Perubatan

New Contrasts

Having spent three weeks in Kuching, I decided to conclude my elective in Bintulu, a small industrial city in central Sarawak. I had heard from other elective students that Bintulu, while featuring fewer tourist attractions, offered the chance to get more hands-on experience and to see some exotic medical cases. I decided that since my primary goal of this elective is to experience healthcare under different settings, it was worth the journey.

Bintulu, a coastal city of approx. 200,000 residents, a third of Kuching’s population. I quickly discovered that the city center offers little compared to Kuching, and worse, that the hospital is located 18 km away. The Lonely Planet describes Bintulu as an ‘undistinguished commercial centre.’

I consider myself relatively well traveled, to the point where I generally completely tune out the safety video (and hence would probably drown if there was an actual emergency landing over water). So I was impressed to see MASwings take a more humorous and entertaining approach:

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‘The ATR72 may be different from other aircraft you’ve flown.” To see the complete video, click here.

I arrived in Bintulu Hospital expecting (and in some ways hoping) to find a low-resource, low-tech clinic, and in some ways it was:

A home-made Continuous Positive Airway Pressure (CPAP) machine, used to treat respiratory distress syndrome (RDS) in neonates.

But for the most part, I found the standard of care to be remarkably similar to that found in Kuching. In some ways, it was even superior. Most of the patient records have been converted to electronic, and the doctor:patient ratio seems to be better, letting physicians spend more time with patients. 

I was also able to see a panoply of patient cases. In the pediatric ward, I saw pretty well all the complications of prematurity: necrotizing enterocolitis, bronchopulmonary dysplasia, apnea of prematurity and respiratory distress syndrome. In the medical wards and clinics, I got to feel a Chronic Lymphocytic Leukemia-induced splenomegaly and tactile fremitus (learning that ‘blue balloons’ is preferred to ‘ninety-nine’), both for the first time. I met patients suffering from Melioidosis, a Burkholderia-caused fever, and Guillain-Barré syndrome, an odd condition that causes acute paralysis.   

One of the differences between Malaysian and Canadian healthcare is that in Malaysia, a sick doctor (on right) wears a mask to prevent the spread of infection. Probably something the Canadian system would do well to adopt. 

Arguably the most interesting case was a man suffering from cerebral tuberculosis. Having crossed into a vegetative state, the doctors had been treating the patient palliatively for some time. In Malaysia, there is only hospital and home-care, with nothing resembling hospice care in-between. The result is that many palliative patients take up beds in hospital, which is not just to either the patient or the healthcare system. Hospice care is under-appreciated in Canada, but it became clear to me that it ought not be underestimated.

Into the Borneo Jungle

This past weekend, I volunteered with a Malaysian chapter of the Sai Baba Center, an NGO that helps deliver supplies and medicines to far-flung villages. In Kuching, a local man named Charlie is the backbone of the operation. A quiet, shy man, Charlie has dedicated much of his life to volunteer humanitarianism.

A month ago, an Iban longhouse/village named Ratau Entebang Rantau Betebang was the victim of an unfortunate cooking accident, in which the entire longhouse, home to 120 farmers, was burned completely to the ground. Most lost valuables, all lost their home. Our objective was to bring some much-needed supplies (corrugated iron roofing, water tanks) to help the rebuild. The team consisted of Charlie, his wife Shannon, a volunteer Chandran, myself, and 3 other UK medical students entering their final year: Emma, Nadiah and Lydia.

From Kuching to Sarikei, a 5-6hour journey. Rantau Betebang is actually not found on Google maps, which is another way of saying it’s a little off the beaten path. Sarikei (pop: 56,798 according to Wiki) is the nearest “big” town, separated from Ratau Entebang by an hour of winding and hilly red dirt roads.

Emma. Modeling a hat found on road. She has a beautiful spontaneity, a trait which I wish there were more of, both in myself and in the world.

On our way to the village, Charlie asked us whether we would be comfortable running a medical clinic for the villagers, who don’t receive regular medical attention. The doctor who was scheduled to come had to cancel last minute, and we likely would be the only ones with any medical experience who could help. We were all initially ambivalent, as we were wary of causing harm due to our inexperience. Nevertheless, after further discussion, we agreed to try, while also agreeing that we would not try anything out of our depth.

As we approached Rantau Betebang around 5 p.m., it was as though we were descending into the thick of the Borneo Jungle. It began to rain, heavily, turning the surrounding countryside and roads into mud and goo. Still, the rain seemed of little consequence when we arrived at the longhouse and witnessed the scale of destruction.

Rantau Betebang the day after we arrived, under considerably nicer weather. The heap of burned longhouse was considerable, although the framework of the new longhouse had made good progress. The villagers seemed pleased and amused at our brief stay.

