Friday, May 7, 2010

The inevitable truth.

This post is written purely base upon the author's initiative. The author's choice of vaccine is based upon his/her own decision, and NOT being paid or given remunerations in any  form by the pharmaceutical company
Another day had passed, as I was driving back, the faces of patients that I've attended to still fresh in my mind. Perhaps it's my attitude towards work.My working hours isn't limited to the time in the clinic. But patients have access to my cell phone, as I believe if they needed help, or in case of emergencies, they could get hold of me.
As I reached the gate of my house, I could see both Isabelle and Natalie running towards the front door, excited to see me. Nothing beats this feeling of warmth and love that awaits your arrival. I am lucky I have a home, instead of merely a house to return to at the end of the day.
The loving hugs, jumps of joy, and heartfelt laughter by my two daughters is the best moments in my everyday life. Stress and worries of work that I bear on a daily basis seeps away the moment seeing this two angels calling out "daddy" is comforting to the ears and soothing to the heart.
I'll shower right after dinner, then it's family time. There is so much joy at home. Isabelle excitingly telling my wife and I how her day was, and Natalie never seem tired from all her running, and jumping. This little angel never cease to amuse both my wife and I with her spontaneous,unpretentious, adorable expressions. Leonidas's eyes would brighten up and coos happily upon seeing both his elder sisters.

The struggle that one needs to go through in life, the ups and downs, joy and jubilation, it's all part of being human. Many believes if we do good, there will be a place reserved for us in Heaven. But why want to wait till then? The happiness and joy we experience within our family is heavenly. It is my "heaven" on earth.
Suddenly my cellphone rang. I answered the call made by my uncle. Over the other end of the line, the situation is a direct opposite of mine. He told me he wasn't feeling too well, that he is feeling nauseous, similarly a few weeks ago he had experienced the same thing. He was brought to the hospital by my cousin. But this time, he was all alone at home.
While talking to my uncle and advising him through the phone what to do, as i listened to him, I sensed loneliness, depression, hopelessness, and sadness.
As far as I have known my uncle, this is the first time him being so expressive. He yearned for someones to talk to.
To him, the fact that my aunt had passed away hasn't sunk into his mind. There is no closure for him. He will forever wonder why was it that there wasn't any indication, early symptoms, or signs to suggest and to prompt them to go for further test?
The first time my aunt was brought to me was June last year, what transpired on that particular day is still fresh in my mind.
16th June 2009, was not a good day for me,my uncle,and my aunt.
She came with jaundice for the past 2 weeks, with tea coloured urine and clay coloured stool. At the age of 61, a person who comes with such clinical picture, one has to think of the worst case scenario.

With a heavy heart and filled with reluctance, how i wished I was wrong in my diagnosis. Somehow, truth need to be told. So, carefully, i explained to them the worst possible reason that could result in such clinical manifestation.
I referred her to Hospital Selayang for radiological investigation to confirm my diagnosis. I remembered hoping I was wrong, that perhaps I was just being overcautious. After CT Scan abdomen was done, the report came back:-

That's it. The whole world crumbled, knowing that her days are numbered. Less than 2% of patient survived more than 5 years upon diagnosis.
Unable to accept the grim fact, since then, I saw the change in my uncle. He was desperate for a solution. Knowing that western medicine aren't able to help, he started searching the net for alternatives or holistic approach. Suddenly, their 38 years of marriage seemed like a fleeting moment. Simply too short a time for any couple to be together. Too soon for death to set them apart.
A sense of helplessness, an endless plea, a cry of sorrow and the endless question as to why it happened to them was simple overwhelming. Cancer, do not recognize race, age, social status, or religion.
Death seemed more difficult when the disease slowly eats you up, emaciates, weakens, turns you into a frail lifeless body. Witnessing the change for the worse was indeed a heart wrenching experience. There is this disturbing possibility with each hospitalization could be the last. Unknowing whether with each admission, would she be discharged alive....
Throughout the while 9 months of battle with cancer, her spirit seemed to die off by the bits.
Her physique deteriorates, as well as her morale.
No matter how my uncle encouraged her to give a good fight, and be positive, that they will go through this battle together, but the fact is, at the back of his mind,the inevitable will happen. My aunt is dying with each passing day.
The last time she came to my clinic was 16 March, she was feverish, dehydrated, and desperately in need of IV fluids and get her blood cultured to identify the bacteria which doesn't seemed to respond to a prescribed broad spectrum antibiotic.
I infused her with 4 pints of normal saline, and immediately sent her to Selayang Hospital. Unknowingly to her, this admission would be her last.
The first time I saw her 9 months ago, she was a hefty 86kg lady, and just before she got admitted to hospital the last time, she was merely 35kg, severely anaemic, lethargic, and frail.
I can't help shedding tears as I was writing a referral to the hospital while she was in the procedure room next door with IV fluids being infused into her.
I wondered what was going on in her, my uncle, as well as her daughter's mind. Words simply couldn't justify the feelings that she had then. Somehow, a few days after she passed away, my cousin told me that my aunt knew this would be her last admission.She mentioned that her mum was particularly sad when she left home while coming to my clinic, as if she knew it would be the last time she step out from her home alive. She seemed sentimental, caressing her favourite pet dog Bo Bo goodbye, and seemed reluctant to leave the house. She knew she won't be coming back again. I remembered 10 days prior, she developed high grade fever which I insisted her to get hospitalized. The medical officer in charge of the outpatient department just discharged her with a broad spectrum antibiotic.

