Chapter 6: 1966-68

After my orientation and three months working at the male medical and surgical ward, I was offered a position in the Operating Theatre as staff nurse in-charge. The position had all the responsibilities of running the Operation Theatre Suite in conjunction with the Surgeon but no monetary gain despite the challenges and headaches of organising the place and changing the attitudes of staff by re-education. This offer was an honour to me, but I had to have the assurances of the matron that she would give me the support I needed in the position. My experience as a staff-nurse in Malaysia was hardly six months and to take on a job as charge nurse would be very daunting. I was still learning many nursing skills such as intravenous injection, diagnosis of simple ailments, managing the hospital, and acting as a dietician outside office hours which were not taught during my undergraduate training. The matron assured me she would give me all the support I required. She informed me that the theatre had a good staff of two male orderlies and two assistant nurses. The Health Department had posted a Surgeon to the hospital and he wanted to work with a staff nurse at the theatre. There would not be any major surgeries initially as the Surgeon wanted to have a few changes in the theatre and get to know his staff before attempting any major surgeries. No other staff nurses dared take up the position as they did not feel they had adequate theatre training. The surgeon's wife was also believed to be an interfering person. I was given a week to think over the position before accepting.

I had only three months of operating theatre experience during my nursing training in Australia. The position would be a great challenge to me and being young I had a great taste for challenges in life. The matron appeared very supportive but when I met the surgeon and his wife, who was a gynaecologist with a diploma at the hospital, I felt vibes that they were difficult doctors to get along with. I had to use my own judgement and give the couple the benefit of the doubt. I often like to give people a chance to prove themselves rather than get influenced by other people's opinions. I was mindful to be on guard however, and beware of the things people had warned me about.

The staff at the theatre appeared respectful to their seniors. I had never been addressed so politely before. This culture of respecting their seniors and elders is a part of many Asian cultures. The assistance nurse in charge at the time was aware of the headaches of being in charge. She only had a years' practical theatre experience and no management skills at Alor Star Hospital, Kedah, Malaysia. She appeared friendly and polite enough to work with and to gain some experience from. There was no night duty and only office hours working in the department. However, there would be on call duties and the rotation was amongst the three nurses at the operating theatre. There was one theatre orderly on call at the same time too.

Night duty was a shift I detested. I just could not sleep when I was on night duty. Moreover, night duty disturbs the circadian rhythm of the body. There was so much noise around the place that one could hardly sleep. Even with "Do Not Disturb" and "Night Duty" signs on our doors, people would still talk and shout along the corridor. The Ayar Mah (maids) would be mopping the floors or dusting the place and making clucking sounds in the nursing home. The most one could sleep would be four hours. I often wonder how I survived all those years of night duty without making serious mistakes whilst on duty.

The hospital had open wards and when on duty during the night, one could not get away from being bitten by mosquitoes, even though we covered our legs with draw-sheets or blankets and had mosquito coils under the nursing desk. Many of the nurses' legs had visible bites and scars on them. The patients slept under mosquito nets to prevent them from being bitten. Malaria was prevalent in the rural areas where wet padi (rice) was being grown. I did not wish to be a malaria victim. I did not enjoy night duty, even though work was lighter than when I was on day duty. With the exception of very sick patients, most patients were sedated for the night and so the work was lighter on night duty than day duty.

The operating theatre was only small, with only an operating room with one operating table. There was a small entrance used for an anaesthetist room or to perform minor surgeries, instead of having them done in the operating theatre. I was told the Surgeon had asked for a little extension at the side of the operating theatre for use as his office and out-patient visitations. There was a small space near the entrance of the operating theatre for storage and as a change room. We had a cupboard for storage two steps into that little space. During the rainy season I remember the basement-like area being flooded more than once. The orderlies had to mop the floor and we had to wear Japanese-styled slippers or thongs to work. In the operating theatre, there were two cupboards for surgical instruments and a little space at the back extension for a small steam autoclave and one small and one large boiling sterilizer. There were two large metal trolleys which the nurses used to set up their sterilised instruments for minor emergency surgery. The instruments were sterilised daily and set up on the trolleys with one thin sterile dressing towel underneath and one on top to keep the sterilised instruments covered.

