unprepared mothers

8:00 PM | 29 June 2020

Sitting on the other side of that plastic screen, I see more than a few pregnant women every day, each one of them recounting a different tale of how patriarchy has strangled the notion of even basic human rights.

95% of these women hail from families where making ends meet is a struggle but where bringing a child into this world is like going out for grocery: that’s the amount of thought these people – who make up a good chunk of our population – put into something completely life-changing.

Deciding how many children their malnourished bodies can bear is a right unheard of. These are women who need their husband’s permission before they can even get – in layman’s terms – injectable iron to correct their anaemic state. These are women whose primary doctor is chosen by their mothers-in-law, or their aunts-in-law, or some other lady relative. Anyone but herself. When does she have the next kid? That also gets to be decided by the other women in her family. These are women who have to beg their husbands to ‘allow’ them a C-section because they can’t bear the labour pains or because it’s technically not possible.

I see the helplessness in their eyes and I wonder what their childhood was like; if anyone asked them ever what they would like to be when they grew up? I wonder what they would say… Had anyone ever actually asked them that?
I see how the lack of control over their lives feeds their hidden demons, the same demons that viciously come out when it’s their turn to give their place to another woman, just like their mothers-in-law. It’s a cycle, one that will never stop. Not unless we educate these women and solve the problems that have made them who they are.
How can a woman who can not even stand up for herself protect and nourish a child? Food and water and clothes are never the only things that a child needs; they need kind love, care, and compassion for their intellectual, moral, and spiritual growth; all of these being part of the ‘*rizq‘ that is supposed to come with this little human.

I remember looking at one of these women rather closely today. Her doe-like eyes carried an unheard tale. The eight-month-old in her lap testifying to how unprepared his mother was for another baby. A haemoglobin level of 7.2, her refusal to get further tests done, and a husband who was sleeping at home did nothing to confute my views.

I see these women waiting to welcome a new life into this world and I do the only thing I can – speak to these parents about the huge blessing that they’re being bestowed with, that a mother’s responsibility is more than just to birth this child and the father’s responsibility is more than just to facilitate and finance that birth. And I say a little prayer for them: may every child born into this world find the warmth of a loving home, the kindness of those we call our own, the miracle of humanity, and the power of faith and true love. Amen.

*rizq: provision

Dr Ziauddin Memorial Hospital, Gole Market, Nazimabad.

Voluntary e-medical consultation

I, Dr. Arfa Masihuddin, would like to volunteer my services as a doctor if anyone here needs any guidance regarding their medical complaints.

Please DO NOT visit hospitals for your minor ailments, regular health checkups, stomach aches, headaches or minor pains anywhere. Your blood test reports, kid’s poor nutritional habits, 15-year-old backache and other OPD based cases can wait.

Hospitals are infected in one way or the other. Please stay safe as you might become the source of transmission of the virus to your friends and family.

If you need any medical help, you can reach out to me on E-mail/Messenger/Instagram for all types of medical consultations.

I’ll try to get back to you as soon as I can, with the best of my knowledge. If I’m unable to assist you, I will refer you to a specialist who can.

If you do reach out, please send in your medical queries in the following format:

💊 Your name and gender:
💊 Your age:
💊 Any pre-existing medical conditions / health issues you regularly take medicines for:
💊 Your symptoms / current medical issue:
💊 Duration of your symptoms:

🦸 Stay at home and play your part in saving the world.

📧 E-mail: walkingthoughts.am@gmail.com
☎️ Contact number: +92 306 0984838
📷 IG: @drarfamasihuddin


A special feature on the Subcontinenttimes

The following was a special feature on the page Subcontinenttimes.

• • • • •

“’Donning’ and ‘doffing’ every alternate day as I gear up to tend to patients in the ER of a tertiary care hospital in Karachi; that’s how we are observing quarantine for you.
It’s true that the shiny pictures popping up on my newsfeed arouse a strange sense of envy – and even fear – and then a lot of guilt at that envy. But then I remind myself to be grateful to these people staying at home, enjoying their safe time. It is, after all, the only way this quarantine can rescue the world.
Every time we receive a patient and take a quick history, and the alarm bell goes off, we gulp down another gloomy thought and joke amongst ourselves if this one is going to finally get us, like that senior colleague we heard about the other day on the news. It’s the new normal, you see.

An unprotected CPR on a suspected COVID-19 patient – now dead – or meagre, insufficient PPE, or another X-RAY of an asymptomatic patient revealing infiltrates on both sides of the lungs, or just a young man nervously hiding his travel history: it’s how we count the hours here.
No textbook had prepared us for this. No exam had tested us on how to navigate through an unprecedented global emergency while struggling to do no harm, to protect everyone, to be kind to our scared patients, to fight off poor administrative policies, and not be used as a frontline human shield. Nothing.

