Working in an Ambulance Service in Malaysia
My lecturer once told our class, in a tone that bespoke of sacred stones, as 55 pair of enthusiastic, albeit naive eyes trying to peer through the words of experience, that “the moment you arrive at the station of your ambulance service, drop your bags, tighten your belt, and get on your rig to examine the equipment and resources you will have to work with in the field.” And with this sanctimonious advice, which i have clutched dutifully on my chest, i flung open the very first ambulance i would touch and work in, and be hit by a warm whiff of soil, disinfectant, hints of sweat not of the athletic kind, warmed rubber – for the ambulance had sat in the hot sun for a good part of the day.
My colleagues had then counted through the supplies with me, pointing to a stash of gauze, and now holding bottles of saline for infusion, now zipping open the “Trauma Bag”, showing off the neat content of roller bandages lined up in transparent covered cloth boxes, thick paded gauze, the all too ubiquitous triangular bandages, all fitted nicely in a 40-litre red backpack. My colleague was prattling away as i found myself intrigued by the mini-cylinder that would be the mobile unit for oxygen supply for many of my future asthma and cardiac arrest patients. And then i ran my fingers along the moveable cot that would be the comfort and perhaps a sense of not small amount of hope, for those who would find themselves lying there, covered with a white sheet of blanket, and setting their eyes away from an injury, or an annoying pain.
Slithering through the streets of urban Malaysia, of white and stripes of blue or yellow, green or red, moon or star, often times distressing wails of sirens echo pass an office window, some tall, some old – one cannot help but wonder how is it that ambulances appear in such variety and bear no common identity? It probably requires less effort to recognise a Malaysian police vehicle than an ambulance. Now if we were to seriously consider our previous question regarding the identity of the ambulance, we are really skimming on the thin ice of a much larger, and more intricate question – How does emergency pre-hospital services operate in Malaysia? How does it really work? And i have come to discover that, asking a simple question such as this, would be the undo of an innocent minded medic, aspiring to fulfill a career that is all but an unfamiliar dream.
Making Paramedics
It is not very uncommon for one to hear of friends or family members grouching about work, and in a fit of passion pounds a proverbial hammer upon a drastic decision. In that kind of mental angst i too, have suffered the same fate, holding upon a hope that being a paramedic would correct a certain ill feeling that was bred out of the common love for commodity.
The most common qualification that will provide the largest workforce in this industry is the Diploma in Medical Assistance, which completion will be awarded the title Assistant Medical Officer (AMO) or Penolong Pegawai Perubatan. The sentiments of those who even dare to entertain the fancies of assuming the responsibility of being a medical community watchdog is nicely seen in the LowYat.net forums. Simple and direct enquiries of how one can become a paramedic in Malaysia meets with long and convoluted suggestions; that one should weigh the value of prospective job opportunities with the government and private hospitals, private ambulance services, NGO’s, and if those training would be valid for inter-agency, or even international recognition.
The Health Ministry of Malaysia requires aspiring AMO’s to complete a 3-year course, which will then secure them with a position in a government hospital, not only working out of the ambulance and the emergency department, but more so, in community clinics, various specialist clinics or departments that call for their clinical skills. Qualifications other than this particular one, receives not even a sideway glance for consideration to enter as a paramedic into the public hospital workforce. This system in effect centralises the mechanism for paramedic training and becomes almost the sole employer of the qualified personnel. People who decide later in life that they wish to pursue a career in prehospital care would have very strong reasons to shun from such lengthy training.
This is in comparison to various countries, Western or our neighbouring Southeast Asian Countries, whose entrance in the field of ambulance paramedicine can be completed in modules of several months. As many would already know, Emergency Medical Technicians go through levels – Basic – Intermediate – Advance and finally onto Paramedic. Each level requiring some 2-6 months of training depending on the different training bodies, country protocols, and target clinical level. I find this a lot more accessible than any 3-year Diploma programmes currently mandated in this country.
My story is a bit more unusual, unlike a highschool graduate who frets about his specialisation in university. But interesting waves are those of countercurrents, don’t you think? My Ma used to comment upon every passing doctor, who are part of the larger family, or one spotted walking down the street opposite from where we were having lunch, or one who happen to dress like one according to her stereotyping habits, that all these privileged humans of this industrial breed called medicine, are very wealthy, cash rich fellows. And little girls took it to heart that they are, considering the sting that the sun’s ray would reflect from their all too shiny cars to hurt my eyes. But that Californian dream was quickly made irrelevant from my life since i made a decision to not enter into the science stream in the last 3 years of highschool. I took to the more frivolous subjects of history, accounting and such. And so, the dream got watered down to a far less praised cousin – allied healthcare – no big bucks here.
