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Thursday, January 16, 2014

It was one night shift I didn’t expect.

Prior, everything went on as usual. Returning home after the afternoon shift, I had a quick Linner (Lunch+dinner) then went to ‘collapse’, as my wife would call it.

It would be 9.30pm when I peeled my eyelids open, a few hours of tossy-turny restless sleep, the only kind my biological clock would allow. Its internal rhythms gone haywire from the odd and erratic working hours of a casualty house officer .

Punching it at 9.55pm, I soon took charge of Yellow/Asthma bay, and received passovers from the previous shift.

Around 1030pm, the Triage Officer came through the Yellow Zone doors holding the phone, a puzzled expression on her face

I was Ke-pohing in the red zone at the time, and overheard the case.

“Dr Fateha, ada kes panggilan dari Fook-Lu-Siew Minta Confirm Death.”

I glanced at my Medical Officer, she, at me; both amused by the request, one none of us had heard before. Fook Lu Siew is a Funeral parlour, dealing with the recently departed of Taoist and Christian Faith. It has been a most unusual request. Only those certified dead are brought there for embalming and last rites.

“Yong, you nak Pergi? ”

I nodded in affirmation, my adventurous spirit kicking back in. This came right after a Helicopter Medical Evac from Kota Marudu a week before;

This time, I think I’m ready to bust some zombie-myth.

As the Ambulance rounded the bend at the Tuaran Road-Bulatan Nanas Flyover
I pondered the possible scenarios

what made them feel the patient came back ?

- I asked my Medical Attendants
“Pukul Berapa patient meninggal?”

“I ada Tanya tadi, bilangnye-6.30pm”

“Sekarang pukul sebelas sudah. 4 jam lebih. Mana Mungkin?”

Were they so distraught they couldn’t let the patient go they started having visions?

“Dari Mana patient tu L/O? (Last Office)”

“Palliative Ward”

Now. Palliative ward. Palliation = Comfort/ End of Life Care. This means the patient’s family should have been prepared mentally for the eventual departure.

There must be signs of life convincing enough to shake them to call the hospital.

I had to consider the possibility of misdiagnosis of death then.

Siapa MO yang certify death kamu tahu tak?”

“Doktor XXXX”

“Tapi, dia baru transfer dari Neurosurgery lah, Mereka tu hari hari certify brain death, tidak mungkin dia boleh miss diagnosis”


The ambulance doors opened.
I wasn’t all that ready to have 20 pairs of eyes looking at me immediately after.
Some held grief, some held frustration, the ones that I avert eyes from were the ones that held, hope. I was afraid I might dash them.

The leader of the pack approached. His eyes held hope. But I had to make it clear.

“Encik, saya faham bahawa kamu orang rasa bahawa dia telah hidup balik. Kalau itu benar, saya rasa keadaan sedia-adanya kurang bagus sebab dia telahpun berada di palliative ward. Kalau betul dia ada peluang, kamu mahu saya tekan dada untuk hidupkan dia balik?”

Looking left and right at his family, he nodded. “Ya Tuan Doktor. Kita mahu dia kembali”

This meant they had expectations of her springing back to life.

This is going to be a difficult counseling session.

As thoughts raced through my head, I was brought into a middle sized room, housing a wardrobe, a bathing tabletop for cleansing the body, and a wide rear area housing other ceremonial items.

I placed myself at the Right corner of the table.
There she was, a young lady maybe mid twenties… maybe that’s why they couldn’t let her go..
Her peripheries were blue, her eyelids tightly shut, no apparent rhythmic rise and fall of the chest.

Most likely a goner, I thought, as relatives streamed into the room, closing the door behind them

My Assistant prepared the AED (automatic External Defibrillator) machine for heart rhythm analysis, while I whipped out the pen torch and the stets.

No Pupil reflex.
Negative Doll’s Eye reflex.
No …Breath sounds.

I could sense that their gaze are all upon me, my breath grew quicker
No heart sounds.
The AED machine was very silent. No beeps. It showed a very flat X-axis line.