Every time I step out, I fight off the fear of exposing my brave family. The unconditional love of my mother never leaving my side as I see her blowing duas over me as I step out of the car, knowing that she’d rather have her girl home, safe and sound, but also knowing that it’s the bigger battle that needs to be won. It’s also the slow, startling realization that humanity always comes first, that no amount of wealth or social status can win over the power of the Unseen, and that at the end of the day, nothing really matters, you know? Except peace of heart and freedom from the self-imposed rules of our society. After all, the world is managing fine without all it’s fanciful desires, isn’t it? But, thankfully, once I manage to get past these, I jump from being a doctor to the writer that always consoles me: there’s words, and heartbeats, and poetry, and letters, and books, and chai, and Ammi-k-haath-ka-khana. A little happiness, a little peace, and lots of lovely memories.”

Dr. Arfa, @drarfamasihuddin
Karachi, Pakistan

Link to the original articles: Part 1 |Part 2

A letter for her (XXV) – Pul-e-sirat

11:47 PM | 20 March 2020

I just received this message from a doctor friend:

“The Sindh Government urges all able-bodied young women and men to come forward to help in the war against coronavirus-2019.
The expo center Karachi is due to be set up as a field hospital and isolation center for all COVID-19 positive patients. We require volunteers for health care assistants (HCAs), doctors, registered nurses, and supplementary staff.
Personal protective equipment will be fully supplied. The safety of healthcare workers is our prime priority. If PPEs are not available, recruitment will not take place. Please fill the form attached to lend a hand in the nation’s time of need. Pakistan Zindabad!


I feel like a warrior out in the battlefield without any weapons.
My hospital isn’t providing us with any personal protective equipment, we’re being asked to see patients in OPDs, and prepare patients for elective surgeries. These aren’t easy conditions to work in. But I’m doing what I can, Nani Jaan; raising my voice, trying my best to do whatever I can. I was always interested in public health, remember? I guess now is the time to honour the oath I took when I graduated. As a human, as a Muslim, as a doctor, as a Pakistani, I carry a huge responsibility – to heal, to protect. As I intend to do that, I’m also caught in a conflict between my duty to my community and my responsibility towards my family. I do not wish to endanger them. But then see which way things are going! It really does seem like the world is ending anyway so why not just dedicate the rest of my life to healing humanity? Yes. I do wish to volunteer for this camp. But it also depends on what the situation at my hospital is. I’ll let you know, of course. I never begin anything without your blessings, do I?

On the Day of Judgment, I will be asked about how I made used of my knowledge, my health, my abilities, even whatever small talent I have. This health, this knowledge, this talent – it’s all His amanat. That’s what you taught us, didn’t you? This, too, is jihad.
So when I have nothing else to present to Him, maybe these small efforts will make it easier for me to cross Pul-e-Sirat. Because this is Pul-e-Sirat; both in this world and the next.

Need your prayers more than ever.

Gearing up for house job

As exciting as it may sound, starting off house job after an overdose of the theoretical knowledge can be a little scary. When I was on the start-line of mine, I received a few pearls of wisdom from a senior colleague. I thought it’d be a good idea to share it on this platform, for the benefit of all those starting their medical careers with me. So here are a few tips to get you through:

