Helplessness Amidst an Epidemic

Due to a random combination of events, I finally had the chance to return to China for Lunar New Year for the first time in 17 years. A chance to celebrate the largest holiday of the year with my family - who wouldn't jump at the opportunity?

I was also excited for the chance to do some volunteer work with local Chinese hospitals - 2 local hospitals to be precise. One of these hospitals is the busiest Women's Hospital in my hometown city of Dalian, and I was excited to observe how the local surgeons perform their gynecologic cases, to learn from their expertise and experience. The other hospital, this one a stone's throw from my home, is the very hospital where I was born. To volunteer and work as an obstetrician in the very hospital where you were born, it feels like life come full circle.

Of course, all those plans were disrupted from the very day (probably from before) I set foot on home soil. During my overnight shift on L&D 3 days before I left the US, I heard rumblings about a novel Coronavirus (2019-nCoV) outbreak in Wuhan, China. The nurses discouraged me from going back to China. One of the charge nurses told me flat-out not to go - what if I don't make it back? But I refused to change my travel plans. I had stayed in Singapore during the height of the SARS epidemic, stayed in Uganda in the midst of a minor Ebola outbreak, survived every single flu epidemic every single year (yeah, there's a flu epidemic every year, causing way higher numbers of serious illnesses and fatalities, but we're all losing our heads over this Coronavirus outbreak, go figure), this novel Coronavirus doesn't scare me. And if this really is the end of the world (which I'm fairly confident it's not), then I want to spend the end of days with my mother, my family, on my home soil.

So I boarded my flight and flew to China. I had a wonderful New Year's Eve dinner with my mom, my aunt, and her family. And then, I underwent 14 days of semi-quarantine. The Chinese government took extreme measures to prevent the spread of this 2019-nCoV epidemic. The Chinese New Year holidays were first extended to 2/2/20, and then to 2/9/20. Everything except for the most necessary services were closed down. In those 14 days, I left my home a total of 3 times, each time with a face mask, and single-use gloves.

I contacted my medical contacts in China. Could I still come volunteer? No, they said, no outsiders were allowed. There was a shortage of health professionals, could I help out? No, they said, no outsiders were allowed. What can I do, I asked? Stay at home, don't go outdoors unless absolutely necessary. My home city of Dalian sent a medical team of 500 healthcare professionals to the Hubei province to help with care of the 2019-nCoV patients. I was absolutely devastated that there was nothing I could do, a useless person sitting at home doing completely useless things.

This situation was absolutely crazy. This is why I became a doctor - to help those who need my help the most. A major epidemic was breaking out in the country of my birth, the country of my family, the country of my people, and all I could do was stay indoors, at home, helpless. That uncomfortably familiar feeling I used to have during my time as a student came roaring back - the feeling of complete and absolute helplessness - watching as medical disasters unfolded before my eyes, with zero ability to do anything useful. How could this be happening to me again? In this situation? In this country? I'm a fully qualified physician with excellent training, dammit!

Never again, I swore. I pulled up the application for Médecins San Frontières. I'm going where the epidemics are, where the catastrophes occur, where my purpose lies. I feel like I'm finally going home.

The Ones Who Remember Us

I was heading to the front desk, asking the clerk to add a patient to my clinic panel, someone who needed to be seen for a same-day visit. As I was walking away, a young lady stepped in front of me.

"Do you remember me?" she asked.

"I'm so sorry, I'm afraid I don't." I scrutinized her features, trying to jog my memory.

"Well I remember you," she said, taking her cellphone out of her purse. She pulled up a photo of a gorgeous young boy. "His name is Dylan, and I wanted to thank you for saving him. He's bright and strong and joyful."

I was speechless. So I gave her a hug, and told her that her son was beautiful. I apologized to her again, for not recognizing her.

She smiled and said "Don't worry. You may not remember me, but I will always remember you."

All those sacrifices I had willingly made...

When I was growing up, I felt stifled by the strict Singaporean education system. It was all work, all study, all the time. I remembered my earlier school days in the US so fondly. We learned about the universe, and played games (played games??!!) in school. And I couldn't wait to go back. The first chance I got, I sped my way back into the US education system, just in time for college.

I confidently turned down my acceptance into NUS to study Medicine. I wanted to pursue a liberal arts education, to become a well-rounded human being. Ever since then, my visits back to Singapore have been few and far in between, and always for the same reason - a brief visit to the US embassy to get another stamp on my passport, allowing me to stay in the US for the next few years. But every time I came back, I contacted my Singaporean friends to meet up, catch up, reconnect. Facebook helped to facilitate these meetings - thank you Mark Zuckerberg.