It would be a little puzzling to some when they found out that my education background was really in general Psychology. To have made that leap from something as wuzzy-fuzzy as psychology to something as unforgiving of carelessness as rigorous medical practice.
Didn’t See That Coming
If troubles had the insidious smell, or had we the sense of a watchful Shepherd dog, hears the slightest hint of coming, as the underground roar with the faraway hoof rains, then we would not fear. During the recent EMS conference that was held in Penang, our speaker from Taiwan, Matthew Ma intimated a sentiment that everyone working in the emergency services will share, that “…lives are saved not by response, lives are saved by preparedness…” – but if only all was as simple.
The rumbling of the air-condition in our office laces the air with a coolness that’s perhaps a little too cold for goose bumps to sit comfortably. Chats and laughter shared between workmates, recounting quirky patients, confounding disease symptoms, eccentric doctors at the emergency department, as if played as a soundtrack, attempting to disguise a sort of alertness one can observe springing at each step we take, each glance we snatch at the quiet phone sitting on the far corner, ever ready, ever threatening to bring bad news…
When the phone finally rings, it bursts forth, encapsulating all time and space, engulfs our minds; I might as well compare that to being transported altogether into a very different reality – Someone is in trouble. Who we will see, what awaits us, we cannot tell. But it is this state of mind that we have to go forth and stick our faces into the thick or thin of events, clean or filth, rain or shelter, housed on stilts or mortar; Aye! We go…!
If we are lucky we get a prompt from our dispatch operator who got the 999 call from our unknown victim, saying if our patient might be conscious, fainted, dizzy, severe headache, chest pain, with history of diabetes or hypertension. If so, we work in our heads with whatever little we were given and still had to maintain a full openness to anticipate totally different presentations. The siren pounds through the neighbourhood, pacing our heartbeat as we snake pass traffic lights, swearing at unscrupulous drivers who tries to obstruct our journey, or disregards our plea for speedy access pass them. Our thoughts riding the sharp wailings, all this time calculating in our heads what we might ask our patients, what related diseases we should consider when examining our patient, what should we look out for in his pile of medicines, what might we do in case she suddenly deteriorate during our care, and what if he couldn’t give us any information, what shall we do, what shall we say, what shall we think?
The slight squeel of our stretcher creeks softly in our ears as we tread carefully into the looming dark. The long, narrow, corridor guarding our flanks, albeit stenched of urine, from what might be a 12 storey high fall onto a grass field. Laundry are out, old shoes strewn on sides, some divorced from the other, some covered in the full thickness of dust. A whiff of heated air argued with the sweat already making their way down my face as we walked pass a air-con compressor unit. We would then receive some rough caress of messy potted greens on our arms before hearing a panicky voice ushering, or more of hasting our arrival at their home, “Over here!! Over here!!”.
Contrary to popular belief, a medic’s job is by far more humbling than any television drama prefers to parade. I once told a good friend of mine, that to be allowed into the deepest lair of a stranger’s home, to be able to see where no one else would otherwise ever see, makes one appreciate more the real vulnerability that torments every human; and our clumsy ways to protect it even if poorly so.
Lugging heavy bags containing a small oxygen tank, medical equipment, instruments and accessories, straining our eyes through the dimly lit living room, cautioning our every step in case anything comes between our feet and safe ground, we arrived beside an old man sitting limply on his bed. Mr. Lim was half dressed, having his chest exposed. His son was supporting his torso, which would otherwise surely fall backwards. His eyes were closed.
My partner and I quickly began a routine collection of vital signs. The sphygmo that tells us about his blood pressure showed us good numbers, glucose level was suggesting that his brain wasn’t starved of energy, he wasn’t having a fever although his pulse seems to be thumping faster than average. There was nothing that immediately suggests an obvious condition that explains his lack of purposeful consciousness. We then turned to his family members for more details prior to our arrival. And then we were told that he had vomited a negligible amount of spit into a nearby tin can, and they had wiped off dripping sweat from his body. From any standard emergency text, sweat and vomiting on a pale and weak body should always raise the suspicion for cardiac conditions drastically whether or not your patient has a chest pain. Especially for old people, this little observation is even more pronounced. Sure enough, once the ECG cable got connected, old man’s heart rate came back at 150 beats per minute! For his heart to be beating this fast, he could go down out of sheer fatigue, or he goes into a suffocation involving the whole body simply because his heart is not able to send enough blood through. There was very little else we could do for him there.
