Between 9 May and 30 May, I was a patient in the Klinik Kepakaran Pembedahan Kardiotorasik (Cardiothoracic Surgery Unit, CSU) of the Penang General Hospital.
I had an open-heart operation to treat my enlarged aorta, and severe aortic regurgitation. Datuk Dr Basheer Ahamed Abdul Kareem, the director of CSU, performed the Bentall procedure, aided by a team of doctors and nurses, on 11 May.
I was discharged on 30 May. During that period, I thought of my experiences with the ward, patients, nurses, and doctors.
The rectangular ward was a relatively modern, air-conditioned and brightly lit part of an old building. It had 22 beds divided into four spaces, two each with four beds and six beds. Some beds were used for the newly admitted. Others were designated for post-ICU recovery. The rest were occupied by patients awaiting discharge. Since the ward had its beds facing the nursing stations, little inhibited communication between nurses and patients.
The ward could have been improved. Its connection was well guarded at one end. The other end was occupied by a cupboard full of patients’ uniforms and rooms filled with unused stuff – older machines, surplus furniture, etc. From my impressions, the ward was well equipped but lacked a few items, such as consumables that included adult pampers and ‘wet wipes’.
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In the morning, patients sat on long heavy chairs some of the armrests of which were worn out. There were specific times for changing the patients and their bedding, giving them meals and medicine, providing them with hot water, and the doctors’ checking on them. The lights were partially dimmed around 9:00pm and mostly turned off around 11:00pm. The next morning, ‘lights out’ would be finished at 5:00am.
Patients stayed for different periods, a week to 10 days being the norm. The patients were racially well distributed. In age they were mostly between the 50s and the 60s. The majority were made up of men. I did not know the patients’ socioeconomic profiles. Their appearances and speech suggested they were there for the most basic of reasons. The operations were performed free, or virtually free except for special payments for replacement ‘spare parts’. The CSU had a very good reputation and the hospital was convenient for people who lived in its area of coverage, northern Peninsular Malaysia. The patients I was with came from lower to moderate-level government service or smaller-scale private sector backgrounds. They were often retired. They had undergone or were being prepared for major cardiothoracic surgery.
A patient initially stayed in bed, spending long hours of being sedated or being in semi-consciousness before coming around to full awareness. It was tiresome to be bound by tubes. But one could not have expected much more since the operations were major ones. As one’s condition improved, one was put through physiotherapy – simple breathing methods to expand the chest cavity and guided walks through the ward. A doctor said tersely, “We discharge those who can walk to the toilet and bathroom on their own.” Perhaps that explained why a number of patients walked but, despite the urgings of the physiotherapists, not many went through the breathing techniques.
Bound to their monitoring devices or because of their conditions, the patients were largely quiet. They spoke with their visitors and or their neighbours in soft tones, or kept their own counsel. The mood was somehow sombre, the voices hushed, and the smiles faint. The unofficial rule of the community was empathy and help in the smallest things – alerting a nurse, pointing out fallen things and offering advice: there was a community of the sick.
The nurses were mostly young to middle-aged Malay women and some men. They were formal and proper or worked in good spirits. The older female nurses were more informal, conversing as they worked. The more vocal among them maintained cordial relations with the doctors, laughing and bantering with them.
The nurses performed many kinds of service. They checked the monitoring devices, took blood pressure, drew blood and sent it for testing, applied intravenous medications and saline solutions, distributed oral medicines, did dressings and removed sutures, changed bedding, clothing and pampers, cleaned the patients, removed portable urinals, took the patients to other departments (for ultrasound scans, for example), maintained records of the patients, etc. Those services were performed from the patients’ admission to their discharge.
As a cohort, the nurses were remarkably competent, courteous and cheerful. They addressed me as “Uncle”. To my embarrassment, they unfailingly said, “Sorry, Uncle”, before or while doing anything for me. I tried not to bother them; yet I often had to call on them for small matters. They worked in shifts.
I did not investigate the salary levels at which they worked. They were probably placed at the lower ends of the civil service salary hierarchy. One hopes that they received terms and conditions commensurate with the calls placed upon them, and the excellence with which they responded. I am glad I thanked them each time they did something for me. Perhaps they knew me better than other patients who had not stayed as long as I did. To me, they provided a level of service not inferior to that of Japanese nurses who operated in a wholly unfamiliar cultural context.
Many doctors served in the ward, men and women in approximate balance, racially well distributed, and ranging in age from the 30s to the 50s. As a group they spoke to the patients in Malay, Chinese (both Mandarin and some dialects), Tamil and English. There was no ‘white coat syndrome’ on this ward of adults. Some doctors wore blue ‘scrub suits’ as they came to the ward between surgery, for work shifts or rounds. Many wore non-uniform clothes, simple as those worn by the majority of the Hospital doctors. Their work dress imparted a strange quality. One did not distinguish between them by their dresses, only by their faces, and these were partially covered by masks, and patterns of speech.