After much thought, I told the matron I would take up the position. I told myself that I could learn from the assistant nurses and surgeon about how I could assist in running the operating theatre. I liked to learn and an opportunity to gain a variety of nursing experiences in different departments in my nursing profession would be a good thing.

On my first day, I was welcomed by the staff. The head assistant nurse showed me around the operating theatre and gave me a rundown of how the operating theatre functioned and how she managed it. In the morning, the required emergency instruments were re-sterilised and set up for the day. If the instruments were used, they were washed and re-sterilised by boiling and replaced onto the trolley for further use. If there were gloves to repair or injection needles to sharpen and re-sterilise, the nurses attended to them. Most of the equipment and surgical supplies were re-used over and over again until they were unusable. Costs had to be cut to sustain the health services. I got most of my information and gossip from the staff when we were preparing or recycling our medical supplies. Some of the things staff were used to required change and re-education. Being new to the place, I had to introduce changes slowly. I had to be careful that I did not introduce too many changes that would cause resentment and conflict between the staff and myself.

There were many changes I wanted to introduce, for example, changing our uniform and shoes to theatre gowns and shoes before entering the main operating theatre, and not encouraging patients or other members of staff to enter the main theatre and make it a thoroughfare. The dust and dirt brought into the theatre would contaminate the operating theatre and cause infection. In those days, simple operations, like appendectomy, sebaceous cyst removal and simple incisions became infected. I once saw the Mentri Besar, (Mayor) of the State entering the operating theatre to be seen by the surgeon or medical officer. The outpatient department then was seen as not an appropriate place to examine such a high profile personal. One had to introduce change gradually so that conflicts within the department could be handled. I was than learning from members of staff, not only the running of the operating theatre, assisting at the operations but also the politics around the place. My learning curve in the nursing profession was great. Even though I had completed my training and completed many nursing qualifications with distinction, there was still a lot to learn. Medicine changed constantly. There were often new procedures or treatments being discovered and introduced.

The instruments used in the operating theatre were sterilised by boiling. Hard water was used and as a result there was sediment caked onto the instruments, causing them to discolour and malfunction. The water was so hard that after boiling and leaving it to settle, one could see an inch or two of sediment at the bottom. I always left the bottom portion of water to be tipped out. During my observations at Kangar Hospital, the rate of renal calculi was high and I was sure that this was due to the hard water that the people were drinking. As a priority for change in the operating theatre, I believed the steaming method for sterilising should be used, rather than the boiling method. I requested larger cloth dressing towels. The dressing towels given were too thin to maintain instrument sterility for over a few weeks. The matron could not provide me with thicker towels so I had to compromise. I asked for more draw-sheets for the operation theatre. The thicker material for draw-sheets could be used as a second layer of dressing towels to protect the sterile instruments. Matron kept her promise and gave me whatever help I required. She had to maintain her budget and could only spare the money for new dressing towels and draw-sheets to the operating theatre and nowhere else. I told the nursing staff that the method of boiling the instruments and keeping them sterile on the trolley with only one sterile dressing towel over the trolley was not adequate. I explained that keeping operating instruments on a wet "sterile" towel that was opened a few times a day and kept overnight was not adequate and would cause infection due to operating instruments being contaminated. The wet sterile towel would not have kept the instruments sterile for over a few hours. Changing this procedure of sterilisation meant more work for us but we needed to prevent wounds from being infected. We should not allow patients to suffer unnecessarily and subject them to more visits to the doctors and more medication to take. Moreover there would be a rise in health costs to the country. Most patients were treated free or had to pay a minimum of fifty cents Malaysian as payment during those days. The reasoning was accepted by the staff albeit with much persuasion. I was successful in introducing the change and as a result there was less wound infection. The staff also noticed the end result and were happy to accept the change. I was able to influence the staff through re-education thus changes were gradually introduced to the operation theatre.

