Excerpt #46: Clinical Challenges in JB

Excerpt #46:  Clinical Challenges In JB

I had two unique clinical challenges in JB. One was the large number of pediatric burn patients; the other, psychiatric patients with acute surgical problems from the nearby mental institution at Tanjung Rambutan.

            The pediatric burn patients touched me. Nothing tugs at your heart more than to see a child in pain staring at you pleading for help with their weary, watery eyes. Their frequent dressing changes were painful and had to be done in the operating room.

            I wanted to collect as much clinical data as possible on those two challenges. For the burns, I assigned Yahya, my most senior trainee. I saw the potential of many papers, and what better way to help launch his career than to have him publish a couple of papers with me. I guided him on effective literature search as well as chart reviews, and to think of future trials on a prospective basis to be conducted to improve their care. I was most interested in the preventive aspects.

            Most were the results of home accidents, in the kitchen from spilled hot fat and boiling water, as well as during Hari Raya and Chinese New Year celebrations from exploding homemade carbide cannons and fire crackers respectively.

            Village families cook on caste iron, round-bottom kualis. In the traditional kitchen with three metal spikes protruding from the ground, those kualis are stable. When placed on the parallel bars of the ‘modern’ stove-top grill, they tip with ease, splashing out their hot contents.

            The psychiatric patients presented a whole different set of problems, one being delayed diagnosis. Their psychotropic medications also interfered with their intestinal motility. We had many complications arising from that, their hard stools rubbing against the inner lining of the intestines forming stercoral ulcers that could perforate, causing life-threatening peritonitis. Managing colostomies (artificial opening of the bowel on their abdominal wall) in such patients proved problematic. I assigned that review to another trainee.

            Meanwhile my formal seminars were going well. We did one on surgical emergencies in the newborn and reviewed the few cases of tracheo-esophageal fistula (TEF) in KL from the adjacent huge maternity hospital. In all cases I was called in late when the patients were in extremis from their lung complications. Despite extensive preoperative chest management, none of the anesthesiologists would touch those patients. I was wasting my time, they counselled me. One accused me of wanting to “experiment.”

            I had scrubbed on a few such cases during my residency days. Being rare and complex cases, they were done by the attending with the residents as first assistant. That was how we learned.

At my seminar, I focused on the need for early diagnosis to avoid the chest complications that doomed these patients. I told the audience that I could not care less who was the one calling me if they suspected a case. Even the student nurse could call me, I emphasized. The essence was early diagnosis and intervention if we ever hoped to salvage these unfortunate babies.

            A few weeks later I had an excited call in the middle of the night from an intern in the maternity ward. She had been through a rotation in my unit and recalled my earlier seminar. She said that they had just delivered a baby who might have TEF. After telling her to also call my medical officer, I came right away. She was right on her clinical diagnosis; I complimented her. I instructed the nurse on elementary pulmonary care.

            I called the anesthesiologist. Like his colleagues in KL, Dr. Poopathy too balked. I was wasting my time and giving the parents false hope, he added. I told him that this baby had the best chance being that he was born just a few minutes ago and had no lung complications as yet. I did not know what it was that triggered him to change his mind. He came right away.

            In the operating room as we were setting up, I reviewed the instruments and went over the procedure with my team. It was less my instructing them, more my mentally rehearsing a thousand times the many steps in my mind.

            As soon as I opened the infant’s chest, I gave a huge sigh of relief! The anatomy was exactly what I had anticipated from the x-rays. I would need minimal dissection to connect the esophagus and close the fistula. The surgery went so smoothly that Dr. Poopathy was taken off guard when I uttered my signature phrase signaling the end of a case, “Let’s get out of here!”

            A few hours after surgery seeing that the infant was doing so well, we decided to extubate. Later in the afternoon I checked on the baby and he continued to do well. The next day I removed the chest tube. Now the only tubing attached to the infant was the intravenous line, a vary tangible and reassuring sign of improvement to the mother and also us.

            Later in the afternoon as I was making my rounds, to my horror the mother was nursing him. Seeing that both were so contented, I did not interfere. The baby was not very good at sucking nonetheless I gave him an A-plus for effort. From then on, the recovery was smooth and fast. The mother’s only concern was the baby’s cry. It was shrill and high pitched. I assured her that this was common with the condition and to give it time.

            I emphasized to her to continue nursing and not rely on formula so the baby could develop his sucking skills and instinct. In Malaysia then, as in most developing countries, bottle feeding was the rage while breastfeeding was associated only with the poor and those unable to afford “modern” formula. With all the negative associations with breastfeeding and the glamor implied with bottle feeding, the results were often catastrophic as those formulas were mixed with less-than-clean water. It did not help that the major formula makers, in particular Nestle, were giving away generous samples of powdered milk free to new mothers, a marketing technique drug dealers would later emulate with devastating effectiveness.

            When we lived in Bungsar, our daughter Melindah had a febrile seizure and was hospitalized at GHKL. Karen brought our son Zach along and would breastfeed him in the open so the other mothers could see that it was something cool and that even “white” women did it! In JB too, Karen would ask the nursing mothers in her group to come to the hospital to demonstrate breastfeeding. It helped that Dr. Tan, the pediatrician, was also enthusiastic about breastfeeding. I reminded my patients that infant formula was but powdered cow’s milk, and cow’s milk is best only for calves.

            On second thought I wondered whether that was a good reminder to this particular patient. She was Indian; to them cows were sacred. I hoped she would not treat powdered milk as being holy or divinely sanctioned and would stick to breastfeeding!

Next:  Excerpt # 47:  Tolerating VIP Visitors

Excerpted from the author’s second memoir, The Son Has Not Returned. A Surgeon In His Native Malaysia, 2018.