Does Parkinson patient cry?

The door of the Paediatric Department opened slightly and in pop the head of Dr Vimahl from neighbouring Oral Surgery.

‘Alexis here?’

Oh must be another translation job. I gladly went over to the Oral Surgery section, happy to offer my middle-man service to speak in Cantonese to patients.

Dr Vimahl briefly said ‘This patient has psychotic problem. Alleged motorbike fall when knocked over a bicycle. He sustained midface Le Fort fracture, and we plan to do ORIF for him next week. It will cost somewhere about RM1000 or RM1200. Ask him if he is OK with that?’

When I heard the word psychotic, I naturally wondered if this mid-age patient is a safe man.
He was wearing the shabby hospital patient attire, seated on the dental chair. Mid face swollen and his left eye shows subconjunctiva haemorrhage and periorbital haematoma. His eyes are not even.

I addressed him and translated what Dr Vimahl told me to.
His calm demeanor and ability to converse with me granted an immediate coherent stamp.
‘I had been sick all these while, and on long term medications. I never work… I don’t know if I can afford that operation. I need to check with my folks…’ he answered in
Cantonese.

Dr Vimahl managed to reach Biker’s father and passed the phone to me.
I explained the situation to Biker’s father.
‘My wife and I are already in our 70s… Of course I would like the operation done. But honestly, RM 1200 is way beyond our ability. We cannot afford….’ I noted the tone of burden. The situation is rare. To think that some people can spend RM12,000 on unnecessary operations. Usually, government hospital is affordable. It is meant to be.

Many people in their 40s or 50s would be taking care and provide for their aging folks. Not the other way round. Aging parents still need to scrap not only for their own retirement, but also to take care of a sick middle-age son. As the old Chinese saying, it’s their funeral fund!

As Dr Vimahl worked on Mr Biker, I became the mediator and explained to him what is going on, how we are helping him now.
That was when we noticed his feet and arm is shaking.
Apparently he is on medications for Parkinson Disease too.

‘Why are you shaking, Mr Biker?’
‘This is the side effects of the psychotic medications I am taking. Sometimes it’s worse.’

‘Was that before or after the doctors found out about Parkinson?’
‘No. I never had these tremors. Only after I started the medications.’

Dr Vimahl told me ‘Ask him how did the accident happen?’
And I translated the question.

Mr Biker began his story in Cantonese.
‘I was on the motorbike. When I reached a junction, suddenly 2 school kids on bicycles dashed out in high speed. I think they were racing one another. I tried to avoid them, but I still hit one of them. Mind you, I was not driving fast. I fell from my bike.’

Although his voice was controlled and his body in composure, I couldn’t help but noticed a tear fell down his face.

He continued without stopping.
‘The boy sustained minimal injury, I think. Don’t want to report police.’

He finished recalling the incident. And I couldn’t be so insensitive so as not to notice Mr Biker, although psychotic and having Parkinson Disease, he has emotions too. He just shed a tear like a man. Kids are not the only emotional being. Adult patients are patients too, not another fracture face case. He has his own other life challenges too.

I reached out and pat his shoulder.
I slowly went back inside to the Paediatric Dentistry Department, where I am working now. ‘Get well soon, Mr Biker.’

Angelic Colleague

That’s senior officer, Dr Khor Swee Ting =)

Reassurance

Many research papers and textbooks would suggest management of Temporomandibular Joint Pain Dysfunction Syndrome (TMJPDS) similar, if not exactly the same, as such.

Step 1 – Reassurance and Conservative Management
• Soft diet
• Jaw exercise
• Heat or cold therapy
• Short-wave diathermy
Step 2 – Occlusal adjustment
• Splint
Step 3 – Pharmacotherapy
• Muscle relaxant
• Painkillers
Step 4 – Surgical Intervention

In that order.

Now the name TMJPDS might sound too big to digest, and the introduction itself is intimidating enough to make people skip this blog. But wait!! TMJPDS is a very common problem. (Refer DH Felix 2004, Clinical Dentistry, Chapter Oral Medicine)

It associates with jaw pain, dull ache, localized to the muscle area, causing strain or limitation of mouth opening.