When I returned after college to extend my F1 visa so that I could further my studies in medical school, I realized that my Singaporean friends had all finished medical school and were already doctors. A slow and painful realization started to seep into my consciousness. I still had no regrets though. No, none at all! I had studied abroad in Paris. Gone to Kenya on an Anthropology trip. I majored in Psychology and Biology, and minored in French and Creative Writing. I had had a life, an amazing college experience. I had no regrets.

When I returned during medical school to get yet another extension on my F1 visa so that I could defer graduation for a year and take a detour through Uganda to work out my life and career goals, I realized that my Singaporean friends were either in the middle of residency or already done. The slow and painful realization grew stronger and more painful. Did I regret my choices and decisions? No, I don't believe so.

The next time I needed to apply for a US visa, I skipped Singapore all together, and went to the US embassy in Guatemala. I said that I was going on a Spanish immersion trip, to learn Spanish in order to communicate with my largely Hispanic patient population. But did some part of me want to avoid Singapore, avoid seeing what my friends in Singapore had achieved, in stark contrast to what I had not?

And now, after all these years, here I am, back again. I too have finished residency. I too am an attending physician working in a large academic hospital, living the dream. "Where did you imagine yourself after all these years of struggle? Ideally? Where did you see yourself in your most daring dreams?" Lily asked me as we were chatting about these nostalgic feelings brought up by my wandering trip down memory lane. I thought about it long and hard. "I guess I always imagined myself right here where I am, an attending physician working in a large academic hospital, living the dream. I guess I just didn't realize that all those sacrifices I had willingly made to achieve this goal, that those sacrifices would be so costly."

I have missed almost every important life event in my family and friends' lives - weddings, births, even funerals. I have moved to wherever I had to, to further my career. I have broken up with multiple significant others because I prioritized my career above my relationships. And I look back over all those sacrifices that I had willingly made over all those years, and in that moment, standing in the middle of the city where I had come closest to calling home, I felt a pang of regret.

A tourist in my own country

It's been 5 years since I've returned to Singapore. The last time I was here, I barely recognized Singapore as the country where I had spent most of my formative years. It had changed so much, become so much more modern, man-made, congested. The MRT system had been overcrowded with people at all hours of the day.

This time around, the government had caught up with the population boom. The MRT system had been expanded, and even the trains were wider than before. "A new MRT station being built every month" the advertisements boasted throughout the country. How was that even possible? But it clearly was. Just in the last few years, enormous buildings had popped up all over the country, changing the skylines and the landscapes by an incredible measure.

I had the good fortune to be exploring the city through the eyes of a first-time visitor, Lily R, friend, world traveler, adventurer. Over the course of 3 days, we hit up all the cool and exciting spots around the country, eating furiously the whole time in order to maximize our consumption of the local dishes. Orchard Road, Marina Bay Sands, Little India, Sentosa, Chinatown, Clarke Quay, Tiong Bahru, Holland Village, Marina Bay Sands (she really liked the lights), Telok Ayer Street, Chijmes. We had been on our way to our final holiday destination - Haji Lane, when we were waylaid by the rain. It came on with furious determination and did not let up at all. So we settled in comfortably at the closest bar and drank pints of beer while watching the Winter Olympics. Not a bad way to spend her final hours in this country before hopping onto her next destination - Australia (the country, and the continent).

Final journey

I happened to be walking by the ICU and saw Sarah, one of the Alabama medical students, sitting by one of the patients looking profoundly worried. I went up to her and when I got closer, realized that the patient she was sitting next to was all wrapped up like a modern-day mummy.

“What happened,” I asked Sarah. She told me that the patient had come in overnight. A 10-year-old girl with epilepsy. She had had a seizure and fell into the cooking fire, suffering full-thickness burns to 40% on her body surface area, including most of her face and upper torso. She would definitely lose both of her hands, with the possible exception of her left thumb. Her eyes were swollen shut, and so they had no idea how badly her eyes were damaged, or if she would ever be able to see again. That is, if she survived.

“When we got here this morning, she had gotten almost no attention from the night staff. No IV fluids were hanging. And guess what she was on for pain?” I ventured some guesses. Pethidine? Morphine? “Ibuprofen,” she spat out in anger. “So I’m sitting here making sure she gets caught up on IV fluids, making sure she gets morphine. She’s only ten years’ old and she is suffering from intolerable pain. Why doesn’t anyone seem to care?” “You’re here. You care. She’s lucky to have you to advocate for her,” I told Sarah.

