by Dr. Andrew C S Koh
Houseman ship in the Ivory Tower
I have sometimes sat alone here of an evening, listening, until I have made the echoes out to be the echoes of all the footsteps that are coming by and by into our lives,Charles Dickens, a Tale of Two Cities
Where the love of man is, there also is love of the artHippocrates
In July 1977, I found myself working in the ivory tower called the University Hospital Kuala Lumpur, presently known as the University of Malaya Medical Centre, as an intern, or houseman. This is a one-year compulsory training for all new medical graduates before being granted full registration as a medical practitioner under the Malaysian Medical Council. I spent the first 6 months of internship in Internal Medicine and the second 6 months in Obstetric and Gynaecology.
I was given provided accommodation in the houseman’s quarters located on the top 14th floor of the University Hospital block.
I will start my story in Internal Medicine first. Each house officer was assigned to one medical ward. I was assigned to ward 13, located on the 13th floor. I took care of 28 patients in ward 13. This ward was under the care of a medical officer, a lecturer, and a Professor. I worked from 8 am until late in the evening but I had to be back at midnight to look after the cases in ward 13. We called this Cinderella call and we did not particularly like this system because we can’t go anywhere after midnight. There was a restriction of freedom but this was good training. It drove home the point that life as a doctor was not going to be easy. You need to have the calling, the passion, the commitment, and the willingness to sacrifice your time wholeheartedly. Half-hearted commitment will not do.
Houseman ship in Medicine was extremely demanding. My day starts with an early breakfast in the hospital canteen. Then off to the ward to do a fast ward round, making sure that I know each patient by name, provisional diagnosis, latest blood tests and imaging results, management plans, and so forth. There would be new admissions that came in the night before which I was not familiar and others were the older ones that were admitted earlier. By 10 am, the medical officer will come with the lecturer to do the daily ward rounds. Going from one patient to the next until the last one may take a couple of hours, depending on the complexities of each patient. After that, I would have to clerk all the new cases admitted via the outpatient department or the accident and emergency department. My job was to take a full history, do a physical examination, and document these on to the case notes. The medical officer would come by later to check on each case and order the appropriate investigations and recommend the plan of management. Then it was back to clerking new cases, doing ward procedures, and reviewing tests reports, until late into the evening before passing over to the houseman on call.
The highlight of my stint in Medicine was the weekly Professorial grand ward round. My Professor will come in at 9 am with the medical officer, and my job was to present every case to her from head to toe. The ward round usually took a long time to complete because the Professor was very long-winded with her teaching and frequently sidetracked by telling long stories and no one dares to interrupt her! By lunchtime, we would have covered possibly 8 or 10 patients at the most and there were so many more to cover! The team adjourned for a lunch break and resume the grand rounds until 3 or 4 pm. After this, I was back to clerking new cases and reviewing reports. By this time there would be a backlog of cases to clerk and my day would end very late!
The houseman ship provided me with hands-on experience, learning through apprenticeship, and supervision. The medical officer was my mentor and I tagged along with him as close as I can without encroaching too much onto his personal space. Now was the time to put into practice all that I have learned in the last 5 years of medical school. I could learn as much as I wanted to or I could be slip shot and just do the bare minimum. It was entirely up to me and I chose the former route. I got on very well with the nursing sisters building up a relationship with them over time. I learned a lot from them as some of them had been in their profession for decades.
The stint in Obstetrics and Gynaecology was an entirely different ball game altogether. There was no more Cinderella call. If I was not on call, I would be free after doing all the duties for the day and passing the cases over to the on-call houseman. History taking was short and sweet and straight to the point. Lecturers and Professors did not breathe down my neck and were not interested in a detailed history of every case.
Here I learned how to deliver babies, observed forceps and vacuum deliveries by the lecturers, assisted in Caesarean Sections, tubal ligation, vasectomy, and minor surgeries. There were some dramatic incidents as well. A pleasant lady who was a long standing staff of the department of Obstetrics and Gynecology came in for a Caesarean Section and died suddenly on the following day. The lecturer said she had a fat embolism, a rare but fatal clinical syndrome.
One day, when I was on-called, a lady who came in for an emergency hysterectomy had a postoperative intractable massive hemorrhage. The Professor on call was called into the operation theatre. To stop the bleeding he performed bilateral internal iliac artery ligation and saved the day. So many pints of blood were transfused but she was survived! The Professor was praised for his prompt and life-saving decision. This was the first they had to resort to this measure to arrest post-hysterectomy hemorrhage in the Hospital.
Of course, the most unforgettable, most painful, and most unfortunate incident was the MH 653 fatal air-crash in Johore on 6th December 1977. It took the lives of all 7 aircrew members and all 93 passengers on board including the late Professor I S Puvan, Professor of Obstetrics and Gynaecology of University Hospital. He was such a well-loved and well-admired Professor with such a big heart, powerful persona, and everyone including his patients missed him so dearly. His impeccable bedside manners and pleasant personality were second to none and hard to match. A real life Dr Kildare. Even until today, I could not forget about him.
Working in the labour ward was equally exciting and dramatic. We would not know when a patient would come. They usually come in at the most God-forsaken hours of the night but seldom during office hours. Patients came in with variable degrees of pain. Some came in screaming and shouting in pain while others came in with more respectable and tolerable pain. It has to do with the pain thresh hold. Generally, Indian women seemed to have a much lower pain threshold. They tend to scream and shout with each contraction and demanded more and more pethidine for pain relief which was not good for the fetus. I learned from the midwives. Some of them had been in the profession for decades and were very experienced. The Indian word for breathing in and out is ”muchu” and the Indian word for pushing with all of your life is ”muku”. When you want her to breathe in and out, you would say ”muchu” and when you want her to push with all of her life you would say ”muku”. The problem was when the houseman mixed up these two commands and said push with all your life when he wanted her to breathe in and out and to breathe in and our when he wanted her to push with all her life! I was told that this had happened to some houseman before my stint but whether this was true or not I could not confirm. They said that truth is stranger than fiction.
I remembered one day I reported for duty in the labour ward, after taking over from the previous houseman. The labour ward seemed to be too quiet because there was no patient in labour. All the midwives were relaxing, having a jolly good time, and you could have heard a pin drop. Being a newbie to the trade, I blurted out, why is there no patients in labour? The mid-wives rebuked me and said do not be a jinx. Not long after this, patients started to come one after another none stop until my shift was over! Now I understand why Paul Simon and Art Garfunkel said in their song, silence is golden!
To be continued….