One assumed that they would be inured to their patients’ suffering. They were but they remained compassionate. One saw this when a single or more doctors stopped during their rounds, called to the side of the patients, to check their conditions, and ask for special forms of treatment. At such times, the doctors spent more time with the patients, focused on the latter’s condition, seemingly not worrying about other cares.
Mostly the doctors came twice to see the patients each day, in the mid- to late morning, and in the late afternoon or early evening. These rounds enabled the doctors to ask how a patient was doing, and to see if any medication or form of treatment had to be adjusted or changed. The doctors came in groups of four or five and a nurse with files. One or more of the senior doctors consulted the notes of the nurse and decided on the next course of action.
Roughly the same questions were posed to the patients: How are you? Have you had any pain or fever or nausea, or any other problem? If a patient did not display any such symptom, he or she would be passed over fairly quickly, for example, after a brief check of the shins to rule out water retention. The patients relished the doctors’ rounds which broke the daily tedium because they allowed a patient to take in what the doctors said among themselves, or to ask about oneself, or to seek some reassurance. Beyond a time, every patient wanted to ask, “When can I go home?”
It is astonishing that the doctors could have done so much for the patients, expecting little if anything in return. “I wouldn’t undertake your operation if I couldn’t have the cooperation of my team,” my chief surgeon said to me. For my operation he had the assistance of a large team of five surgeons, five nurses, three anaesthesiologists, and three other doctors manning the by-pass machine. They attended the operation from 8:30am to 4:00pm. It was a full day’s work, and still some of them conducted ward rounds. It was crazy for a doctor to work over 30 hours in a shift. Yet the doctors did so in turn. They remained jovial, complaining of their burden but in a lighthearted, head-shaking, and almost disbelieving, manner as if the matter could not be avoided. And some had even to work outside Penang during their shifts.
The CSU is an important unit of the hospital, small compared with the much better-known Institut Jantung Negara (National Heart Institute) in Kuala Lumpur. The unheralded CSU provides more than essential cardiothoracic operations. It regularly gives warfarin to certain patients, post-operative reviews, and advice to potential patients.
Its surgeons periodically perform emergency operations in different parts of the country. Each day many demands are placed on them, judging from the number of patients who called at the CSU for its outpatient consultations. These are the days of the Covid pandemic, an ageing society, the unstoppable move of public specialist doctors to private practice, and rising inflation – especially of the costs of private sector medical care.
The hospital is crucial to those who look to CSU for excellent, free or almost free, cardiothoracic surgery. Besides, patients consult the doctors many times, even after their operations. Government servants or retirees pay nothing while non-government patients pay only RM5 per visit.
But the CSU’s ameliorative role can only be maintained if there is an adequate expansion of its specialist and nursing personnel, the purchase or refurbishment of technical equipment, and an improvement in the terms and conditions of the doctors’ and nurses’ employment. So much remains to be done that calls for a substantial and sensitive allocation of financial resources to the public sector hospitals.
Money is presently invisible in the ward. Money is not something that is considered by the doctors, nurses or patients in the daily ward scenes. That is the crux. The Penang General Hospital offers services to the public at no cost or, at most, at minimal cost. The CSU operations are very expensive if performed in a private hospital. I paid RM1,000 – RM500 each for the replacement aorta tissue and the aortic valve – and that because the doctors knew I could afford the amount. But I saved about RM250,000 by having my operation at the hospital. The post-operative recovery is costly, too, because of the high expense of staying in the ICU and the ward, and the many kinds of prescribed medicine. The patients are rarely burdened by the costs of medical care. Nor are the doctors and nurses. Medication and special equipment are used as needed, never primarily decided by monetary ability.
Services are performed as between professionals and patients. Never is race an issue. When I was discharged, more than one nurse held my hand and warned me in Malay to have no visitor, to wear the ‘chest hugger’, to desist from heavy work, to stop carrying weighty things, and so on, for three and maybe six months. What a contrast this conduct presents to the obsessions with race that are toxic to our politics. At the CSU and the hospital, public service is provided with no care for the racial identity of the patient. That is how the service should be accepted. One can imagine Malaysia being a more comfortable place to live in if the country was managed like the CSU and the hospital.
On the Sunday evening of 29 May, one day before my discharge, the chief surgeon and his close assistant, Dr Dalvinder Singh, came to check on my condition. A proud Dr Basheer showed me a smartphone photo of a ceremony of a large number of well-dressed members of the medical community that he attended in Kuala Lumpur. The photo was part of an examination of ‘wannabe specialists’ and a medical conference. “I’m so glad we have seven cardiothoracic specialists this time,” he remarked. “And I hope they will stay in public service … to serve the rakyat.” – The Edge Malaysia