A different world – part one

I’ve been spending my last single-married days gypsying around a small part of this enormous country. It’s wonderful to pick up conversations and see the years of distance, and some of my lingering resentments, melt with time. I’m surprised at the generosity and tenacity of many friendships through enormous changes within my own family life, and equally varied changes in my friends and colleagues as they graduate, switch careers, retire, get engaged, move cities, change churches, and more. It’s also been a new experience for me to actively seek out and spend time with my parents’ friends who supported mum and flew a long distance to be at her funeral last year. I long to tell her about these catch ups but I suppose they’d never have happened if she was still around because she was so social herself.

My travels took me back to work as a locum hospital resident. Whilst clinical work in itself is pretty much the same wherever, the context was completely different. I’ve forgotten how much quicker mainstream consults could happen. History taking can take a quarter of the time, patients often know or have a list of their medications and doses, you can give a script without explaining what to do with it, and people have their own mobile credit to make follow up phone calls.

It was nice to see say, an 18 year old guy, be responsible and organised enough to catch an Uber back to the hospital for a follow up review. There were some lovely older people and I kind of miss geriatric medicine. Some amusing university students too, as they caught glandular fever from each other at college, or came in with dramas post O-week pub crawls and parties. It was refreshing to not come across any injuries secondary to domestic violence, or deal with heavily intoxicated patients, despite doing several weekend evening shifts.

On the other hand, the level of entitlement was incredible. A category 4 patient, essentially recovered from her mild community acquired pneumonia, complained that we provided a “very poor service” because she had been waiting for 2 hours. A man waiting for a similar length of time to be seen for gastritis after deliberately eating “very spicy” food for an entire week complained about the ridiculous wait times and wanted me to promise him that pathology results will be available within 30 minutes. Oh you have no idea, I thought. At best you’d be waiting 4 hours for these ED presentations at my local hospital.

There were high earning government employees rocking up to ED instead of their GPs, complaining that GPs in town don’t bulk bill enough. Whilst looking up the hospitals I came across locals reviewing these public hospitals on Google, like… complaining about the food. Friends who lived here told me news stories in the past where a MP kicked up a fuss when someone in their family sat in the waiting room for hours like everyone else. Another politician tried to get a specific combined oral contraceptive pill banned in the country when his daughter had a deep vein thrombosis – um, all COCPs have the potential to increase clot risk. Plus his daughter went on a long-haul flight and had a genetic disposition to forming clots (which was discovered during the workup after getting her DVT).

The level of health concern was also a massive contrast to my usual workplace where, for example, a woman with an eGFR of 3 refused to go into hospital to start the process of dialysis.

Here, a mum brought her 7 year old son in because he swallowed a tiny bit of water and had a few coughs afterwards. A couple in their 30s re-presented after being discharged earlier that day because they didn’t know how to give oral paracetamol to their one year old – they almost didn’t let the nurse show them how either because they didn’t want the kid to spit out the medication again. Another man told me he was well informed and knew about antimicrobial resistance, but kept asking what needed to be done about his URTI – furthermore, he wanted me to confirm whether it was a “reoccurrence” of the same URTI from 3 years ago. Someone who self discharged post surgery (hence went home without a follow up appointment) tried ringing outpatients twice and couldn’t get through, so came into ED to get his follow up arranged.

I try to treat patients respectfully and listen to their concerns regardless of why they’ve presented. But I feel that some people living in our capital need a bit of perspective about life elsewhere in this country before complaining that the government doesn’t provide for or spend enough on healthcare in their city.

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Urban sketching #2

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Sketching with C in 2018 – half are mine and half are hers. See also urban sketching #1.

She has heaps more awesome ones done on days that I didn’t draw anything but I’ll let her share them on her own social media accounts (of which there are many). And why do teenagers want to hide all their stuff, including drawings, from family but at the same want to share everything with everyone else on the world wide web?

Men are hopeless, women are trouble

A (more) light-hearted post, after several heavy ones. He’s already told everyone in town so I don’t have any qualms about writing this story.

On the hunt

This matter came to the forefront of my attention one fine night. My sister was out and we went out to dinner with a family friend who was around my father’s age.

Quickly their bantering turned to women. “As young as possible, and pretty,” said the man. My father agreed, “I met some old classmates and the ones our age look terrible,” but added, “I don’t need a young one.” At home he’d already concluded that young women don’t marry for nothing. More importantly, they may say that they don’t want children, but there are many years ahead to change their mind.

I rolled my eyes and told him on the way home that guys my age have more sophisticated conversations than this. Or perhaps it’s all the same once you’re single and available.

First meet

Between the time of my grandfather’s death and funeral, he went on this peculiar trip to a “nearby city to see some friends”. After the funeral he spent about a week sorting out the estate and financial affairs, before hopping on a plane to the same city again, supposedly on the way home. I was under the impression that this place was close or en route, until I saw on Google Maps that it took 5 hours to get there by high-speed rail.

I called an emergency meeting with his sister and we concluded there must be a woman. My aunt raged about men being hopeless, “Your father is clever but when it comes to these things… 男人的脑子混掉了.”

Meanwhile my sister and I were doing some detective work from home. Her iPad has a linked Apple ID and initially we could see just one photo with a woman’s hands caught behind the food, geotagged to where they were in China. Several days later there was an actual profile photo. Coming home that day my sister stopped me, “Hey sis, gotta show you something, I see a woman!!”