There was haste in the way we shove the stretcher to Mr Lim’s side. Everything in our mind narrowed into one fact – Old man here needs to get his heart rate stabilised and he needed it now. Mr Lim in tow, rigged up with lots of oxygen via a mask, our wailing van slid down the rural bends into the highway heading to Penang General Hospital, painting the town red and blue against the cars we have shoved aside. As we entered into the Emergency bay, doctors were standing by to receive him, we had called up Dr Jenny while on our way. They rushed him into Red Zone, tubed, wired and pumped with drugs.
17:20 – Dr. Jenny called to inform us that Mr. Lim didn’t make it.
The Dilemma
My analysis runs along 2 lines – personal vision and financial mobility. The difficulty with deciding to embrace the career of emergency paramedicine in Malaysia is a fairly straightforward analysis. Can one expect to organise one’s life according to what she values and to her plans of development and expansion, with the current market wage, and workload? And is the general options provided by the industry viable to social mobility and continuous growth?
As mentioned, Emergency pre-hospital healthcare in Malaysia looks very much like a monarchy – Centralised education and hiring based on very narrow qualification requirements. For one in her late 20’s, to re-enter into a 3 year government approved diploma programme is just taking too much time, in return for a government hospital based job. Private ambulance services on the other hand hardly respond to public medical emergencies since the operations model is based on profit making. Save being called to a subscriber’s emergency, the rest of jobs are of non emergency (non-acute conditions), inter-facility transfers – which is not what i had in mind.
To See with Four Eyes
It might be a little too exaggerated to say that your partner on your shift could make or break your entire week, but I believe that in EMS, at least one partner you get in your length of service, is going to push and change how you view your job, and your world. Kenneth, is just this one partner.
Kenneth is someone you know you can lie your back on. And when you’re out on a mission to pluck people off dangerous highways, aggressive crowds, in all kinds of confounding places, you want someone like that. Kenneth has a knack of putting his third eye out for any situations that has gone awry and needs retreat or be managed. And the best part is, he does it with the cutest sense of humour. And if this is not touching enough, try asking him what kind of patients he would like to have and see just such patients creep up over the day.
I owe him a very deep gratitude for the little but all too important things he taught me. He always said that the emergency is not ours, it’s our patient’s emergency. This is too different from saying that we don’t feel the urgency for our patients’ needs, but we should not go into a state of emergency ourselves, and then lose the ability to assess our patient with a systematic rigour, having the presence of mind to manage what problems our patient’s body is giving him, drive safely so as to not endanger our lives and the lives of other road users, etc… He showed me that in life, even in such critical place as a site of medical emergency, we really don’t have to take ourselves so seriously. Working with him, we could speak with chuckles over an unconscious patient not because we don’t feel sorry for what our patient is going through, but because we know that if there is no immediate threat to life, adrelin and stress is unnecessary. He taught me to look out for the cute little things in life, a funny line in the lyrics of a song, a quirky personality, a good smokey beef burger every now and then, the joy of a good nap, the comfort of a nice hoodie, the coolness in being mischievious, the real laughter you get from being childish sometimes. And for someone as congenial as that, he stands for only the highest standards in all the patients that he sees. And who else could read chapters after chapters of medical education on weekends, go out for long distant transfer trips, and after breaking ribs during CPR, then goes back home to bake a pile of dark chocolate brownies?
Taking It Away
It is so difficult to pin-point what one will learn when you spend some time working in this industry. On telling them that i work with the ambulance service, many a friend would ask me if i was easily affected by patients who die. Honestly, the amount of deaths that we witness does not make us grow cold towards loss. But on the contrary, it sensitises us even more to notice the living. Initially, I thought I would be prompted to think about many things if i were given the chance to rub shoulders with people who dies; but there is nothing to learn in death. it is the only thing that I found I can elicit nothing from. It is the true void. If nothing else, what an ambulance job will teach you, is that the simplest things that keep people alive, is simply having life itself – to have a pulse, and breathing. It is that straightforward.
snout sniffer 