Today one 15 year-young girl came with symptoms mentioned above. She was referred from a private clinic. So, upon registration, she was charged a (hefty) RM30. Yes, if you come to any government specialist clinic with a referral letter from private clinics, you have to pay RM30 for registration. (Refer Akta Fee Malaysia)

Alright, my colleague and I agreed with Step 1 without much consideration needed. It was pretty obvious from other clinical findings. So I told the sweetie about soft diet and exercise, bla bla. And I proceeded to reassurance. And somebody doesn’t want to be reassured. I don’t mean the sweetie, but her mother.

She literally stood up and asked ‘That’s all?’

‘Yes, it’s that simple. Majority of people with TMJPDS got their problems solved with just Step 1.’ Reassurance, right? And I’m practicing evidence- based dentistry. (quotation?)

‘If it’s really that simple, why didn’t the referring doctor told us? But instead refer us to specialist?’
Damn, it seems like simple methods are too good to be true.
I knew in my heart this is going to be another case of unmet expectations.

‘And what if two weeks later, there is no improvement?’ Mother asked.

‘Then we move to the next phase of treatment. Occlusal splint and/or medications. And the extreme end involves surgery.’ I’m professional.
Mother obviously won’t buy the conservative solution and I think she already etched in her mind that 2 weeks later, her daughter is not going to get better.

‘What about medications? Will they help?’

‘O yeah, I would love to give you placebo, you woman ….’ No, I didn’t say that.
‘We will consider that at sooner stage, but not now. For now, don’t worry. It’s a common problem with simple solutions. We will monitor your daughter’s progress in 2 weeks time.’ How many times I have to say that.

‘So we have to come again and again?’

‘Yes, you’re going to see more of me.’ I said, matter-of-factly.
The difference between private and government healthcare services is that private clinic is more to Touch-N-Go meet your needs, where as the government clinics need you to come multiple visits. I must say government clinics not only meet the mentioned needs, but we try to provide holistic treatment. Which many patients failed to appreciate.

Finally the mother said ‘OK la, try la try la.’
I knew in my guts that I failed terribly in reassuring her. She came for medications. She paid RM30 and certainly didn’t expect easy solutions for her daughter. She wanted the cause, the risk factors, the diagnosis and the ultimate cure at the every first visit. This is a specialist clinic. But medicine doesn’t even work that way… Or else, what the heck is practicing medicine?

It reminds me of something from the powerful book. Faith brings miracle. Even though the proven solutions are that simple, if patient has the unbelieving heart, she already lost half of the battle. I pray that her sweetie gets well, mostly because she indeed can get well, and partly because my own reputation is at stake. I myself have to be the first to believe that it will work.

As the family left the clinic without so much of thanking me, I shuffled back to my chair and sat down, thinking why some people seek help when they think that they know better?

‘Patient banyak tanya…’ Dr Nazri commented with a smile. Colleagues do understand each other.

‘Tak dapat diREASSUREkan.’ I said.

More Varnish

I did 2 extractions under oral sedation this morning. 2 cases are just too much. After back to back wrestling with 2 kids screaming at my face 1 foot away, my mind went numb. I love kids, but not in the clinical settings. It was so mentally and emotionally draining. To pacify, to restrain and to trick the children. I don’t trick them. The parents do.

‘Ok Ok we’re going home after you take the sedatives.’
‘Ok Ok we’re going home after we apply some ointment on the gums.’
‘Ok Ok we’re going home after Dr gave the jab.’
‘Ok Ok we’re going home now. Ah…. Bad bad tooth is gone.’
Sorry la, Aunty. We still have to monitor him for another half an hour before you can leave the clinic.

‘Ok Ok now we can go home.’
Sorry, Aunty. You still have to pick up some medications from the pharmacy before you can actually go home.

Young kids are so pure. Everything is black and white, no grey area. Their minds are so simple. Either you’re a bad guy or you’re a good guy. To every kids, dentists are in the bad guy category. We can start with a lot of gimmicks to build rapport, but once we pick up the mouth mirror, STAMP! Bad Guy.
Arghhhh, it’s driving me crazy.

I read something by Edwin Louis Cole today.

People could’ve done a better job if the material they use had been of better quality. Which means, the quality of the product depends on the quality of the material used.
Its corollary is equally true: The cheaper the merchandise, the higher the gloss.

What’s the connection of my paedo encounters with this insight? Lolz. I honestly have no idea. None, just some random thoughts.

