Work 2018.1 – part two

The reflections on work 2018.1 are a little overdue. I usually write about my terms when they end but my time at the Aboriginal medical clinic has rolled on past my 12-months term.

Thinking about prayer

I’m struggling with prayer personally. I’ve also struggled with whether to, and how to, pray in the clinical context. Last year we had a Christian couple share on the topic of “praying with patients”. They are highly respected and the most generous colleagues. Still, I was taken aback when their take was to not pray or talk about your faith. Or if you had to do it, do so discreetly to protect your professional reputation and registration.

Early this year I was given a book about a Christian neurosurgeon who routinely offered prayer with his patients. The surgeon ventures way further into spiritual conversations than I would consider doing. Nevertheless his conviction to attend to spiritual needs where appropriate, and his reservations in doing so, are relatable and helpful. The story starts with him, a confident neurosurgeon, feeling terribly nervous and self-conscious in the pre-op area because he had made up his mind to offer prayer with a patient for the first time:

“If I prayed and things went badly, it could ruin patients’ faith. What if that happened? Will it shake their faith or make it less likely that they would ever want to know God? Would they be angry with me or with God?” – Gray Matter, David Levy

Praying prayers in clinic

Not long after I read “Gray Matter” I was sorting out medications for a patient with bad lungs and heart. People travel in and out of town and medications are sort of, well, not a priority for the journey. Frustratingly, reception will squeeze them in “for scripts” between booked appointment. Sometimes these patients are very unwell and had just come out from the ward (or ICU!) because they took their own leave from hospital.

Even in these days of electronic health records, there are often no up-to-date medication lists and you need to call up multiple sources to prescribe safely. Remote clinics dispense medications onsite and patients expect this from urban centres too, but we aren’t funded to do the same. So working out which pharmacy, which dosing aid, when pick ups can occur and how to assist with transport all takes a long time.

I was doing all that whilst half-heartedly making small talk. She got my full attention when she started complaining how doctors think they know everything, but “God created me and my body!” Every day she prayed for her heart and lungs because God made them and knew exactly how they worked. I agreed with her that God is creator and we doctors do not know everything. I offered a short prayer, which she joined with great conviction. She should still take her medications though.

More recently I offered a pap smear to a woman who didn’t have one for more than 15 years. She consented and appeared to understand what the procedure would involve. Then she stopped as I motioned towards the examination bed and I wasn’t sure if she was still following. “Wait wait,” she said, “I’m just going to pray.” She was a follower of Jesus. So I said go ahead, and closed my eyes too. I caught a few key words as she prayed an animated and expressive prayer in language.

Learning from patients

Of course not everyone is Christian, and many also speak about curses and black magic with real fear. Witch doctors are often sought after in conjunction to Western medicine. But my biggest surprise working in this environment remains how spirituality isn’t something to be “shame” about. The gospel can be offensive but not every conversation mentioning God has to be awkward or confrontational.

One woman didn’t want an intramuscular injection in her buttock that day, because she wanted to sit down at Bible study that evening. Another expressed that her final plans were to go back to country and she was not afraid to die, because she will meet Jesus. Still another, who had her children taken from her and her partner for alleged domestic violence (towards each other), mentioned several times how she was praying for her daughters in foster care. She knew Jesus from her mum, who worked as a Christian leader in the local women’s shelter in a remote community. Last post I wrote about the man who expressed how he chose to walk straight as a Christian leader.

Children of God

Many times I couldn’t help but question, are you really a Christian? Why are you still smoking and not taking your medications? How can you be in trouble with the police and child protection? Or live in those overcrowded houses with scabies, on welfare?

Each of us are accepted as God’s children if we truly believe that Jesus is our saviour. Yet acknowledging we are in the same family of God is challenging because I have an unspoken assumption that real Christians will be like myself. It’s hard for us to see any wrong in ourselves and even if we do see our sins, we think these sins of respectable middle-class citizens are somehow acceptable before God. When the religious leaders looked down on the sinners shunned by society in Jesus’ time, he answered them:

“…It is not the healthy who need a doctor, but the sick. I have not come to call the righteous, but sinners.” – Mark 2:7

Before I could work out how to do it myself, I saw an example in my patients of how they talked about God and prayer openly, acknowledging faith in everyday conversation, like it was a natural part of their lives. I think honestly wrestling with difficult questions is still important but I also saw here the strength of people who could just pray, rather than spending an excessive amount of time wondering how and whether prayer works. Those are lessons to learn.