  • Never ever give Benzos for sleep. Give Zolpidem or Melatonin instead. Teach good sleep hygiene.
    Sleep hygiene means dimming lights before bedtime, not using phones before bedtime, stopping all caffeine intake with lunch (caffeine has a 6 hour half life).
  • Always give an Omeprazole 20mg before bed whenever you are prescribing NSAIDs
  • Always, always listen to the heart and lungs (the base at the back, especially) on every patient. Always give the abdomen a cursory palpation in each of the four quadrants. Vitals are called vitals for a reason. Make sure to do them for every single patient properly.
  • Always ask about “pishab mein jalan” (dysuria) while reviewing the systems. So many people have UTIs, you’ll be surprised!
  • For colds, make sure to ask if there’s itchy eyes (which means it’s not a cold, it’s a seasonal allergy). And if there is a cold, with fever less than 100.4 C, tell your patients it’s viral, it’ll take time, and just give them Panadol and Xylometazoline nasal spray (but you can’t use it for more than four days, because of rebound congestion — Rhinitis Medicamentosa). Ear infections, on the other hand, are almost always bacterial. So Augmentin may be given.
  • For conjunctivitis, it’s advisable to give antibacterial drops to prevent secondary infection. Ciprofloxacin drops are good. Tobramycin drops are bad because aminoglycosides are toxic to the epithelia and retards healing.
  • For UTIs, Cipro is your best friend. But you can’t give it to kids.
  • For vomiting, Ondansetron is great if the GI tract is the reason for vomiting. And there’s no risk for tardive dyskinesia like there is with Metoclopramide (which Pakistani doctors love for some reason).
  • Always try to simplify drug regimens when possible.
  • Use the teach-back method to check patient understanding (ask them to tell you back what time and how much they’ll take what medicine).
  • Don’t ever promise anything you can’t do. If you don’t know something, don’t be afraid to say you don’t know but you will look it up and get back in a while.
  • Medicine is insanely vast and it’s impossible to know everything. Much of it is learnt via osmosis in the hospital. So don’t worry. When in doubt, first do no harm. Nothing is more important than patient safety.
  • Relax and take your time with the history. Go through the whole sheet, don’t skip any section, no matter how silly or embarrassing it seems to you. Even the marital history section: just ask if they have any concerns with their marital life; it’s a very common presenting complain in the urology and gynaecolgy clinics.
  • Make sure you have privacy while examining the patients – draw the blinds. But also remember to have male chaperone (from your side – meaning a nurse or doctor) when examining a male, and a female chaperone if examining a female. Explain what you’re going to do before you do it. Summarise stuff at the end and give the patient a quick plan of action. It makes them feel like they’re in this with you, even if it’s as simple as, “now we’re going to do some tests and the relevant consultant will see you to decide what’s next”. You’ll be their primary doctor so it’s a big deal. You’re their advocate.
  • And if a patient is giving you a long, bizarre history, just ask them why they came to the hospital TODAY. What brought them in. That’s your chief complaint.
  • Don’t forget to ask about any current medications. A presenting complaint might be the side-effect of a drug they’re already using.
  • Always check labels and expiry dates before giving any drugs.
  • Remember to check the time of your patient’s surgery to keep them on adequate NPO. RBS and blood pressure monitoring, and a thorough baseline workup involving the coagulation profile is very, very necessary.
  • Don’t be afraid to consult Medscape, Pharmapedia Pak, and MDCalc: these are some important phone apps that’ll come in handy.
  • Always double-check the patient’s name and MR/file/registration number when posting/prescribing medicines, tests, checking test results.
  • When writing down your follow-up or shifting notes, always sign off with your name, the date, and the time.
  • Use social media for your benefit. Follow pages that will keep you updated on the latest clinical guidelines. Here are a few you should turn on the ‘see first’ button for:

    1) Medscape
    “Medscape is the leading global online destination for clinical information and educational resources for physicians and other healthcare professional.”
    Facebook: https://www.facebook.com/medscape/
    Instagram: https://instagram.com/medscape?igshid=1awsi87uc5vp5

    2) NEMJ
    “The New England Journal of Medicine is the world’s leading medical journal and website.
    Facebook: https://www.facebook.com/TheNewEnglandJournalofMedicine/
    Instagram: https://instagram.com/nejm?igshid=12s9ntxbrh7y1

    3) Brief Medical Updates
    “Brief Medical Updates digests the latest research and guidelines into concise, practice-informing summaries for clinicians.”
    Facebook: https://www.facebook.com/BriefMedicalUpdates/
    Instagram: They don’t have an Instagram page, yet. But we hope they will, soon!

    4) DaktarSaab
    “Equipping people with teh tools and enabling them to take better care of their, and their loved ones’ health.”
    Facebook: https://www.facebook.com/TheDaktarSaab/
    Instagram: https://instagram.com/daktarsaab_?igshid=971eam89jg1z
    YouTube: https://www.youtube.com/channel/UCFXYzvf1OPP4e87L3YCoyhQ

    These were just a few know-hows to help you navigate through your house-job. If you have something to share, tell us in the comments below and help out your colleagues! 👇

House Officers

As I embarked upon another one of my firsts – first day as a house officer at Dr Ziauddin Hospital – I was told repeatedly that house job is just a lot of boring clerical work; lots of documentation and running around. A month into it, I beg to differ. Slightly.

Graduating with the theoretical knowledge that is required to licence us as medical practitioners, we find ourselves without a map when it comes to caring for our patients. It’s true that the clinical years during med school lend us an opportunistic window to closely observe patient management, but the lack of professional responsibility that comes with the status of being a student tends to get to the best of us. As we wear the badge of a ‘House Officer’, that, fortunately, takes a timely leave.

When there’s a will, there’s a way. And even through this clerical work, a lot can be learned only if we pay attention, slide up our learning curve, and realise that this work that we’re doing is not small, is not insignificant.

Let’s walk down this aisle together, fellow house officers!