The next change I had in mind was to change some of the ways duties were performed in the wards. I was to get the ward staff to send the reused intravenous drip sets to the theatre for sterilisation. The boiling method in the ward for reused intravenous drip sets was not adequate. Patients developed rigors during intravenous drip with just the normal saline drip. There were no disposable drip sets. Latex tubing was re-used until they blemished. Needles were blunt. I remembered using a blunt needle on a patient and could hear the needle piercing into the skin. Poor patients, I could feel their pain. However, wards were not my area of jurisdiction and I had to be careful and make sure I did not offend any of the staff. The matron gave me permission to introduce the change to the ward. All intravenous drip sets after use had to come to the operating theatre for steam sterilisation. I made sure that the ward staff perceived the change as reducing their work load and not as an insult. This introduction would mean more work for the operation theatre staff. I needed to convince the nurses and orderlies that it was worth it as it benefited the patients and one day their relatives might be one of the patients. The introduction was accepted reluctantly but eventually as time passed it became part of the routine work for staff. The ward staff brought the used intravenous drip sets in exchange for a sterilised set. I got the used sets soaked in Savlon, an antiseptic, overnight. The orderlies washed them in the morning and hung them to dry. The nurses removed the needles and adaptors from the tubing. The needles were sharpened with a sharpening stone. The insides of adaptors were cleaned before connecting back onto the tubing. They were then packed into metal boxes for sterilisation. It was a tedious job but the rate of infection from intravenous treatment was reduced drastically after the introduction of intravenous drip sets with steam sterilisation. The ward staff was happy that they had sharp needles to insert into patients' skin. Soon I was told by matron that the ward staff would like to have their syringes and needles brought to the operation theatre for cleaning and sterilisation too. I was willing to accept the extra work for the benefit of the patients. The operation staff felt good in accepting the change too as they realised the importance of good quality care to patients. Operating theatre rubber gloves were also washed, dried, tested, powdered, repacked and sterilised by the operation theatre staff. Not mendable gloves were used for finger stales for rectal examinations or the insertion of suppositories. I hoped the hospital would see the need of an autoclaving department and the need of the use of disposable equipment. When? Time would tell.

My few months as charge nurse in the operation theatre were satisfying and fulfilling. Soon after the surgeon got settled into the hospital and had changes made to the operating theatre, he asked permission from the medical officer in-charge of the hospital to go to Alor Star General Hospital for some theatre experience. I soon found out that the surgeon did not have much practical operating experiences after obtaining his qualification from London, England. After completing his qualification he could not get a position as a surgeon in England or Thailand, where he came from. At the time Malaysia was short of doctors, especially doctors with specialist qualifications. Malaysia recruited many doctors from other countries especially India to fill positions in rural areas. Local doctors only liked to work in the cities.

Permission was given to the surgeon to observe operation sessions at Alor Star General Hospital twice a week. I was invited by the surgeon to attend the sessions with him. He would be driving to Alor Star in his own car and I was to take a lift from him. I was to wait at the front entrance of the hospital at eight in the morning every Wednesday and Friday. The trip to Alor Star General Hospital took about an hour. We spent about six months travelling up and down between the two hospitals, twice a week, and spent about six hours at the hospital observing. Sometimes we were invited to assist with minor operations. I soon realised then that the Perlis surgeon did not have as much experience as I thought in surgery.

We stopped going to Alor Star General Hospital after an accident, at the advice of his wife. I supposed she was scared after our car overturned at a ditch between Alor Star and Kangar. We were not injured but were shocked from the accident. She did not wish her husband to have another accident. I worked under him for nearly one year and we removed only a few appendixes. We removed a lot of cysts and ingrowing toe nails, and some other minor operations like D&C by his wife. I realised then the surgeon had not gained much confidence to operate and to work with his staff. He often referred his patients to Alor Star Hospital. In those days the hospital ambulance took patients to Alor Star for referral and follow-up. In one and a half or two years at Kangar Hospital, this surgeon did not contribute much to the operation theatre. We became more active and did more major operations only after a Korean surgeon replaced him. The Korean surgeon was more experienced than the original surgeon and was more industrious too. We got along very well and I learnt a lot from him, and he from us.