“Most of us assume that we have a lot to teach the materially poor about God and that we should doing the preaching… but oftentimes the materially poor have an even deeper walk with God and have insights and experiences that they can share with us, if we would just stop talking and listen.” – When Helping Hurts, Steve Corbett & Brian Frikkert

The author in that book stumbled across a group of locals in the middle of an atrocious and poor urban slum. They were gathered in a makeshift cardboard shelter to sing hymns and praise God. He was encouraged by their authentic prayers and sincere faith.

“…Has not God chosen those who are poor in the eyes of the world to be rich in faith and to inherit the kingdom he promised those who loved him?” – James 2:5

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Walking straight

Last week a man came in for a health check. I offered the standard pathology tests, including a “men’s check”, in the most no-obligation, neutral way possible. He worked as part of the teaching staff in an Aboriginal ministry college but it’s hard to assume anything about patients. I work in an Aboriginal clinic, in a region with some of the highest rates of STIs in the country.

He looked at me, not dismissive or offended, but gave a considered response in simple English (not his first language). “Yeah we can do check up, but I don’t think I need it.” Then he explained, “I’m a church leader in community. I need to walk straight,” and gestured a straight line forward with his hand.

“I’ll be honest, when I was young man I came to town and drink. Not drunk, but drink a bit, and have women. You feel attractive when you’re young.” He continued, “Now I don’t do that. We need to practice what we learn. I’m community leader as well, you can’t go to meetings with everyone looking at you and know you do those things.”

Wow, I don’t expect patients to articulate their commitment to church leadership with integrity, in the middle of a consultation:

“In the same way, deacons are to be worthy of respect, sincere, not indulging in much wine, and not pursuing dishonest gain. They must keep hold of the deep truths of the faith with a clear conscience.” – 1 Timothy 3:8-9

Outside ICU – part two

Continuation of outside ICU – part one. Did I mention this was supposed to be a short stopover on the way to our honeymoon?

Ward rounds

Little quacklings scurry around with their white coats and masks. I guess the big quacks are too old to scurry. There’s a squinty-eyed one with a bow-tie above her ponytail that swishes behind as she walks. Another girl (young male doctors are scarce) talks slowly and dreamily, as if she will drift into the clouds any minute. I don’t learn the medical jargon from them.

All visitors talk about 指标 but under my aunt’s command, our ward rounds are more sophisticated. We slip the friendly PCA a bottle of whisky to report the obs in real-time, at least twice a day. I’m told he’s better than the short female PCA who blatantly demands big bribes every few days because she’s looking after your relative, but doesn’t deliver.

One uncle takes his daily walk down to the doctor’s room. He’s friendly, slick and smooth – a professional middleman, or a senior consultant, as he likes to call himself. Settling confidently into a chair, he finds an obliging young doctor to log him in. Thanking them, he proceeds to navigates the electronic medical records himself, taking photos of all relevant pathology and radiology reports for the day, forwarding the 数据 into our family chat group. My aunt nods approvingly, telling us this uncle is diligent in completing assigned tasks. She turns to her own husband and says he’s good too; slow but steady. Then she points to her younger brother, my dad, and shakes her head.

Each person reviews the numbers on their phone and we huddle to discuss today’s progress – 今天的度血样饱和度，血样分压，白细胞计数，肾功能，纳，钾。。。The family is non-medical but have worked out things that I didn’t know after 6 years of medical school, such as the basics of BiPAP settings or the effect of steroids on WCC.

Visiting hour

Visiting hours start at 3:30pm but no one is allowed into ICU. The first sliding glass door opens but the second opaque door remains closed. Peering behind staff entering in and out, all that’s visible is a small waiting area with gowns and masks, which don’t seem to be used very often. Beside the door is a small square window.

Arms clamber over one another to be the first to get their mobile phones in through this window. The PCAs takes them to the patient’s bed and the video calls start. In a few minutes the two TV screens on the wall flicker on, each screen split into four quadrant. There’s a camera, similar to a CCTV camera, above each bed. You can briefly zoom into a quadrant for a better view, until another relative steps forward to click back into their quadrant. It’s like a zoo in this narrow corridor, with movement, voices and echoes growing increasingly loud.