Just then, a young woman walked into the ICU and headed straight for the patient. She looked into the little girl’s unrecognizable face, and started crying silent tears. She gently touched the gauze wrapped circumferentially around the little girl’s face, whispered a few words that nobody else could hear, and turned away. We both watched the little girl for a few more moments, and then I slipped away, unable to bear the heavy atmosphere any longer.

The next morning, when I walked into the hospital, there was a huge commotion in the hospital compounds. As it turned out, the girl had had a tracheostomy overnight, and had stabilized. The Alabama students had all taken shifts overnight to watch over her and make sure she received continuous IV fluids and morphine for pain. The night staff was so over-stretched that with all the other emergencies going on, she would’ve surely been neglected without the additional attention afforded by these amazingly caring medical students.

The decision had been made early that morning to transfer the patient to Kigali, for the ability to sedate her and keep her comfortable, for the availability of ventilators. Everyone and their mother had come to see the little burn victim get loaded into the ambulance. The patient’s family had resisted the idea of transferring her. None of them could go with her. They did not have the money or means to return from Kigali. So if she were to die, she would die alone, without her loved ones by her side, and there would be no way for her family to transport her body back to Kibogora. She would likely be buried somewhere in Kigali, far from friends and family. But once her family understood that there was not enough morphine here in Kibogora to keep the patient comfortable, that at the very least, she would be sedated and pain-free in Kigali, and her chances of survival would be marginally improved with the transfer, they relented and allowed her to go, solo, on what will likely be the furthest and final journey of her life.

Death of a baby

Julie, the American nurse who has been working longterm at the Neonatal Intensive Care Unit here in Kibogora District Hospital, sat down in front of the distraught mother. The woman’s husband sat beside hher. One of the nurses stood by, ready to translate. Julie launched into a not-altogether unfamiliar speech. After all, there had been 4 neonatal deaths this month, and it was only mid-February. Julie told the mother that her baby was dying. His breathing had slowed down significantly, the heart rate was very low, the baby was turning blue. “There’s nothing more we can do.”

At first, the mother had no expression on her face. Just a blank look. Julie proceeded to explain to her that her first baby, who had died less than a year ago, had died of a different cause. That baby had died because of extreme prematurity, and this one has some sort of genetic defect. This baby looked syndromic – an odd shape of the cranium, non-symmetric chest, rocker-bottom feet, etc. Hopefully, because the 2 babies died of different causes, history will not repeat itself, and her next baby will be born at term, alive, healthy, thriving.

The mother suddenly burst into tears. The news had finally travelled from her ears and reached her heart. She sobbed uncontrollably. This was the second baby she had lost within the same year. Her husband sat by her, expressionless. He didn’t say a word.

“Would either of you like to hold the baby?” They both said no. Neither of them would even look at the baby. Julie asked if she could pray for the baby. The couple gave their assent. We all took great comfort in her words, words that described happiness, and heaven, and innocence, and hope for the future. Right after the prayer, the couple left the NICU, without even a backward glance, a final embrace, a kiss goodbye, for their dying child.

“That’s the culture here,” Julie told me. “They don’t even look at their child if they know the child is dying. To them, baby is already dead.” One of the American medical students picked up the baby and gently held him. “It’s so sad, someone should hold this baby and comfort him until he passes.” So she held and caressed the baby until he took his last breath.

Ward 5C - A tale of poop and professional growth

After working for 2 weeks on Ward 14, I felt ready to graduate to the next stage – Ward 5C, the high-risk labor ward. Rumor has it that it’s just like Ward 14, except with ten times as many patients, and half as much staff. You really have to know what you’re doing in order to not get lost amidst the chaos and turmoil. I’ve been well-trained by the midwives and Lauren. I was ready for the challenge!

I arrived on Ward 5C, fresh and ready to take on the world. Minutes after joining the team on morning ward rounds, a mother started screaming her 2^nd stage scream. Nobody else paid her any attention, so I rushed over to assess her. Yep, just as I had suspected. Her baby was crowning. I gave her strict instructions not to push (“TOSINDIKA!!!!” I yelled.) and ran around prepping the delivery set. When I was ready, I took up my position on the maternal right, ready to support the perineum as the baby’s head popped out.

