abortion country II

"Do you think it's a miscarriage."

I purposely avoided her eyes, leaning over to fasten the tourniquet.

"Well, it's... something we have to consider, given the history."

18 year old female, approximately 12 weeks pregnant, one week history of lower abdominal pain and sudden onset frank PV bleed today.

"I mean, I know you're not allowed to say... but do you think it is one? I think it is."

Gravid 2, para nil. Elective termination September 2017. 5 foot tall with large mousy eyes and an angular nose, she was small in a way that somehow also managed to be lanky. To me, she seemed younger than 18, which is to say that if you were to rank her on a bell curve in terms of phenotypical precocity, specifically with regard to the estrogen dependent secondary sexual characteristics relating to mammary glands and fat redistribution, her spot would be somewhere in the lower centiles, which is to say that to me she looked like a kid. She looked about as adult as she probably felt right then - no longer a girl, not yet a woman.

I could tell she had steeled herself for the ordeal. I pictured her, after the initial panic, riding the ambulance in silence, surveying her predicament with a growing resolve. Throughout the history taking, she displayed a good-natured equanimity I had come to associate with the older patients, a calmness that comes from acceptance.

When she said, "I think it is," I looked up from the tourniquet. A lot of times, the answer to 'how should I respond' is 'what does the patient need to hear' and the clues typically tend to reside in the face and the eyes. Does she want for me to deny or corroborate? Does she need the honest truth or a well-meaning platitude? Which will cause the most harm? Which will do the most good? But I saw no pleading or desperation or bravado in the face that accompanied the statement. Only a gentle resignation. The declaration was simply that, a confession with no expectations, with no reciprocal obligation.

I turned my attention back to the tourniquet. "Well, I think... You know... we'll - we'll see what the gynaecologists say... but, you know, it is something... we do have to consider."

She was quiet for a moment, then looked away. I winced internally, wanting to give her more than 'who knows', and having basically told her, 'well, it isn't not a miscarriage'. But it seemed that was enough for her. She withdrew again into her resolve and then only asked innocent questions about blood bottles and being a doctor.

Minutes later, we sent her up to the gynae ward to be assessed. Would it have been kinder just to say, 'in all likelihood, it probably is a miscarriage'? For one, I wasn't clinically experienced enough to be certain of the diagnosis without a scan to confirm. And even if the diagnosis were certain, I wasn't equipped with the knowledge, wasn't in the right setting or frame of mind, hadn't practiced the magic words to counsel her on what it meant, what to do next or how we could support her.

In medicine, you sometimes find yourself in situations where it is your privilege and duty to break news that is life changing. Sometimes it's good. 'The operation was a success.' 'Congratulations, it's a boy.' Sometimes it's not so good. 'The biopsy results have come back, and I'm afraid it is not what we hoped it would be.' Sometimes the best way to break bad news is to let someone else do it.

In a year's time, I wonder if she will remember that cloudless day in May, the one she spent in hospital. In ten years' time, she will recall having a miscarriage when she was 18, and it will be an indelible part of who she is - a part of the bedrock for the house that she calls herself - and my microscopic role in it will likely have been forgotten.

Likewise, I will forget what she looked like, what we talked about, how I felt about the whole thing. But maybe some of it will have made a difference. Or maybe what you say doesn't matter at all. Maybe it gets swallowed up in the tide of everything else that happens. A kind word. A comforting hand. Can small acts of kindness make any kind of lasting difference? Is it metal in a broken bone, that stays in and supports their weight forever, or is it just honey on a dressing, covering over a wound temporarily to help it heal.

As you begin to age, you begin to lose friends, hair, family members, bladder control, memories, and you begin to realise that life is as much about what it gives to you as what it takes away. The day you find out you are pregnant. The day you find out you aren't any more. These landmark moments form the raw material, the minerals and marble out from which you get to carve meaning and identity. And as life gradually stops giving, and starts taking more and more, you begin to understand that life is also about finding yourself in quarries sometimes, and trying to give each other good marble to work with, even if it's just a pebble.

reality tv

analog man

angel of music

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the note in itself has no meaning. It could be any note in isolation, it doesn't matter, doesn't convey any feeling. But put two together and now there's a story. A tension maybe, a harmony perhaps. Now add another and you have a chord. A chord can be sad, can be happy, can be strange, can be jazzy. It's the relationships between the notes that give it meaning. The distance. A semi-tone, an octave. And then add a melody, separate them in time, play them sequentially, add another relationship. The timing, a quaver, semi-quaver, ghost note. How long - how short, what you decide will give the song another quality, another dimension. The scales are the fundamentals. Now I realise why. There are certain structures that resonate with us. Certain distances that just feel right. Major scales, minor pentatonic scales, Dorian. We give them names, the same way we name plants, children. There's a feeling of having discovered them instead of invented them.

