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It has only been 3 weeks. well, almost. the extended hari raya and christmas break aside. the experience in melacca general hospital is priceless. i have encountered many things that i think will remain etched in my mind for a long long time. it was as close to having a culture shock as one who comes from the same culture can get, if you know what i’m sayin’. here are just some bits and pieces.

countless men, some almost reaching their 60’s, with HIV due to past, and some still are, IVDU. one came in with meningitis symptoms, a ‘buang daerah’ case due to previous drug traficking (i dont even know such things exist!) another has had tb before, defaulted treatment, and came in again with tension pneumothorax secondary to ptb. countless others whose cd4 is closing to 400. none of those who i met are on HAART treatment.

this old chap had copd for a long time. then he came in with community acquired peumonia. try the curb score; he scored positive in all parameters. the oxygen saturations was also very low. CXR findings confirm bilateral lung involvement. he was pulling off his biPap machine all the time because he was confused. yet 2 days later he self-discharged (must be his relatives who made the decision-he was confused!), against medical advice.

he came in with STEMI, for the second time. the first one was less than 6 months ago. streptokinase cant be given again. alteplase is not available (good news-will be soon!)  cardiac cath and stenting is of course out of the question. he got heparin, despite the lack of evidence for giving him that. it’s better than nothing… the next appointment with a cardiologist will be in IJN, as there is no cardilogist around.

he is very skinny and frail, very breathless as well. he said the pain is unbearable. he was admitted again for the 6th time this year. the list of medical problems go on and on. but his CXR is the most interesting part. sitting right there is a very very big blob of white. oops that’s not the right way to describe a CXR. let’s start again. there is a homogenous left mediastinal opacity measuring almost 12 cm (i’m not kidding!) in its widest diameter. it shifts the trachea and the heart to the opposite side. the right diaphragm apears flat. the specialist said it’s aortic arch aneurysm because the outline follows the arch. the manipal college professor was adamant it is a lung ca. ct had been done but sadly the result could not be found anywhere.

and dont get me start on diabetic patients. if i guess any patients in the ward who are older than 40 as a diabetic, i would be right 80% of the time. and they are diabetic on spot diagnosis-that is how severe, or how poorly contolled their diabetis are. some with av fistula in situ-end stage renal failure. some with foot ulcers that stank the whole room and are definitely not pretty to look at. some are sitting prop up, breathing effortfully with JVP right under the auricle even when sitting-in heart failure.

almost all patients are sick, very very sick. there are lots and lots of signs to pick up. to illustrate my point bronchiectasis is diagnosed with CXR only, no need for high resolution CT at all (not that it is available anyway)because at that stage patients simple wouldn’t come to hospital, and would neither be admitted nor investigated as well.

and when the disease is at its severest form, or its most advanced stage, multiple organs are involved. no matter what treatment is instituted, adequate relief from symptoms are not possible, let alone cure. today this man with end stage renal failure complicating diabetis was admitted to the ward after 2 days in icu. he has et tube in situ, and the GCS is only 5. the wife already signed a do not resuscitate order. the young son, barely older than my little brother, ran out of the room, crying. and this is when medicine gets tough. it is easier to think of the patients as an assortment of symptoms, signs and investigation findings, like a puzzle waiting to be configured. when a man’s life is added into the equation, along with his past and his family, it takes another dimension altogether. it involves emotion.

so all in all, it has been really interesting. when i come back to the polished wards in RPH, the image of ward 3-3 in malacca gh will remain in mind. dont get me wrong, not all is bad. anti-tb drugs are free, and poor patients even get money for travel expenses. governement servants only have to pay rm4 for every day spent in hospital and the drugs are free as well. probably more about how things are run and paid for in another blog ya..