**MEDICAL BLOG - Don't read if squeamish!**
This was the beginning of a short week, following my four-day weekend. It had thundered overnight, though not nearly as ferociously as the storm a few nights ago! The air was fresh, a rarity for Malaysia even at this early hour. Aunty Buan dropped me off at the hospital in time for me to arrive on Neurosurgical ICU for the morning ward round at 0800. I found Prof Tan and a Dr Palini (affectionately, Prof Palini) busy scribbling at a desk near a bed; I couldn't see the patient for half a dozen family members were crowded around it, some crying, one man wailing inconsolably, some standing still, shocked. I tapped Tan on the shoulder; he said hi, then motioned me to pull up a chair, which I did. I could now see that the form he was writing was a description of events for this patient; his colleague's form was in Malay but looked very official. The patient was a young Malay boy, not even ten years old. Apparently he'd been admitted a few days ago, having fallen from a couple of metres out of a tree, hitting his head. He'd come into the Emergency Department still obeying commands, though groggy and vomiting. CT revealed nothing but mild bruising, so the boy was admitted under constant observation. Unfortunately the neurosurgical team were in the OT when the ward called next time. The boy had lost consciousness, having deteriorated rapidly a few hours after admission. By the time the team had reassessed him he was coning. They performed an emergency bifrontal decompression craniotomy, but it was too late. Fast-forward a day, and there I was, witnessing the boy's family stood wailing by his bedside, their young child having just passed away ten minutes earlier. No parents should ever have to see that. There was nothing the team could have done. Life might be cheap in Malaysia, but nobody likes the passing of a young child.
Tan took me to the ED, a call to assess a patient who had just come in. 45 year old, motorcycle accident. Another one not wearing a helmet; obvious skin damage over the right side of his head, and a swollen, deeply bruised right orbit, consistent with a base-of-skull fracture. The CT confirmed it, massive haemorrhage in the right temporal and parietal lobes, midline shifted and potentially falcine herniation; there was also evidence of subdural bleed. The petrosal ridge had a fracture, the auditory meatus might be involved too. Assessment of the patient was not great news - pupils fixed and dilated. There was nothing anyone could do for him; another family to break bad news to. Life is cheap in Malaysia; annoyingly, not as cheap as motorcycle helmets and seatbelts.
This cheery start to the morning thankfully gave way to a more positive end to it. Tan patiently allowed me to tag along with him to catch up with patients he hadn't had a chance to see thanks to the paeds trauma in the ICU that morning; we entered the non-air conditioned adult male surgical ward, and noted patients to review were all in good stages of recovery; the same was said about the take on the female ward, and two had to be written up for surgery. If there was a patient involvement in the consent form, I didn't see it - this had either been done already, or wasn't needed here. Tan cannulated one lady, but the other wasn't present for pre-op bloods; he'd come back later for this patient. His phone rang; the consultant I thought. Maybe a reg. One call ended, it rang again, and again after that! Maybe bleeps aren't such a bad idea after all. We headed to another ward, not air conditioned either; a Chinese gent with a cap sat on a chair waiting Dr T's arrival, and acknowledged his presence. Tan disappeared into brown wooden doored side room, beckoning me to follow, and inviting the gentleman in once he'd opened a dressing set and washed his hands. This chap was a patient with Parkinson's Disease; but a year or so ago had been invited to have Deep Brain Stimulation - offered to many at the time by USM! Unfortunately, due to funding cuts, the service had to be withdrawn, but this patient was still benefiting from his DBS device, barely a sign of Parkinson's as he walked across the room, admittedly with a cane, and sat down for this routine appointment for his head dressing to be changed, oddly, I thought, by a senior registrar! The man's son was a qualified doctor in Manchester, England, and had trained there too! My browner skin colour obviously did me justice here - I was asked how long I'd been living in England for!
Prof Tan let me write the notes for a few more patients being reviewed, before he followed up two more cases that he'd seen previously, firstly the young boy from my first day who'd undergone a debulking of his frontoparietotemporal teratoma; he was still very weak on his right side, but this was improving; he was trying to talk again, but had poor control over the right side of his face still. Good to see he was improving though, especially after such a huge brain operation! The 2 week old with an encephalocoele was reviewed next, on the paediatric ward; he was still stable.
A few more jobs to get out of the way, and CTs to book for patients, and Tan very kindly offered to drive me to a place he was familiar with, for makan. We descended into the bowels of the hospital, and users of the underground carpark had conveniently (and owing to its fullness, statistically improbably) left him room to get his white saloon Toyota out of its space. We travelled a while, toward the centre of the town, and arrived at a Chinese-run eatery near a river flowing through a man-made drainage ditch, water visible only sometimes through its green weeds and lilies. The cafe consisted of the corner of a building, chairs and tables arranged under an overhanging roof, the gloomy kitchen off to one side. Prof Palini, who had been sitting with Tan earlier when I'd entered the ICU, was sitting at a table with his back to us, but recognised us as we arrived and beckoned us to join him. He'd just recently sat his exit exams, one year Tan's senior. The cafe having just run out of curried noodles (curry mee), we opted for rice, egg, and a nice vegetable soup, with iced Chinese tea, and chatted over the very nice meal which Dr P very kindly paid for.
On the way back to the hospital through the area of KB I still didn't recognise, we stopped at a stall serving fruit that Tan had obviously been to several times. It was the Malay equivalent of a Drive-Thru - a tiny stall on wheels parked up by the roadside, that you placed your order through the passenger window! For about RM5 he bought four packets of what turned out to be jackfruits with sugar that tasted slightly of sherbet. They were crunchy, refreshing, and surprisingly nice! Discussing the pros and cons of a life as a neurosurgeon in Malaysia - pro's being harder to identify than the cons which included massively long hours, small teams and a lifetime on-call, we arrived at the hospital, and walked through the main corridors to head our different paths, myself heading to the Jabatan Neurosains offices to sign the non-disclosure agreement mentioned many days beforehand by Prof Jafri.
Home now, typing this blog I sit watching a thunderstorm roll by to the south, noticing cousin Charles has posted a facebook picture of the exact same storm from his 12th floor window in Menara Mutiara. Even though the rain is falling loudly on the roof above, and the sky is overcast, it's still verging on hot outside. Chinese soaps are on TV again, and mum is busy boiling some chicken stock in the kitchen, the familiar aromas filling the bungalow, wafted by the ceiling fans.
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