No matter how lovely you can sing / play a single note, how much vibrato, how strong, how clear. It's the relationships between people that give life meaning, and getting the distances right, practicing your scales, learning to play your instrument well enough to play with others, that fill it with music.

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maybe listening to this kind of music doesn't make you a better person, but maybe it helps you realise that you could be one, maybe even that you want to be one

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it's mind boggling to think that a human came up with this piece. That at some point these notes were just ideas in an individual's head, and then notations, scratchings of ink on a piece of paper.

When you encounter something as elemental and pure as this, it's difficult to imagine that it ever existed as something other than perfection. When you get into the middle, to the rolling, rushing, cascading waves of emotion - it's as if there was nothing to be translated. You forget there is a pianist, a composer. There is only the music - the timelessness of it leads you to believe that it must have predated its inventor, just as it has outlived him.

It's hard to believe there was ever an intermediary between forces of nature and the analogue signals coming from the piano. There is no evidence of human striving, it doesn't feel calculated, contrived or engineered. It feels as natural as sunlight, as the tides, as breathing.

How does this music make you feel? And how did Debussy feel when he wrote it? Which came first - the music or the feeling? And if the feeling came first, where did the feeling come from? Are all our acts of creation simply a transcription of what lives within us? If so, how did it get there in the first place? If the source of all our art is internal, then how is it that we appreciate its beauty intuitively, universally, the same way our ancestors who, without ever having to explain to each other, understood what it meant to stand alone in the reverential night and gaze at the moon.

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"you know, it can be soul crushing - but in a way that's soul expanding when you stop being crushed - but sometimes it's hard to find time to stop being crushed."

late romantic

b mine

痛み / Weltschmerz II

I can bear any pain as long as it has meaning.
- Haruki Murakami, 1Q84

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But he said to me, "My grace is sufficient for you, for my power is made perfect in weakness." Therefore I will boast all the more gladly about my weaknesses, so that Christ's power may rest on me.

- 2 Corinthians 12:9

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how to grow without ever being uncomfortable

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"and found once I stopped thinking I was entitled to a comfortable and easy ride - once I started expecting it to be hard and difficult, I stopped hating it so much."

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My brethren, count it all joy when ye fall into divers temptations; 
Knowing this, that the trying of your faith worketh patience. 
But let patience have her perfect work, that ye may be perfect and entire, wanting nothing.

history in the making

I realise that having grown up in KL I've lost a lot of perspective on the place - my consultant in A&E told me she was going for a visit and asked me for recommendations - and I was so cynical. I said Batu Caves is the touristy kind of thing, locals don't really do it. I sold it as a super industrialised capitalist pseudo-metropolis, with only shopping malls and food stalls and no authentic cultural identity - but i've been watching youtube videos of foreigners talking about what it's like to live in Malaysia, and discovering the country through their eyes - it helps me discover what Malaysia actually does have to offer. One particular youtuber was absolutely charmed by bangsar - the fact that retail outlets coexisted / abutted a quaint little residential area. At the time I held that the juxtaposition and incongruity was a sign of fraudulence. But the Ang Mohs see it as a charming idiosyncrasy. A metaphor or synecdoche for the city whose facets of personality are legion.

I feel like I have a prejudice against the new - the hipster - the things that don't pay homage to the past. Fusion restaurants, franchise coffee joints. Even though they're homegrown and not imported. Maybe these things aren't a false veneer - covering up for a lack of identity - as I initially thought. Maybe this is what Malaysia is. Maybe the Malaysia that foreigners are in love with and gush over is the real Malaysia. Maybe it's really grown into itself, and I simply can't recognise it because all I remember is who it used to be.

closing time / weltschmerz

Closing time 
Time for you to go out go out into the world. 
Closing time 
Turn the lights up over every boy and every girl. 
Closing time 
One last call for alcohol so finish your whiskey or beer. 
Closing time 
You don't have to go home but you can't stay here.

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What do angels understand about being in hell?


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"So is your man going home?"

I wanted to say yes, but I couldn't. It wasn't that simple, unfortunately.

"I mean, he should go home... the question is how to get him to do it."

I gave R a look of exasperation and she grimaced back in sympathy.

"Maybe if I subtly nudge him closer and closer to the exit until he's out of the department..."

"Just say, 'sorry sir, we're closed.'" She said.

I laughed, but I really did feel sorry for the guy.