None of the patients say much – some have tracheostomies, others are barely conscious. Initially grandpa nods and gestures to us but can’t talk with the BiPAP mask. When his numbers looked slightly better, my uncle passes a portable radio through the square window. We gather around to watch the screen – what will he do? He fiddles with it but his hands are oedematous and weak. Hands that, just a few weeks back, were nimble and clever in reviving watches, fixing zips and capturing waterlily shots. He gives up on the new toy because it’s new and unfamiliar. And because he’s tired. By this time we stopped video chats and could only send in short audio recordings or brief written notes.

Outside ICU – part one

Prequel

The 3-day stopover this month was to see my maternal grandparents. They cry each of the few times my sister and I call, so we’re scared to do so more often. Mum was their youngest child and 白发送黑发 is a parent’s nightmare. Physically, they are surprisingly well. Grandma looks a lot like mum but I never noticed the resemblance. Though largely wheelchair-bound, she has regained some strength in her right leg with great determination and perseverance on her part. Her mind is sharper than ever.

The backstory is that grandma had a major stroke three years ago, on the first night I stayed over at their place. She was subsequently in hospital for several months and much of that trip was spent getting to know the local hospital system. Things like, how the nursing staff on the stroke ward aren’t concerned about turns or pressure ulcer prevention, until one appears; or how much nursing care is done by relatives 24/7 even when you pay privately for a patient care assistant to help. I puzzled over why normal saline was given continuously in patients tolerating fluids and why a PICC line would be inserted for this purpose; or why CTs were done in rehab every several days for at least a month to “monitor progress”. Taxi drivers and every person on the street knows why, and of course I got a sham explanation for my naive questions.

Sequel

This stopover suddenly became the trip itself when my paternal grandpa’s straightforward hospital admission deteriorated rapidly into respiratory failure.

Day one. The lift doors open to a wall outside ICU, lined with several foldable recliners – the type you would find at the beach. My aunt sits in one, immaculate hair, blue summery scarf draped across her shoulders, talking on the phone as if she’s in a corporate meeting. There’s just a slight shake in her normally commanding tone. Everyone knows she’s 领导, even in this situation. Inpatient admission at this sought-after hospital happens through money or connections… or a long wait (and not on a bed in ED). Just getting an outpatient appointment in this public hospital is like buying tickets to a concert. The 黄牛 buys all the queue numbers for the day and resells them at over ten times the original cost, splitting the profit between themselves, the hospital security and the specialist.

She’s busy calculating the amount of 红包 to give the head of department – too little is insulting and too much won’t be accepted as bribery technically does not happen in this exemplary hospital. Actually, the doctor wouldn’t have accepted any amount except that she’s doing so as a “friend”. Good doctors at good hospitals are good friends to have and my aunt has deliberately made several over the years. Life here is complicated.

Work 2018.1 – part one

End of 2018.1

It’s been awhile since my last “end of term” reflections and I’m running out of titles for them.

The other day I saw the gardener from that last post for the first time this year. He was standing back to look at and snap photos of his handiwork – after transforming a section of the dusty makeshift carpark in the front of the hospital into a small vibrant garden.

Work arrangements

I’ve had this enviable registrar lifestyle with part-time clinical and non-clinical work. Regular hours, no weekends, lunches where it’s possible to go to the bank if needed, and fairly easy negotiations for (unpaid) leave. I’m realising a few things:

1. Many arrangements are possible in medicine, although not all are financially advantageous.
2. A couple of part-time or casual appointments can add up to more than 1.0FTE – obvious I know, but it’s easy to think a few hours doesn’t count for anything. Managing several remote desktops, inboxes and HR systems also takes time.

Busyness

I hate it when I procrastinate but I also hate this tendency to be busy. Although less frowned upon, an excessively full calendar is as much of my failure in scheduling as lazing about and getting nothing done.

Both reflect an inability to maintain focus and discipline in life.

Focus

Speaking of focus, some of my favourite exercise metaphors (there are many) come to mind during BodyBalance classes:

1. Staying still doesn’t look as difficult as doing weights, but requires concentration and a different kind of strength.
2. When staying still in a difficult balance position, I have to fix my eyes on an unmoving spot. Not the instructor or person in front of me because they wobble and then I fall over too.

The second one I initially discovered from a patient rather than the gym instructor. I was removing a foreign body in clinic and despite trying to stay still, this patient’s eyes would flicker away as the needle approached each time. When he later focussed on a spot in the room the stillness was so remarkable that I thought I should try it myself.