10 days had gone, yet her fever persisted. I did a urgent blood test just to rule out viral infection, however the result was suggestive of bacterial infection. I was stumped as to why the fever didn't subside even being hit hard with such a strong antibiotic. Immunocompromised patients may present an uncommon symptoms even when infected by common infection.
It hurts to see her then, so frail that she could barely walk. Both her daughters supported her by holding both her arms. She looked pale, dehydrated, almost lifeless...Her stare was blank and unfocused. She could hardly speak.
She was so weak, that she can't take food or liquid orally. It struck me then..... I believe my aunt will always have the thought of why this happened to her? Imagine if you knew you're days are numbered, what would you do?

Once inserted the IV lines and while receiving the drips, I called my uncle and cousins to my consultation room  and had a chat with them. Through my experience, I've seen enough deaths, and as I looked at her, I knew she had just a few days left.

My aunt is was a gentle lady. She has never lost her temper. She was a motherly figure to both her siblings and to me.
As my uncle and cousin went out for their meal, I was left alone in the clinic with her. I sat next to her, asking whether was the air conditioner was too cold, how was she feeling, asking her to be strong. I gently held her hands, and she gave me a weak , yet reaffirming squeeze.
Upon completing 4 pints of normal saline, her blood pressure picked up, and I wrote a referral letter to Selayang Hospital.
Her admission on the 16th June would be the last one.....
10 days had passed, and I had not received any phone calls from my uncle. On the 27th, I called my uncle up,he sounded tired, exhausted, and depressed. I remembered him telling me, "She's not doing well"... I don't know why, but the sorrow was simply overwhelming. After the conversation, I sat silently with both my eyes shut. The inevitable is near.
I went straight to the hospital the next day right after my clinic... As I walked towards the ward, I can't help but to wonder how many times have I walked through this corridor since my aunt's first admission.
She was on bed no. 3. The beeping of the cardiac monitor reminded me of ICU in Kuala Lumpur general hospital. She had difficulty breathing. That is the first sign of the inevitable. I knew her time will end soon, but not this soon.
She was breathing with the aid from an oxygen mask. Despite that, her oxygen saturation was merely 86-90%.
We was weak. I spoke to the staff nurse in charge. She mentioned the order from the consultant was "No Active Resuscitation" if my aunt collapses.
I sat on the bed, held her hand, giving her support to fight on. Though her breathing was laboured, her weary eyes lightened up when someone talks to her, encouraging her to stay strong. But somehow, she knows she wouldn't last long. Before I left, I whispered to her ears,asking her to pray to Lord for His guidance and protection. She reached out her hands and gave me a hug, thanking me for all that I've done for her. I refused to accept it as within family members, no thanks is needed. I haven't done much, in fact, I did not manage to alleviate her problem, not even a bit.
As I left,I signaled to my cousin to step outside to have a word with her. I asked her to inform her uncle and aunts(they weren't aware that my auntie was warded...and dying.)to visit her as I doubt she's would last more than a day or two the most. I briefly explained to them what are the different phases that her mother would go through so as they would be prepared for the worst.
First, she would become disorientated, she wouldn't able to recognize place, person, or time, then would worsen when she become unresponsive. Only the basic reflexes would be present. Her blood pressure would plummet, then brain dead, though her heart may be beating, and she would appear to be breathing, but these two functions are controlled by their respective centres  within the brainstem.Her basic reflexes would be absent by then, then her breathing becomes shallow, heart beat slows down to a complete stop.My cousin cried upon hearing my explanation. The eldest among three daughter who is same age as me, who is jovial by nature, a person who always wears a smile, was so overwhelmed with the idea of losing her mother, cried bitterly.
As I walked towards the parking lot, it was already 10.30pm, and I felt like crap.
During the morning while I was in the clinic, i called up my cousin, seemed like everyone, including the my other aunts and uncles, cousins, friends, my grandmother, all of them visited her during the morning. She was still orientated, but in pain. She thanked them all for visiting her. By the time I reached the hospital after my clinic, she was already disorientated.
My uncle sat beside her, hugging her the whole time, kissing her forehead, whispering tender words to her, hoping she would able to hear. My aunt's stare was blank, expressionless, a sight that brought tears to my uncle. My aunt was still able to mutter some incomprehensible sound, much to my uncle's dismay, not knowing what my aunt was trying to convey.
By 12.30am, my aunt's blood pressure plummeted to 70+/40+, so low that the blood could hardly reach the vital organs.Her oxygen saturation was 60+%. Her stare was blank. Her eyelids were half shut. Her skin was cold and clammy, I could hardly feel her pulse. She was already brain dead. But I kept it to myself as I couldn't bear telling my uncle who keep on kissing her forehead, and spoke gentle words to her.
By 2.20am, her breathing seemed to have stopped. I called upon the staff nurse on duty that particular night to attach her to the cardiac monitor to ascertain a flat line. The cardiac monitor was beeping, however her pulse was not palpable. What appeared on the cardiac monitor were merely the electrical impulse that continues to discharge within the heart.
At 2.35am, she flat lined.....
By the time i left the hospital, it was 5 minutes to 4am.
It's been slightly more than a month since the passing of my aunt. The entire 9 months ordeal of seeing my aunt being eaten and emaciates with each passing day, her final hours, her funeral rituals, all of these had traumatized my uncle so much that he neglected his health, often times he found himself talking to the picture of my aunt. Occasionally he breaks into tears while in a midst of doing something.
He has difficulties falling asleep. Claimed to wake up every hour or two, and often finds himself crying while asleep. His world is void, the absence of his wife whom he was married to for 38 years made him felt lifeless, that he is merely existing, not living. He seemed to have lost his purpose of life. He was grieving, and still is.
I wrote to Hospice Malaysia hoping they have counseling for adjustment disorders, someone who is experienced in saying the right things to those who grieves, hoping to alleviate the pain they have.
The reply that i received was this:-