He was 67 years old and had backed his car into a fence after drinking two bottles of brandy. The police found him in his car, intoxicated. He reeked of alcohol and lived alone, so they brought him to Chorley to be assessed. He told me he was having trouble coping with the chronic pain in his knees so he decided to drink today. Didn't mention anything about his history of depression and intentional overdoses. Denied being actively suicidal. And after I had concluded there was nothing medically wrong with him, he told me, "when you get me to the ward, could you give me a sleeping tablet, so that I can just rest and see how I feel in the morning. I think I would like to just go to sleep and forget about all this." I told him there wasn't anything we could do for him in hospital. I tried explaining that he would be better off at home. "Please," he said. "I'd prefer to stay a night in the wards. The nurses will look after me."

When I admit a patient, I always ask myself - how will this benefit the patient? What will this admission achieve? Will it cure his substance abuse? Probably not. Will it help him feel better? Maybe. Will it deprive another patient of a vanishingly scarce and invaluable hospital bed? Absolutely.

One of the hardest parts of being a junior doctor is learning that you can't fix everyone - and that some people aren't looking to be fixed. What my patient wanted was palliative care, an opiate in the form of a hospital bed, a holiday from being himself. Corporate policy is to get rid of these patients in a benevolent manner. To reject them mercifully. To kindly decline.

The word 'triage' comes from the French word 'trier' which means 'to separate out'. The term was used during World War I by French doctors treating soldiers who had been wounded on the battlefield. In its earliest form, victims were divided into three categories.
1. Those who are likely to live, regardless of what care they receive
2. Those who are unlikely to live, regardless of what care they receive
3. Those for whom immediate care might make a positive difference in outcome.

It was a way of deciding how to allocate scarce resources to achieve the greatest good for the greatest number of people. The same principle applies to triage systems in use today for dealing with natural disasters or crises. In advanced triage, there is an expectant / black category. The only reason this would exist is that we believe that in certain situations, allowing some people to die will ultimately allow for more people to live.

Maybe the right thing to do was to kick him out because he would be fine and get better on his own. Maybe he was the walking wounded, and all that was required to heal was time. Or maybe it was the right thing because he was irrevocably terminal and admission would have had no effect on prognosis. Maybe he was expectant; beyond help, beyond hope.

Or maybe he didn't fit into any triage category. Maybe the natural history of his sickness dictated that he would keep repeating this cycle of behaviour, oscillating in a kind of limbo between living and dying, recovering and relapsing and recovering and relapsing irrespective of any treatment - before ending up in hospital for good.

But none of this made a difference to the patient in front of me. This man was trapped. He was  suffering and desperate to escape it, pleading. And what I do to cope is think about abstract principles that justify my actions so I don't have to think about the feeling I got when that man looked at me. Why doesn't he understand and just go away quietly? I'm doing my best to explain the logic behind my decision, as if logic held any sway over his actions.

How must it have seemed to him? How unfair. How unmerciful.

But I didn't understand a thing about the man in front of me, what drove him to act this way, what demons he was trying to escape. If I did, it would be harder to turn him away, and I had decided I was going to turn him away. When did humans become arbiters of mercy and justice? What gives me, a green as grass junior doctor who knows only the barest of details of this man's life, the right to decide whether he stays in hospital or goes home? Why does my decision automatically overrule his? Does the fact that the hospital institution backs me up suddenly make it ethical to turn these patients away? When did I get to decide that some lives are worth more than others? When did I get to decide that some lives cost too much to save?

We are taught that capacity is decision specific. "Do you understand that staying in hospital will not make you better? Yes. Do you understand that you are depriving another patient of a bed, who will likely benefit from it more? Yes." What do I do then?

We have a duty to protect our patients from harm - and that includes the potential harm that exists as a corollary of choices that other patients make. Choices that are sometimes illogical and selfish. To protect them from negative externalities even if it means placing an embargo on compassion. If we admitted those who were medically fit for discharge, we would have less room for the septic, the fractured, the at risk of exanguinating.

Our job is to care for these people, to give them everything we can afford, to bend over backwards to meet everyone's needs - but it's also our duty to understand that some people don't get better no matter how much you give, and that we can only afford to give so much.

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As doctors, we hone our empathy. Learn to focus it, harness it. Train it to palpate the psychological distress of the person in front of us, identify tender spots and strategically deploy sentiments that will be maximally efficacious / analgesic / palliative. We use empathy to deliver targeted therapy, but sometimes also to profile a patient's mental health, patting down its outline - nothing too invasive. We make sure they aren't carrying any sharp objects, ligature wires, explosive devices. And once we are satisfied they don't pose a risk to themselves or others, we reel in the acumen, holster our empathy somewhere between frontal cortex and amygdala until it's needed again. We don't probe any further or venture deeper. At most, we offer a little squeeze on the shoulder as we withdraw our feelers - a consolatory touch implying the embrace we don't allow ourselves to give. A brief, brusque nod of vulnerability as we retreat to a safe distance.