Now, to truly comprehend the profound horror and irony of this upcoming moment that I’m about to describe, you have to first understand something about me. Throughout my medical career, I’ve gotten used to dealing with all sorts of nasty secretions and excrements that most people wouldn’t consider topics suitable for polite conversation, even for war criminals or rapist-murderers. Nothing really fazes me anymore. I’ve ducked from massive splashes of amniotic fluid exploding out of the uterus (sometimes not altogether successfully…), I’ve jumped back just shy of a giant gush of blood shooting straight out of an accidentally nicked vessel directly at my face, I’ve gotten urine sprayed all over my face when a careless doctor slip-shoddily pulled a catheter after surgery, scrubbed in on a surgery when a man’s complete intestinal contents (mostly in the form of fully-formed feces) spilled right out into his peritoneal cavity, and we had to wash it out with over 30 liters of warm saline, with most of that shit-soaked saline flooding out of his body, off the operating table, and onto my surgical scrubs – yes, it soaked right through the supposedly water-proof sterile gown and got to my scrubs; and yes, I went straight for evening rounds without changing my scrubs because the case had taken so long that we were waaaay late for rounds, and my chief resident deemed it more important to get the rounds done than for certain members of the team to not be a health hazard to herself or anyone around her. You could say that my tolerance for intense grossness is quite high. But one thing that I absolutely cannot get used to, that I absolutely detest, is dealing with human feces passing out of the anus.

From my experience so carefully detailed above, you would wonder how that can possibly be, wouldn’t you? Shouldn’t my month-long rotation on colorectal surgery, with all my varied experience with all the varied forms of products of digestion, have sufficiently immunized me against my personal disgust for shit? But you see, shit you encounter during a procedure or a surgery, while you’re fully dressed with layers of protective gear (which as we have already found out, may not be that protective after all), that kind of shit is enshrouded by a sterile, clinical atmosphere, which removes you from the usual connotations and associations that you may have developed with regards to human excrement. So what I’m trying to say is, the shit you visualize with your camera while doing a colonoscopy is NOT the same as the shit you visualize with your very own eyes passing out the anal canal of a woman who is pushing out her baby. The latter is infinitely grosser than the former, and I have not become acclimatized to it. Yet.

So back to the story. I’m standing next to the laboring mother, waiting to deliver her child. Imagine my surprise when instead of the head, it is the baby’s butt that’s popping out. When I had checked her, what I had thought was the head was actually the baby’s breech. This was a super-premature baby, and the “head” felt softer than it should have, but I figured, hey, it’s a premie, maybe their heads are just softer like that. I had also read the patient’s file, which listed the presentation as cephalic, and so, I guess I felt what I expected to feel, without really doing my job. Hopefully, I shall never make that mistake again.

“Breech! Breech! It’s a breech delivery!!! I need some help!!!” I started yelling, hoping to capture the attention of some senior medical personnel, someone who actually knows how to conduct a breech delivery. I was completely ignored, of course, my cries blending in harmoniously with the cacophony of laboring women’s shrill screams of pain. I didn’t know what to do, so I did what I was taught to do – support the perineum – not that this lady needed much support. The baby’s butt was so tiny it posed no danger to her perineum at all. However, as the tiny baby butt slowly moved out of the mother’s vaginal canal, it started passing meconium (fetal poop, for those of you lucky enough to be uninitiated into the world of medical euphemisms for poop), a slow steady paste, like toothpaste being squeezed out of the tube. At exactly the same time, the mother also started passing feces, perfectly in sync with the fecal motions of her baby. I was in total shock. I didn’t know what to do. How do I deal with this dual onslaught of poop? Whose bum do I wipe first??!

“Ok, MY,” I told myself. “Get a grip. You can do this. Breathe, just breathe, and do your job. Deliver this baby, damn it!!” I took a private moment to swallow my anguish and disgust, and sprung into action. I grabbed some cotton and brusquely pushed the maternal poop out of the way. I decided to ignore the baby’s poop. It seemed a little more innocuous. I continued supporting the perineum, and the baby was progressing along just fine, slowly sliding out of the womb. I had stopped shouting at this point, deeming it a waste of my time and effort to continue trying to draw attention to this maternal complication. However, I was still mumbling “Breech! Breech!” at a barely audible decibel, probably because I was still mentally stunted by the shock of this whole experience, more so than anything else. An American doctor working with Mulago to improve their maternal health practices happened to walk into the labor suite, and heard my feeble mumbles. She immediately realized the gravity of the situation, and that I was way out of my league, delving in unchartered waters. She donned a pair of sterile gloves, and took over from me, just as the baby’s body had been fully delivered, and proceeded to safely and successfully deliver the baby’s head.  

I breathed a massive sigh of relief. Everything was going to be fine. I had even managed to escape the situation psychologically intact, more or less. No situation involving a laboring mother and her poop will ever faze me again. Not after this – my first delivery on Ward 5C. Oh, and one more thing… All the horrible rumors you’ve ever heard about this ward – they’re all true.