Interlude

After he came back there were a few months of late-night talks and stories about how interesting this lady was. By that stage he had figured out that my sister could see any saved photos. So instead of having them on the phone album, he was saving them by sending a copy to mum’s WeChat account. “Oh,” I teased as he showed me a photo, “you’re showing mum your girlfriend?” Not that she would be upset. At hospice she had an animated chat with me thinking about which lady friend would be suitable – when he found out what we were talking about he rejected the idea immediately, saying that women were trouble.

Second meet

Now, the estate was a difficult piece of work and required court to gather all beneficiaries at the start, then again on a later date. So a few months later he went back to China again. Apart from the signing at court on day one, he’d also scheduled extra days “to sort out stuff”. It was fine that he was getting to know this person (of an appropriate age) but I was super annoyed about his holiday coinciding with my sister’s school deadlines, the flu I started getting just before he left, and a week where I had extra work commitments.

The last straw was when he told me over the phone that he wouldn’t attend my settlement as promised. “Can’t go because it’s my first day back at work. It’s alright, just pick up the keys. It’s an old and crap unit, not like anything can change.” You mean you can take a week off for her and not half an hour out of your day for me? That’s it!

But he changed his mind and rocked up. As we were leaving the unit he volunteered, “Don’t worry lah, it’s over, story finished.” He recounted some anecdotes from the trip and the string of things that went wrong from the very beginning to the end. “All I could think about was that song, ‘She’s a Little Princess, little princess, little princess!’ You know the one C used to watch when she was little? Every episode starts with I want… I want…! I said you need to change and she said but you promised to treat me like a princess!” I laughed, what, did you really say that to her?

“I told her yeah, I was taking this seriously but even little princesses need to grow up.” Ouch, that’s harsh. I took the opportunity to remind him who his real princesses were and how grown up they were. “When I got to the airport I blocked her straight away. Then I got a message saying blah blah blah.” How did that happen if she was already blocked? “I blocked her but forgot to block her mobile phone as well.” Oh, you heart breaker!

Marking milestones

Without a particular effort to do so, I make mental notes about all sorts of sad anniversaries. Kind of like Facebook’s inbuilt “on this day” function.

First hospital admission

oct2017

08/10/17 from her WeChat moments

07/10/18 Edited from my diary that I hardly write in

One year ago mum went into hospital and it was the beginning of the end but we didn’t know that at the time. It was a weekend and she felt bad going into hospital because she already had an outpatient appointment the following week. I said to her, it’s okay, that’s why people are on call and this is a medical emergency. Stop thinking about hospital expenditure (she was a health economist for 17 years).

ED wasn’t too busy. I helped her to say the “right” words – numbness, weakness, bowel and bladder problems. Medical oncology and radiation oncology were involved straight away. An after hours MRI was done. Soon she had radiotherapy – the consent discussion was that you can either have it and have permanent cord damage, or not have it and have permanent cord damage anyway.

During her hospital stay I asked the team to chart aperients from the start but this was brushed off until her abdomen became distended later on. When the chart for Endone ran out at midnight, she and dad arranged to sneak in supplies from home because the ward nurse and covering doctor sometimes took a few hours to get around to it. I was too embarrassed to do the smuggling in my own hospital.

And with that she was home in a few days, walking unaided. It was like a miracle. They bought her more than a month of relatively normal life. Until it happened again.

Second hospital admission

dec2017

06/12/17 Aug & Dec PET scans

On this day in 2017, she was admitted to hospital for the second time with spinal cord compression.

Mum was interstate at her scheduled PET scan and sarcoma sub-specialist appointment when the numbness returned. So what did they say about this yesterday? I asked, when she presented to ED the morning after they flew back. Oh, I didn’t tell them, she replied with a little, slightly crazy laugh. What? I looked at her incredulously. They’d want me to be admitted and I don’t want to die there.

As farsighted as she was, none of us expected that she wouldn’t be coming home again. If the change between these PET scans happened quickly, the pace picked up even more thereafter. We could touch and feel the subcutaneous nodules grow from pea-sized (on admission) into incredibly large, golfball-sized masses within a few weeks.

I’m glad we’re going away this year, given the many one-year marks that are coming up:

  • Church carolling – We have a video of the church group singing this hymn with her and I haven’t been able to re-watch the video since. I think the words mean something deeper when you’re dying: “虽然我的肉体和我的心肠渐渐的衰退,但是神是我心里的力量,是我的福份直到永远”
  • Christmas – Mmm delicious hospital food… turkey? Jolly trolley? (Daily alcohol was offered to palliative patients and family members!)
  • End of year thanksgiving – I was so upset at the combined cell group thanksgiving last year because all I could hear was people being “blessed” with a smooth-sailing life.
  • New years – Dad didn’t think C needed to cut her trip short but mum and I insisted. So we got her back in record time and did a NYE countdown together with sparklers. We’ve taken thousands of photos, all across the world, but these would be the last ones we’d have with the four of us together. Mum dressed up and put on a headpiece and fake fringe. She looked okay propped up with pillows in her hospital bed but was actually barely able to sit up due to paralysis.
  • Mum’s birthday – She wanted me to organise a “big one” and we did, cramming in more than 30 people into her hospice room. We arranged for her three siblings from China and US to come and surprise her. She used all of her remaining energy at her party and that night was the last time we saw her awake and conscious.
  • And… her death day – two days later.

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