We helped the villagers unload the supply truck. At times the unload was precarious and unsteady because of the rain and mud, but the villagers were hospitable, lending us their rain hats and smiling and waving despite their general inability to speak English and our total inability to speak Iban. The iron roofing was put up with surprising speed, creating a dry area for us to help the villagers chop vegetables and prepare the evening’s stew. After dinner, we found a couple of villagers who spoke some English and from whom we were able to piece together what happened to the old longhouse. We were all quite tired and decided to head to bed around 10 p.m. in preparation for the early clinic we had scheduled for the following morning.

Sleeping under mosquito nets. Lydia, pictured.

After a long night that was frequently interrupted by numerous animals, we woke up, grabbed a quick breakfast (vegetable stew again) and got ready to see patients. It seemed as though the entire village had shown up and filed in, and those who weren’t ill gathered around as if we were putting on some kind of exhibition. We split into groups of two, and each group was given a modestly talented translator. The clinic began and it was intense. Many of the villagers had osteoarthritis from their hard manual labor, and a few others had wound injuries that I was able to help clean and dress. A lot of patients had hypertension; one patient had a blood pressure of 225/125. Some interesting cases included seeing one patient with bowlegs, and another with extreme psoriasis that had destroyed virtually all the skin on his feet. We prescribed basic medications for the patients (acetaminophen was a mainstay), but for the osteoarthritic and hypertensive patients, I wondered how much a 1-2 week course of drugs would help, and whether the intermittent treatment the villagers were receiving would really alter the course of disease.

Emma and Nadiah interviewing a patient.

Some villagers awaiting treatment.

We worked from 8:30 to 2:30 and saw 50 patients. I thought that in the balance of everything we did more good than harm, although the best thing we probably did was before the clinic when we helped bring the iron roofing. We left to return back to Kuching, the six-hour return trip feeling a bit shorter than when we came.    

*July 22: Correction on the name of the village Rantau Betebang

Dr. C.’s Soap Box

Wednesdays are for grand rounds with Dr. C. A much-decorated physician, Dr. C. is flamboyant, eloquent, domineering, intelligent, old-fashioned, well-educated, and arrogant. People either love him or hate him, although I’m not sure which camp I fall in. He is without doubt a talented speaker, but he does tend to be overly verbose at times. I blame the latter on his retirement, as he is someone accustomed to being busy and important, and rounds are one opportunity where he is both.

Rounds generally follow a format where Dr. C. goes through patient cases. Slowly, because he makes frequent interjections and often lapses into anecdotes from his past experience. The anecdote is a powerful but dangerous weapon in medical argument. They tend to be extremely persuasive in determining future decision-making of that particular physician, but anecdotes are often exceptions and rare cases and thus inapplicable to the majority of patients.

Today’s case was about tetanus, and Dr. C. began to narrate a story from 30 years ago when a man presented to clinic complaining of having stepped on a piece of metal*. Seeing no large incision on the patient’s foot, Dr. C. wanted to be cautious anyway and surgically explore the wound. He spoke with a surgeon, who declined to open up the wound on the grounds that the injury did not seem severe enough. A couple of months later, the patient developed complications including a local abscess and lock-jaw. A subsequent surgical exploration revealed that a 2-inch piece of metal had become lodged in the patient’s foot, somehow having penetrated the skin without leaving much of a visible lesion. Dr. C. used this story to state that for the rest of his career he would surgically explore even minor incisions if he was concerned about tetanus. While I understood the merits of the anecdote, I wondered if the risk:benefit of the surgical intervention would have actually been justified for every patient indiscriminately.  

Dr C. leading the grand medical rounds, despite his retirement retaining great influence at SGH. 

I spent the afternoon at a rheumatology clinic. The clinic was set up in the same way as all clinics at SGH are: 2 patients, 2 doctors, 2 tables. There are a number of disadvantages to this approach, not least of which is the lack of confidentiality for the patients. The two doctors often exchange remarks about unusual patient findings with the patient themselves sitting there and present—remarks that I as a patient would be uncomfortable with. I had the opportunity to palpate a number of synovial cysts from patients with rheumatoid arthritis (which are quite different from Heberden/Bouchard nodes), as well as to encounter a patient with both rheumatoid and psoriatic arthritis, an unfortunate combination.  

The rheumatology clinic, resembling a typical clinic at SGH in the 2/2/2 style. 

*For the sake of confidentiality and conciseness, some facts of this story have been altered.