The CEO speaks

Working in the Paediatric Dentistry department, I realize that screams and crying and wailing are normal part of daily life. Today is no different. And my level of tolerance varies, probably due to hormonal imbalance. It’s the time of the month. I can goo-goo ga-ga to pacify one child and told another to shut up.
One particular beautiful 5 year-old girl came wearing a sunny yellow dress, accompanied by Winnie the Pooh doll, and equipped with an attitude. Her shrieking nearly breaks my ear drum. Hello, my colleague was not even doing anything to her! Some kids are apprehensive and scared, I understand. But one look at her draws the conclusion of a spoilt brat. Thankfully it was my colleague who handles her, otherwise I will suture her lips together.

Thing is, I am still trying to fit in this new department. I am looking for excitement, job satisfaction, passion in what I do. A purpose.

As I was walking in the carpark, I thought of Kah Mun. The Kah Mun episodes had somewhat ended when she was discharged from the hospital. But I miss her, and I hate to admit it. I have nowhere to go at lunch times now, but only to have lunch properly with my colleagues. My kaki-sembang is no longer in ward 6B. It is like I’m so used to care for a person, suddenly I have no one to care for. Or should I say, I could be a blessing to a person, suddenly that person doesn’t need me anymore.
It’s more blessed to give than to receive. Acts 20:35

I never realized the impact of this simple friendship. I certainly didn’t expect all this, the day I copied her number into my phone. I feel God’s abundant blessing over me whenever I visit Kah Mun, even when she can speak naught. God blesses me when I go and bless others.

At the carpark, I was wondering. God, what am I to do now? Each day to work, without a clue, without a passion. And now, no more Kah Mun.

I looked to the sky. The CEO responded
Go and touch another soul la 😉

Sounds great. OK Boss.

Homing Pigeon

‘How’s your day today?’ Vern asked.
‘Ecstatic!’ Better than any drug in the world.

For the past few days, I spared my lunch hours to visit Kah Mun in the ward. She had been progressing excellently in healing day by day. Praise God! Previously with a tube on Kah Mun’s throat, I only managed a monologue for not more than 5 minutes. Now, she being able to talk again, we exchanged many interesting conversations. From schools to traveling to music to pets to sports to future, etc. I told her to pursue her dream, be a doctor, maybe. I silently and shamelessly hoped that I am an inspiration. Muahahaha!
‘But I have many dreams,’ said she.

‘What are you going to do the first thing you get home?’
‘Wash my hair…’

From awkward monologues minutes, my visitation timing extended to half hours, and then yesterday, I didn’t even noticed an hour flew by. I always pray every time I made my way to the ward, that God just be with me when I’m there. It is evident that God blessed the visits. Not only to the patient, but the visitor is very much blessed herself. Stranger doctor- patient relationship turned into a really cool friendship.

Every time I visit her, I would be wondering why the heck the Plastic team wanted to keep her hospitalized for so long? Coz she is not supposed to eat, food must be blended and enter through a tube from the nose, bypass the mouth and directly into her stomach … It is already mind-numbing boring to stay in hospital for 3 days, not to mention almost 2 weeks??

Yesterday was admittedly fun. I borrowed a wheelchair and took Kah Mun for a hospital joyride. I imagined giving her a bowling experience with the wheelchair and human bowling pins, but decided better to behave because I had my white coat on.
‘This is the garden I told you about.’
‘This is the dietary kitchen…. Where they prepare all your meals.’

She is sensitive to cool air. In the ward, it was so hot and stuffy that her family spent quite some bucks on batteries to operate the handy mini fans. So, Kah Mun can almost smell where there is cooler wind or catch a whiff of a/c from any doors ajar.
‘There’s cool air there,’ and she would make me stop right in front of an open door.

‘Moving on… this is the test laboratory.’
‘Yeah, there was once I spent hours waiting for my blood results only to find out that the clinic had not sent down my samples yet!’ says the patient.

Kah Mun said we attracted a lot of attention. Now did we? Not that I care if people were staring, but she seemed to be enjoying it.
As promised to the ward nurses, I returned their patient by 2.15pm yesterday. It felt awesome. As if my lunch times had been the highlight of my day to day mundane work, when visiting Kah Mun made me feel alive. Reason being? God is with me when I am with her.

Today, first thing in the morning after I clocked in, I went to ward 6B.