When the operation theatre was quiet I was often called to relieve the Hospital Assistant (male nurse) at the casualty department. Since the casualty department was next to the theatre, I was told it would be better for theatre staff to relieve casualty staff, rather than the ward staff. I did not mind relieving as I learnt new things and I liked the challenge. A change of department would revitalise me. After relieving a number of times, I soon realised there were quite a number of things that the Hospital Assistants did that I thought were unethical. A woman patient came to the casualty department with a basket full of her farm produce one morning to see me for an injection. She told me she had no money to pay me and offered her basket as payment. I told her the hospital gave free treatments. She was surprised and was thankful and very grateful that I did not accept her fruit basket. Another morning, a young man came for a penicillin injection for a quick fix after visiting Padang Basar, (the Thailand border to Malaysia) for sex with Thai Prostitutes. He offered me M$10 for the injection. Again I had to explain that treatments from the hospital were free. It made me wonder what else was happening in the Casualty Department when one morning I found that half of my penicillin vials were missing from my locked drawer. I dared not rock the boat, as I did not wish to create conflict with the Hospital Assistants as they could be very nasty. Hospital Assistants "owned" the place and had worked at the hospital too long. I knew that in such a place one could get into trouble easily as what was important was not what you know but who you know. When I gently and casually mentioned my discovery to the matron, she discarded my notation and did not do anything about my observations.

At Kangar Hospital I tried to influence change and had successfully introduced some changes that resulted in lifting the standards of nursing. There was still quite a lot I could do but after two years I was burnt out. It came to the last straw when I was told to go with the Medical Officer, and sometimes the hospital ambulance, to the Perlis, Mentri Besar's (Mayor's) house every morning to give his wife an insulin injection and test her urine for glucose and acetone. I was also taken by the doctors to the Perlis Agong's (King's) house to take a blood pressure measurement of his wife when she was sick. As I mentioned earlier the Mentri Besar came into the main theatre to see the doctors as he did not like to be seen at the Casualty/Outpatient department. I felt I was fighting against the hierarchy and kept hitting against a brick wall. I could only do so much. I felt it was time to move on after two years; moreover I was qualified to apply for my midwifery training in Penang Maternity Hospital and a transfer after two years of service to a rural town. To get a transfer to Perak State and be near my family would be most difficult. All the same I handed an application to the Health Department for my midwifery training to Penang Maternity Hospital first. If successful it would mean I would have served three years at Kangar Hospital. I would stand a better chance for a transfer to Ipoh or at least nearer to my home town.

I decided I would try to apply for my midwifery training. To be selected for midwifery, one had to have at least two years experience with a Malaysian Government hospital and be recommended by your matron. One had to wait one's turn as seniority counted, rather than the merits one possessed. The matron would only recommend you if you had been at the hospital the longest. At the time of making my application I was the longest stay staff-nurse with two years experience and a single general certificate, so I would be the most qualified to apply.

I submitted my application for midwifery at Penang Maternity Hospital to Matron. She said she would submit my application but did not inform me if she would be recommending me for the course. I could only hope that she would look favourably at me. I believed I contributed my bit to the hospital and had done my term in a remote town. There was many a time that I felt I had been imprisoned in Kangar. There was no where to go after work except the cinema theatre. I had no car as I could not afford one. I had to rely on my good fortune that I might meet someone who could take me out in their car. This would be rare in Kangar, as all the well to do fellows were usually snatched away by more beautiful girls. Sons of wealthy families would be working or studying overseas or out of town. To be away just for a year from Kangar would be a change. Away from the "prison" with no walls was what I wished. All the friends I had made during my two years had left and new faces appeared. This was the constant change in Kangar Nurses' Home.

I soon heard from the Health Department that I had been successful in my application for my midwifery training at Penang Hospital. I was excited as I was going to a bigger town and a more interesting place. I could do more things to occupy myself and entertain myself better during my spare time after work. I would not be in the rut and feel that my youth was wasting away in a little town. I must admit, I had developed a lot in my nursing career and had been given many opportunities to improve and better myself in my nursing profession. I do not think I would have had so many opportunities had I been at a bigger hospital in a bigger town.

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