My uncle seemed to have symptoms listed in 1,2,3,4,5,6,7,9,10, and I am not sure of 8.
He expressed his regrets for not living life to it's fullest while her wife was still healthy.
Fellow readers, dying from cancer is far from being a dignified death. You start dying on the day you're diagnosed to have cancer. Initially you have a sense of loss in purpose of life since majority of cancer upon its first symptom usually manifests only in advanced stage.Particularly ovarian and cervical cancer.
Indeed death is inevitable for all of us. Irrespective of race, religion, caste, or status, we all die.
But dying from cancer is the worse. Knowing the end is near, and the the final journey is filled with emotional and psychological turmoil not only to the patient, but to the rest of the family members.
Most cancer survivors would vouch and convinced that they were given a new leash of life, a second chance. But not all of us are that lucky.
One of the reason why I put in so much effort in creating an awareness among the public is I do not wish anyone to experience what my uncle and aunt went through. The psychological, mental, and emotional trauma will scar my uncle for the rest of his life. Whenever he is alone, he wished
his wife is still around, instead of forsaking him all alone to go through the rest of his life.
Friends, I sincerely pray and wish non of you would have to face what both of my aunt and uncle went through. We are supposed to grow old gracefully, and enjoy the Golden Years of life. That we are able to sit back and reflect upon the bittersweet memories of our lives. We are supposed to look at our partner's eyes, telling each other how we appreciate their presence, how they complete our life.
All of these is taken away the moment you're diagnosed to have cancer. There's is no more sweet memories, unable to recall even if there was any.
Friends, cancer is ranked 2nd as the cause of mortality in our society, and among malignancies, cervical cancer is ranked 2nd in women.
With the revolutionary discovery of Cervical Cancer Vaccine, it has and will change the course of thousands of lives.
Now we are given the "choice" whether to protect ourselves or our love ones from contracting these killer disease that has a 60% mortality rate. Other form of cancer, we may decrease the possibility by our lifestyle, but that does not guarantee we won't get it. However, with the vaccine, we can CHOOSE not to get it.
Never think it won't happen to us. Because it possibly will. And being ranked no 2. with 4700 new cases every year, it's a serious issue not to be taken lightly.
Those who are in the late stages of cervical cancer would definitely tell you not to take chances. Be wise, get yourselves protected.
I've seen first hand the degree of psychological trauma it inflicts the patient as well as the caretakers. Day and night isn't a routine, it's a ticking clock, a countdown to your demise.
...This is lifesaving. 3 doses within 6 months is a small price to pay in exchange for growing old gracefully.
Show that you care for yourself and your love ones. Share this with your mother, daughter, sisters, cousins, friends,etc... do it now.