The Surgeon’s Knife

My first day of surgery at SGH. Arriving at the hospital at half 8 (can you tell the British med students are influencing my vocabulary?) I met with the head surgeon, who in the British tradition is referred to as ‘Mr’ rather than ‘Dr.’ After explaining his work hours (8-8, 7 days a week!), he gave me a name of a surgeon to find. Thus began a 90 minute administrative run-around that eventually brought me to the operating theatre. I was pleased to discover that there were about 10 ORs and I was pretty free in jumping in and out of different surgeries. I found one patient undergoing a thyroidectomy and lymph node resection for the treatment of cancer metastasis. After hopelessly trying to recall the anatomy of the neck, I contented myself by finding a good spot to watch the surgeons’ handiwork. 

Some surgeries these days are done laparoscopically with tiny incisions, but a thyroidectomy is not one of those surgeries. The incision is about 4-5 inches across, quite deep, stretched wide open and held with clamps. There was surprisingly little blood for the most part, with a couple of nicked vessels the exception but causing only fleeting moments of concern. The lymph node resection was another experience entirely. The searing of each individual lymph node sent off a little puff of vaporized human flesh. The odor was not unlike barbecued meat, but with enough of a twist and psychological baggage to render the smell revolting.

Poco à poco, the surgeons managed to slowly extract the thyroid tumor. It occurred to me that though I have never palpated a thyroid gland in real life, I would have had no problem palpating the this patient’s, so enlarged had it become. When the tumor was finally extracted, it left the neck looking quite empty.    

The extracted thyroid cancer. Probably around 5 inches in length. 

The next surgery I observed was a total right knee replacement. I had heard that orthopedic surgery is the surgical equivalent of carpentry, but I had no idea to what extent that is true. They use power tools! The patient was not under general anesthesia, which I found strange. The noises of drilling, slicing, and the often-crude banter exchanged between the surgical team seemed to be cruel for any patient to bear. Perhaps they are able to suppress the patient’s hearing… 

 

The orthopedic team goes to work with aplomb. 

Selamat Datang

‘Perubatan’ means ‘medicine’ in Malay, and it’s one of the few words I know in the language. Since arriving in Kuching, Sarawak, Malaysia a week ago, I’ve extended my vocabulary to a few more essential words such as ‘terima kasih’ (thank you) and ‘tandas’ (toilets). Another word is ‘panas’ which means hot—and the weather is panas indeed. Mid 30s with close to 100% humidity, I seem to be drenched in sweat as soon as I leave my air-conditioned room.  

I chose to do my 4-week global health elective in Kuching because it’s where my father grew up. It’s not my first time here—by my count, it’s my fourth—but all my previous journeys were sheltered by extended relatives and I expect this trip to be much different. For one thing, I anticipated being pretty much on my own. I organized this elective by myself, through email, and I’m the only Canadian medical student at the Hospital Umum Sarawak, or Sarawak General Hospital (SGH) in English. 

Some essential travel supplies. Clockwise from left: Stethoscope; Author-signed copy of Sarawak Handbook of Medical Emergencies, 3rd ed.; Hospital nametag; Once-daily Malarone anti-malarials; House keys; Stamped passport; Trusty Lonely Planet travel guide; 100 Ringgit note (worth about 32 CDN).  

I was pleased to discover that there are quite a number of other medical students here, almost all from the UK. They have all been here for a few weeks, as doing a global health elective is a component of their curriculum. Though I have only met them a few days now, it seems that I have known some of them for much longer. In the span of only a few days we’ve managed to attend grand rounds and a neurology clinic, to visit an orchid garden and a cat museum, to sing karaoke, and to share some animated and stimulating conversations over the endless poly-meals privy to Asian culture. I already wish that I could spend more time with them than the 1-2 weeks I do have before they leave.  

   

The Hang Hang Hung Hung Inn. Located a short walk outside the hospital, it is a popular spot to grab a quick, cheap meal and to socialize.

I spent my first week observing in the general medicine department. I’ve noticed that the main difference between the Malaysian and Canadian healthcare systems is not so much the technology (the SGH being maybe 5-10 years behind), but rather the culture. Doctors wield power in the wards. Even as a medical student, I wear a long, flowing white lab coat (almost like a Jedi robe), which stands in sharp contrast to the outfits the nurses wear, which look circa 1900s and are completed with hats. None of the nurses wear stethoscopes, and there is no confusion about who runs the floor. Medicine here is practised much more paternalistically. While in the West, the idea of ‘patient-centered care’ is prevalent and catching on in most hospitals and clinics, physicians at SGH expend far less effort in trying to explain to patients their medical conditions. Patients do as they told, even when they don’t understand. (Should we be surprised when we see low patient compliance?)

This weekend I am attending the Rainforest Music Festival, one of the largest events in Sarawak over the summer. It’s a 3 day concert/cultural workshop/foodtasting extravaganza and the attendance reaches 30,000.