‘Good morning!’ I cheered.
‘So early today?’ Kah Mun had not expected me as I normally visit during lunch time.
‘Yeap, and I will visit you again later, but probably not lunch time as I need to go out and run some errands,’ as I clipped a card in her visitors’ scrap book.

Scribbled behind the postcard
Embrace life. It is waiting for you outside of the hospital!

‘I’m going back to work first, will visit later.’ I reassured her, with my signature smile.
Like always, she looked at me walking away and like always, I waved back.
Little did I know, this is the last time Alexis visits Kah Mun in ward 6B. There isn’t a visit later anymore.

While I was outside running my errands, I got 3 miss calls from Kah Mun.
It only means one thing. She is getting discharged! Kah Mun is homing!!!

I rang her up and she told me that she is going home. I was so excited that I think I spoke quite fast and loud. The only regret is I won’t be able to send her off with a hug. You see, God is really good. I so happened decided to drop by in the morning with a postcard addressed to a patient going home after a long hospital vacation. When she hung up, I think I caught a sobbing bye.

Why cry when you get to go home, strong girl? You battled and survived 14 hours of operation, 3 days in ICU breathing on machines, 10 days in the ward, unable to walk and talk, feeding via tube directly into the stomach, losing significant amount of weight, etc.
Why cry…

Don’t cry, darling. I texted her.
With a new and different face, a changed jaw, you’ve got humungous adjustment to make in life. People might stare at you. Life’s other challenges may just be about to start. This would be my sharing today if I get to visit you later. But nope, I had not told you about many important things. One of which is Jesus loves you.

Kah Mun going home. I am simply ecstatic all through the afternoon and at night when I met up with my gang at UTP. My feet never touch the ground. Thank you, God!

Although I knew she won’t be on Bed 31, ward 6B anymore, I went to the ward just to get a kick of things. The nurses already changed the bed sheet and another patient is lying on the bed where Kah Mun used to be.

Life goes on, huh.
And I got myself a new friend.

Kidz

Kids are cute. Most of them. Even when they are crying.

Being in this Paeds Dental department for a mere 1 week, I guess I had my fair share of blood curling screaming and high decibels crying.

Han is a 6 year old boy. Fair and handsome, but very apprehensive.
And he needed an extraction…

We have gentle ways to deal with difficult and uncooperative kids. That is the beauty of medical sedation. We weighted him and gave him his dose of sedative.
Go to sleep, boy. You and I will have a better time.

Thing is, Han doesn’t want to sleep. After 45 minutes, I peered into the Recovery room to see if he was knocked out. Han’s grammy looked at me and shook her head. Not yet? Ok we’ll give him more time.
Checking at one hour, he was only barely groggy.
The sedatives got minimal power over him.

Anyhow, we gotta get going. While carrying Han to the dental chair, he started to stir to wake, which is a bad sign. O yeah, did I mention that this is my first oral sedation case? With grammy on the chair with him, the nurses tried to pacify him back to sleep. Which he did, for a minute or two.

Until one poke of the needle…. Hell broke lose.

Screams can be heard a few cubicles away. Han started to kick within the tight embrace of his grammy. Time is of essence, as my supportive team amusingly grew bigger to 2 officers, 3 assistants/restrainers and 1 trusted ol’ grammy.

I took a moment to get the tooth out, it was grossly friable and carious. All these while, Han was fighting, screaming, crying and kicking. Bad tooth with big big worm inside was taken out and I quickly compressed his gums with gauze to stop bleeding. That was when Han decided to bit on my finger angrily.
‘Aarghhhhhhhh!!!’ this time the doctor screamed.
Damn, I didn’t know that human teeth can be so sharp and it was momentarily painful. Thank God that he released the bite quickly enough for my assistant to reposition the prop to keep his mouth opened.
‘Doc, u ok?’ a chuckling nurse asked.

Han was not comfortable yet. At least, not his heart. He kicked and gosh, he really kicked. With one kick, he sent a water container flying in the air and dropped to the floor. It was OK to wet the floor, but it is certainly NOT OK to kick the container which was attached to the dental chair! The nurse later reported that the screw got loose. Ow….

I still find Han adorable. As long as he didn’t cause damages serious enough to affect my wallet. Kids perceive pain and security very differently. Han had not stopped sobbing long after we kept our hands off him. He buried his head in grammy’s shoulder and refused to look at any of us. Lolz.