“Dia tidak menunjukkan sebarang tanda-tanda bahawa dia masih hidup
matanya, nafasnya, jantungnya semuanya telah berhenti berfungsi.”

“Doktor. Saya tidak Nampak apa kamu buat tadi. Boleh ulang?”
That came from a middle age male in a collared Tee. The one I thought was the head of the family. Fatigue evident in his eyes. He was almost pleading.


This time I explained each and every step as I went through the motions, in Malay.

‘If the Brain and Cranial nerves were intact- the pupils would dilate’
those that stood by the sidelines crept and inched nearer to the table, to see her eyes better.

‘This Corneal reflex is what protects our eyes, when a foreign object threatens our vision. It is absent in her.’

‘If the brainstem was still intact, her eyes would stay fixed on me when I turn her head, evidently this is not happening’

‘She has no carotid pulse, the brain would be severely hypoxic without blood supply’

‘I can hear no breath sounds’

‘There is no heart beat. As you can see, her fingers and toes are all deep blue, that means they have been without oxygen for too long’

A voice came from behind the crowd.
“tadi bukan gitu”

then there was a murmur of voices.

The Man, said: “tadi kami pegang ada denyutan nadi.”
His words carefully measured. No more. No less.
The Strain in his voice can be appreciated.

“Saya tidak pasti, saya bukan kata bahawa kamu orang salah, tapi, ada kemungkinan, ada mungkin kamu terasa nadi kamu sendiri, lebih lebih kalau kamu pakai ibu jari untuk merasa”

Secretly, I wanted to tell them they will feel and see whatever their minds wanted them to see. They would be imagining a pulse in her, when it is their own.

I glanced around the room. Some were fidgeting, some looked at the Man. Others looked at me. The Man looked at the ground

There was a eerie silence that I hope I could pierce. It lasted far too long.

“Apa kata macam ini. Biar ahli keluarga terdekat berada di sini. Yang lain keluar dulu. Saya akan terang dengan terperinci sekali lagi. Lepas tu, kamu orang boleh terangkan kepada ahli keluarga yang lain. ”

At a loss for words, I could sense the Man was glad he could detach himself from the gaze of his family as he ushered them out of the room, save five.

Apparently, he is reluctant to make the call to end the examination. To do so, would mean he is giving up hope, on their behalf.

“Sebelum saya bermula, ada apa apa soalan kah?”

“Doktor, Selalukah orang mati hidup balik? Saya tengok berita itu selalu berlaku”

I almost shook my head in disbelief.
“Itu Cuma berlaku dalam Berita yang diterbitkan Metro sahaja.” -I took the opportunity to have a pot-shot at one of the papers I hate the most for the low quality journalism it carries, with a tendency to sensationalize whatever little bit of inconsequential news it can get- “Kalau yang sebenarnya, ini tidak pernah berlaku dalam pengalaman saya. Tidak pernah yang telah disahkan meninggal hidup kembali, dalam wayang mungkinlah”

“Jadi, Kenapa tadi saya dapat rasa nadi-nya?”

“Seperti yang saya terangkan tadi, besar kemungkinan itu nadi kamu sendiri”

A Male relative chipped in
“Kalau dia mati tadi, kenapa kamu doktor tak tekan dada?”

“Encik, saya tidak pasti apa yang berlaku di wad tadi, tapi kalau tiada tekan dada (CPR), mesti doctor sudah bincang dengan ahli keluarga. Betul tak?

The Man nodded yes.

The Man’s turn to speak. “Tapi, kamu orang tidak shock dia”

I couldn’t help but sigh as I replied, silently cursing all the drama series who showed every heart patient needs to be shocked using a defibrillator-

“Bukan macam tu Encik. Bukan semua patient perlukan renjatan elektrik tu. Itu hanya untuk pesakit yang ritma jantung dia lari encik.”

I Knew I had no one to back me up on everything I have said.
There I was, a young man of 27 trying to convince a family where all its members are considered my elders in age. To make matters worse, I couldn’t speak Dusun.

