer her call among the poor of Calcutta.  

In public life, many non-religious individuals sacrificed time and energy to establish medical services in many newly independent countries of the East. More often than not, personnel in the medical profession do not work 9 to 5 but start early and finish late, not anticipating remuneration but the thankful nod and warm handshake from grateful patients (mind you, not clients!)

The turn of the century saw a change in lay people's expectations and outlook of the medical fraternity. They were no longer held up on a pedestal but treated as another spoke in the cogwheel of machinery that kept the civilisation going. In other words, they were looked upon as technicians to perform specific tasks. There was nothing divine in their calling. The roll call is the jingling of the cash-machine, they say, Ka-ching!!! 

With the spread of anecdotal reports of cures and treatment modalities, the perception is that immortality is real and achievable in this lifetime. With the increasing litigation risk and corresponding growing medical costs, both care providers and recipients look at each other with much scorn. The doctor views every patient as a potential liability and a possible litigant. Hence, he practices defensive medicine, taking care of all differential diagnoses are not overlooked. He must ensure that if God forbid, any unforeseen malady should strike, he must have a watertight case to keep the swarm of prancing sharks in robes at bay.

The patient views their care providers as money-faced mercenaries out to make a kill on others' miseries. They jump at the term of medical negligence at the first instance any medical intervention go south or as uncharted.

In jumps the businessmen who envisage a future in this distrust. They portray the image of a fair middleman who would promote fair trade. In reality, he is just a wolf in sheep's clothing tasked to guard the chicken coop.  His eyes are squarely on the chicken and the pearly white eggs as well. Like appointing Colonel Saunders to act as the spokesperson for the 'Society Against Cruelty to Chicken'!

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With technology, things become complicated.

Captain America: Civil War (2016)

#Scenario 1: At the edge of Sahara Desert, in front of a small district hospital.  After a whole month of travelling on camel backs in a convoy with no untoward incidents, a Bedouin lady just collapsed much to the excitement of the entire village. Long story short, the lady had a ruptured tubal pregnancy, underwent a laparotomy and went back home smiling.

#Scenario 2: FG was draughted to help out in a small town at the edge of the country when a cholera epidemic hit the state. After attending to the needs of the ever-escalating number of victims, it was snooze time. At an unearthly hour of 3 am, the ethereal time between slumber and wakefulness, the phone rang off the hook. A desperate sounding staff nurse was frantically looking for helping hand. A parturient mother had been laboriously trying to expel her offspring since midnight but in vain. The elusive endpoint appeared so near yet so far. Hearing that a new young doctor from the town of big lights had some obstetric experience, I was summoned.
After assessing the situation, weighing between a 2-hour journey to the nearest tertiary facility and the limited resources, FG delivered the baby via obstetric forceps, panting and sweating under the collar.
Everything went well. To the sounds of a hearty cry of a healthy newborn, FG walked out feeling like a superhero with his imagining cape flying to the morning breeze to the nod of the approving hospital staff!

That was the scene in superheroes' movies back in the days. Life was simple, uncertainties in life few and hurdles were hardly hurdles. The world would be threatened by a megalomaniac mad scientist who wants to rule the world; catastrophe would ensue and superhero would save the day. Mission accomplished, everybody happy. With the increasing complexity of criminal activities, the creativity of destructive forces, crime busting is not like it is how it used to be.

Logically, in the medical field where improved medical technology should translate to more happy faces and satisfied patients. Unfortunately, that is not the case. Even, in the superhero business, it is pretty much the same. People want perfection, no collateral damage and the onus to be accountable to adverse outcomes.

This would be the basis of this 2016 eagerly awaited blockbuster. With the increasing public casualties and public property destruction, the wings of the super heroes' league are planned to be clipped. The booboo at Wakanda is the last straw. As the UN is about to pass a ruling to restrain the powers of Avengers, the superhero is required to consent for the allegiance. That is where the problem starts. Captain America refuses to sign the accord while Stark is all for it. Therein, starts the confrontation. The duel becomes more intense after the UN office in Vienna is bombed and Captain America's childhood, Bucky Barnes, is accused of being the bomber.

Even though there are too many action heroes strutting their stuff in gravity defying feats and lighting speeds, there is no confusion in the story or the case of too many meaningless displays of pyrotechnics. We have Iron Man, Black Widow, Captain America, Falcon, Rhodes, Vision, Clint, Scarlett Witch and Black Panther while Ant Man and Spider Man make special appearances.

In the immortal words of Spidey, "With great powers come big responsibility." Life in high places is no walk in the park or a seat in a pleasure cruise. It also has its ups and downs.