Excerpt #60: Operating In A Small District Hospital

Operating In A Small District Hospital

M. Bakri Musa (www.bakrimusa.com)

A few weeks before the airline disaster, it was Hari Raya Haji. I was looking forward to taking the family back to Seremban, and the beach at Port Dickson. My parents too were looking forward to our visit. My last break was at Hari Raya Puasa, just before the Sultanah’s death. I needed a holiday, even a brief one, badly.

            I was to leave that Thursday and have an extended weekend, returning the following Tuesday, the day after the celebration. Late on the eve of our departure, I had a phone call from the State Medical Director. He informed that I had to substitute for the surgeon in Batu Pahat, some sixty miles north. I was not aware of any other Malay or Muslim surgeon in the state. Surely a non-Muslim surgeon would not be so inconsiderate as to take the Muslim holidays off and have a Muslim colleague cover for him!

            Karen and the kids were disappointed; they had been looking forward to that trip. I left after making my rounds, and gave a ride to one of my young patients and his mother who needed a ride home. As they were from a village on the way up there and well aware of how erratic village bus services were, I offered to drive them home. She did not hesitate accepting my offer, with no put-on hesitancy or false modesty of waiting for the second or third offer, in the usual Malay courtesy.

            Again, reflecting on what Malaysia and Malay society have turned into, I wonder what would have been the repercussions today had the moral squad stopped me and found a young woman in my car who was not my wife?

            The road to the village had more potholes than an adolescent’s face pitted with acne scars. It was straight enough along the rice fields but with the ubiquitous pot holes we had to crawl along, with her and her boy in the back being tossed around as I swerved to avoid yet another deep pothole or braked upon another unexpected dip.

            An oft-quoted hadith had it that Allah admitted a man to heaven because he once removed a thorn from a path. If that was the reward for removing a thorn on the road, imagine the special place in heaven for those who build roads. However, that applies only if the road is safe. An incompetent engineer building unsafe roads is laying but a dangerous death trap. Or as American tort lawyers would put it, an attractive nuisance.

            No sooner had I signed in at the Rest House at Batu Pahat, I was called in to the Emergency Room and was met by a Malay intern. He was surprised to see me. He thought I, being a Malay, should be off for the holidays. He was working because being at the bottom of the totem pole, he had no choice. I however, being a surgeon, was at the top of the heap and thus should have had my way. Smart intern!

            The patient was a pedestrian hit by a lorry. It did not take me long to diagnose internal bleeding from a possible ruptured spleen. I explained to the patient and his family the need for immediate surgery to control the bleeding, detailing the risks of waiting. He and his family agreed right away. The intern was surprised, not at the patient’s quick decision rather that I had explained the procedure in some comprehensible manner, and the need for it, to the family members. Judging by the intern’s reaction, I presumed that was not a local practice.

            I did the surgery with only the surgical technician, also a Malay who happened to be, like me and the intern, unlucky enough to be on call during Hari Raya. The case went smoothly. Surgery on Malaysians was rarely a technical challenge. Unlike in the West, they were not obese.

            When I announced that I was closing up, the anesthesiologist was startled as he had just given the patient a booster dose of muscle relaxant, anticipating a long procedure. Seeing that I now had plenty of time, I went into teaching mode, going over with the technician what I had done, showing him the clot that had temporarily stopped the bleeding, acting as a tamponade. It would be easy to imagine that if the clot were to dissolve or get dislodged a few days down the line and the patient could bleed to death; hence the need for the immediate surgery.

            I demonstrated the different techniques of removing the spleen, as with medical splenectomy when the organ is enlarged (hypersplenism), or when it is so large as in malaria that it could be easily injured and ruptured during the removal. There, we would first tie the artery and then inject adrenalin into the organ so the blood would be squeezed out into the veins and be preserved. It would also make the organ smaller and easier to remove, lessening the risk of tearing and uncontrolled bleeding. Indeed, he related an incident when such a tragic mishap did happen.

            Despite my impromptu extended exposition on splenectomy, we still had plenty of time to spare. To fill it up, I asked whether he would like to close the incision. He was more than eager; and was slick with his hands. I demonstrated the various suturing techniques, and when and how to use retention sutures as well as cosmetic skin closures. He was thrilled, and was a fast learner.

            When we finished he told me how much he appreciated what I had shown to him. He never had such an operating room experience since the British surgeons left way back in the late 1950s. Local surgeons were not interested in teaching him or any of his fellow technicians. Those local surgeons treated him and his colleagues not as fellow professionals but as inferiors. He was thrilled to have a young surgeon who behaved like the old colonial ones. He meant to compliment me, but I was saddened by his remarks.

            I had a few more cases that weekend, with that Malay surgical tech eagerly coming in to scrub. He wanted to learn as much as possible from me as he would not have another chance! Wow, he sure knew how to flatter me!

Excerpt # 60:  Envy, A Dangerous Sentiment

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