‘Sorry darling,’ not really sure if this would make any sense to a 6 years old. Sigh, this is another day where you gotta be cruel to be kind.

My nurses colleagues commented
‘Dr Alexis dah takut budak dah…’

Houseman answer first. Eat later.

Today I stepped back into hospital for Paedodontics (Teeth and Children) attachment posting. Just like Ortho posting, I came neutral. Minimal excitement and hoo-ha, perhaps because my favourite Oral Surgery attachment is already history.

New month. New clinic. New colleagues. New boss. Mr Thevadass.

Day one, I am already sent into the Operating Theatre. Which is quite a good notion compared to being in the clinic with nothing to do. Now, we will be dealing with kids.

And yes, hospital is an emotional place. Dammit.

An autistic kid is scheduled for dental clearance under general anaesthesia. Dental clearance would mean that we will fill any restorable cavities, and extract all that cannot be saved. Yeah, I heard that one kid with Down Syndrome had teeth so bad that the surgeon had to (sadly) extract 19 of his teeth.

This kid was sleeping beautifully when I arrived. Next to him was his mother who was struggling emotionally. A softly distorted facial expression as she gazed upon her sick child. Agony. Come on… this is only dental clearance. Nothing terrible will happen. What are you worried about? But we never know the heart of the mother. Perhaps the worrisome issues are bigger than what can be seen.

The anaest team wheeled the kid into the OT, as mummy followed in. They started to work on the kid. I noticed that mummy was fighting back tears at the corner. And lost. She was sobbing, as the medical team busied ourselves preparing her young son for dental treatment. The kid stirred and woke up, and it doesn’t take long for any child to recognize an unfamiliar place filled with unfamiliar people. He cried and screamed for mummy. Mummy snapped from corner, quickly rushed forward, picked him up and held him tenderly.

The Gas Doctor instructed mummy how to hold kid firmly so that anaest team can gas him. The kid was restless and fighting to break free. Mummy alone was unable to restrain him, so 5 or 6 other people helped holding him tightly. Kid was crying, struggling against the grips of 5 adults. Mummy started to cry too and said the most heart-breaking words for today ‘Mummy sorry, mummy sorry.’ She had to do things the hard way, betraying the trust of a young son by cooperating with us.
Gas Doctor held the mask over the kid’s nose. With every gasp of his crying, he inhaled the anaesthetic gas. Soon, he stopped crying and fell asleep. Mummy entrusted him to our hands and dashed outside crying sorrowfully…

Not entirely rational, but very heart breaking. Very emotional. Among everybody there, I am the only newbie and obviously the only one affected. The love of a mother is simply indescribable. I miss my mother suddenly.
I remember fighting back tears when I was in the OT for the first time in my life, thinking about my own mother going under the knife when I was still in university.

Anyway, on a lighter tone, my new boss isn’t as hard as I thought. Yes, he won’t tolerate wrongness. So as long as I don’t screw up, I believe days would be easy? Just for these first days, I decided to use the Dumb (Silent) Strategy, that is to speak only when necessary. Then and again, to be dumb (silent) appears dumb (stupid).

‘Ok, senior officers go take a break and have your lunch first. The houseman here gotta work until operation is finished,’ Dass boss said.

Houseman?
Me, a houseman? I never really thought of myself as a houseman. Housemen are fresh medical graduates who can’t do anything right but still act smart and tough in front of the nurses and patients. They got scolded by specialists. They have to survive up to 72 hours in the hospital before going home. And la dee da. But I am a dental officer, not a medical houseman.
Well ok, my actual term is First Year Dental Officer (FYDO).
Well another ok, maybe FYDO is equivalent to a medical houseman.
Eat humble pie, Alexis.

Then Dass boss came again
‘Define fibrous dysplasia in one sentence.’
Silence of course. Who wanna try jumping into a well just to see if you can jump back out again?

What? I forgot what the heck was fibrous dysplasia the moment I finished my school exam.

‘We start from the houseman first.’
Dang. I tried to distract him by saying something about the current operation but failed. Anyway, I gave him an answer based on my wit.

Day one of 2 months, may the Lord give me wisdom and wit to get along with my boss. He seemed to be an OK guy if we’re cool. My senior colleagues Dr Aida and Dr Khor are just very nice people. They deal with kids, you see.