I knew any waver in confidence or demeanour would mean an immediate failure of the counselling session, followed by an immediate embarrassment at having my superior called here to tell them the exact same thing that I said.

The Man Spoke again “ Mungkin kah dia sekarang dalam coma?”
“ Coma boleh bermaksud banyak keadaan yang lain, Encik. Apa yang saya rasa encik bermaksud, adalah otak yang tidak berfungsi tetapi organ lain masih berfungsi. Tapi encik, seperti yang ditunjukkan tadi semua organ utamanya sudah tidak ada. Lagipun, kalau otak coma, pesakit perlukan bantuan pernafasan dan lain lain, kalau dibiarkan begitu saja, pesakit yang koma pun sukar mahu hidup”

This time, a pregnany lady quipped
“ Tapi badannya masih panas”

I really don’t know how long this is going to drag on. It is very very apparent they just couldn’t let go. And yet I can’t show my frustration.

“Mana kamu rasa tadi puan? Belakang dia kan? Ini bilik berhawa dingin, tadi dia telah dimandikan, seluruh badannya sudahpun sejuk, bahagian yang menghadap ke bawah lah yang akan menahan haba paling lama, iaitu belakangnya.

After that, I went through all the steps to certify patient’s departure.

Then I told them, maybe you can call the other family members and we can open the floor for questions.

They came in once again. This time an elderly lady came to the fore. I think she just arrived from the interior regions of Sabah. She Spoke first

“Urat muka dia masih lembut bah, dia masih hidup.”

I was at a loss.

At this rate, nothing I say is gonna change anything. What am I to do?

To me relief, a family member gently held her hand and brought her to the side, whispering to her along the way.

“Mungkin saya masih muda dan pengalaman saya sekadar 2 tahun. Tetapi kalau anda semua masih musykil, boleh kamu bertanya juga Pegawai saya Encik Ronney, Dia ni sungguh berpengalaman dan boleh membantu saya menerangkan kepada anda semua sekali lagi.

At my cue, my assistant went over to the distraught mother and started explaining to her in Dusun what transpired. The other relatives listened intently.

I could sense the tension in the room lift a little. I walked over to the Man, which I came to learn was the patient’s husband. He squatted next to the wardrobe, holding a cream coloured dress while absent-mindedly smoothing out the edges. I placed my hand over his shoulder

“encik ok tak? Saya tahu memang susah untuk menerima pemergian isteri anda. Kalau kamu semua ingin pihak hospital menekan dada dan cuba sedaya upaya, kami tidak boleh menolak permintaan anda. Tetapi sesungguhnya ia tidak membawa manfaat kepadanya. Ada mungkin tulang rusuknya akan patah.”

He stood up
He nodded but did not reply.

It is almost 12 midnight. An Hour has passed. Just a moment ago, I felt as if I was in the defendant’s box defending the diagnosis of death while the judge jury and executioner were all in disbelief.

“Kalian semua, kami terpaksa balik hospital dahulu. Saya berharap kamu dapat terima pemergiannya dengan hati yang tenang. Kalau ada apa apa soalan, silalah bertanya.”


“Kami pergi dulu.”

As I left the room, I held on to my MA for emotional support.
I felt extreme relief, and I knew I couldn’t have done it without my supporting staff.
When I was a medical student, there was a component of our studies called Personal and Professional development, focusing on self improvement, communication skills and group dynamics. I can really feel its impact sinking in. Without that training, I wouldn’t have been able to keep my cool throughout the gruelling session. Thank you UKM.

I turned to my MA, Ronney

“Bro, berapa lama sudah kerja?”
“Lapan….dekat sepuluh tahun..”
“Pernahkah jumpa situasi macam nih?”
“Tidak pernah boss. Nasib ada boss, kalau saya datang tadi tanpa Doktor escort, entah apa saya mahu cakap”
“saya pun rasa nasib baik ada kamu, susah sangat mereka mahu percaya saya, muda sangat kut”
“tapi boss, badan dia tadi rasa macam suam-lah, macam lain sikit”

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