In conjuction with Mother's Day celebration, Klinik Wan & Keluarga with the help from GSK, will be organizing a Cervical Cancer Prevention Week from the 18th May until 25th May 2010.
Feel free to inquire about this vaccine from the doctor in charge of Klinik Wan & Keluarga, and all counseling is free of charge. It is a policy of Klinik Wan & Keluarga to provide the most comprehensive and thorough health care, as well as creating an awareness among the public as there are a lot of misconception and misunderstanding concerning this vaccine. Media often sensationalize controversial issues which creates unnecessary fear among the public.I personally think it's rather irresponsible for the media to report of death and attribute the cause directly or indirectly linked to the vaccine.
In late September 2009, the death of Natalie Morton, a 14 year old girl who died 2 hours after being administered with Cervarix, was later reported that her death is due to malignancy of the chest involving the lungs and heart.
Clinical trials that was conducted in India using both Cervarix from GSK, and Gardasil from Merck,
where 6 death was reported after the vaccination.
However, an official report released stating that the 2 deaths in the state of Gujerat is due to Malaria and snake bite. While the other four that happened in the state of Andhra Pradesh, was linked to poisoning, pyrexia of unknown origin, and drowning. Click here to read about it.
Indeed the best gift anyone could present to their mother is the gift of access to health. After the counseling, no one is by any means obligated to get themselves vaccinated, but I strongly recommend to as Cervical Cancer is significantly high and contribute to 12.7% of all mortality rate.
Our clinic will organize awareness campaign, with the help from GSK in order to reach out to the public and to provide an accurate facts and data on this vaccine.
As I had mentioned earlier, Cervarix give you the opportunity to decide whether you want to be protected or not. I simply can't describe my overzealous desire to reach out to the masses. I don't want anyone to go through what my aunt went through.
As a matter of fact, when my mother in law was diagnosed to have stage 3 ovarian cancer, it was a shock to me, and i didn't know how to break the news to my wife, who just gave birth to our son. She mentioned that she couldn't accept the fact that her mother was fated to walk along the same path as my aunt did.
No appointment is necessary. But we will be organizing a talk on Saturday, 22nd May, on " How to prevent Cervical Cancer" at 10.30am. For those who are interested, please RSVP before the 18th of May by sending a mail stating number of person who will be attending as well as name of those who wish to attend.
The price offered is for the vaccination is the most affordable one in the nation. (except for public school)
The vaccine that we will use is Cervarix, from GSK.
Why the cheap price? Klinik Wan & Keluarga felt it's only right to make health care accessible to the general public, and not only to the rich and well to do. Klinik Wan & Keluarga's choice of vaccine is based entirely upon consideration of the doctor in charge, and found to be more superior than the other available vaccine.
...and no, Klinik Wan dan Keluarga do not receive any form of remuneration by GSK. Payment can be made using credit card as well, without any extra charges.
You have the choice to either pay individually, or three doses at the same time and save RM15.
Within that week Klinik Wan dan Keluarga offers a reduced price for Thin Prep Pap Smear.
Normal price for Thin Prep Pap Smear is approximately RM90 ringgit, however, Klinik Wan & Keluarga offers at RM45.
However, do know that one need not do a Pap Smear prior to the vaccination, nor need to be followed up by the doctor of Klinik Wan dan Keluarga.
However, one thing I would like to emphasize upon is for your to request for Thin Prep Pap Smear instead of the Conventional Pap smear that has a high percentage of false negative.
This method is far more accurate to detect pre cancerous changes. Instead of using a wooden spatula used in Conventional Pap Smear,

This wooden spatula has faulty sampling collection methodology, as well as deposition of samples onto the glass slides as only 20% is deposited, while the other 80% goes into the waste bin, as it remained on the surface of the spatula.
Instead, Thin Prep Pap Smear uses a cyto brush.
So friends, my sincere intention of spreading to your friends and family regarding this campaign.
"With Cervarix, you are given the liberty to get yourselves choice.
Always remember, cancer does not recognize caste, religion, nor social status. Protect yourself and your love ones today.

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