For a system to function efficiently, there are complete units working in harmony. Just like for you to be able to enjoy the spectacular view from the top floor of a well-built building, its basement and the upcoming floors need to be strong enough to support each other, same goes with any system, including healthcare. The hierarchy determines that our consultants see the final picture – the presenting complaints of the patients, the laboratory and radiological evidence to help them reach a diagnosis, and stay updated with the patient’s condition. For this supporting evidence to be arranged, the residents or the post-graduate doctors step in: their job is to make sure that all the relevant investigations and patient information is relayed to the consultant in a timely manner. And it is them we house officers are assisting by receiving the patients and making sure that the indispensable nursing staff carries out the lab investigations and looks after the initial management of the patient (read: a check-and-balance system).
A single lab value written in the incorrect file or the incorrect column can change the whole management plan and as does the house officer’s inability to recognise any abnormality in these patterns after co-relating them with the signs and symptoms. To be able to perceive if your patient’s sudden new symptom is a side-effect of a new drug that they have been prescribed is just a very small example of why the work out we do is as important.

A few days ago, one of my fellow house-officers noticed the high levels of creatinine in a patient’s blood reports: a fact overlooked by the resident doctor. Having eventually informed the surgeon, the scheduled cystoscopy for evaluation was then done in spinal anesthesia instead of general anesthesia. Point to be noted: had the house officer not noted it, the patient would have undergone a procedure originally contraindicated.

Healthcare is a systematic process where each one of us is required to work with dignified responsibility and recognise this house job – and all upcoming exams like the USMLE, PLAB, FCPS – as an essential and mandatory part of our training. There is no bypassing this.

There’s a lot to learn from! From the moment we receive a patient in the out-patient department and decide upon a criterion to admit him in the ward, to observing what management plan the resident doctor then formulates (labs, medicines, etc) to making discharge summaries that track down the whole hospital management plan – all of this is a good learning ground for commonly used medications and their side-effects, the red-flags of the diseases, knowing when it’s safe to send a patient home, and eventually learning how to deal with medical emergencies.

Most importantly, we learn how to communicate effectively, empathetically, and kindly. Where it’s important to learn how to speak to a patient and their attendants, it is also important to learn how to speak to your seniors, your juniors, your colleagues; in distress, in anger, in happiness. Learning how to control our emotions and maintain a professional decorum at all times is another thing that we lack as a nation.

There are, unfortunately, no short-cuts in life. And to get through this physically and mentally draining period of our training, we ought to repeatedly remind ourselves that every patient counts, every patient is a teacher, every disease is another life story, every day is a new chance at helping save a life. You never know which vigilant act of yours could be the reason someone else is breathing tomorrow. You never know how you can be the answer to someone’s prayer.

Let your patients also save you.

The Heart

“..this narrow focus on biological mechanisms has hurt patients. We have overused stents and pacemakers. We have moved away from the emotional heart to a narrow focus on the biochemical pump. The American Heart Association still does not list emotional stress among the key modifiable risk factors for heart disease – perhaps in part because serum cholesterol is so much easier to reduce than emotional and social disruption. We need a better way, one that recognises the power and importance of emotions that the heat – the metaphorical heart – was believed to house for millennia. Though we know today that the heart is not the repository of the affections, it nevertheless remains the physiological canvas upon which our emotions are most easily written.”

In between researching high cholesterol levels and scientific advancements, we doctors have buried deep the psychosocial effects of stress: how when the heart is screwed, it really is screwed. That’s what Sandeep Jauhar talks about in his book, ‘The Heart’.

The softer matters of the heart go unheard. It keeps on beating, doing its job like an old, faithful watchman guarding the rusty gate until one fine day, you walk to the open gate to see that your car is stolen. Like droplets of paints splashed on a blank canvas, our worries are marking our brains, immobile and yet, growing at the speed of light, eating away our hearts and our kidneys and walking us to pathologies that add eventually add as co-morbids before a new one is diagnosed.

As sad as it is, we prefer to help the pharmaceutical industry thrive to control the flow of – or lack of, rather – the firm, yellowy, cholesterol resting stubbornly on the tiny vessels networking within us as compared to living a life of love and peace. Rest more, eat healthy, exercise regularly, take up a new hobby, stop being jealous of your neighbors’s new car and your sister’s son’s straight As.
I mean… yeah?

The subject of ‘ethics’ should have enough importance to be the ticket to your own graduation ceremony.

28 September 2019

“When will this end?” It finally has. Hope so.

My Internal medicine rotation has drawn an end, also turning the final pages to the chapter of what we have called ‘Ziauddin University’ for the last five years. It will be, undoubtedly, pretty magnanimous to call them pretty decent. But that’s for another time (read: post).

Dabbling with the most common ailments – malaria, typhoid, dengue, diabetes – was personally not as exciting as getting to explore the humanistic aspect of medicine and interacting with professors who commendably accredited enough significance to this side of healthcare.

Prof. Dr Ejaz Vohra, former Dean of Postgraduate studies at Ziauddin University and one of the professors I was rotating with, is known amongst the student body for his admirable efforts in trying to promote narrative medicine as an emerging field.
Dr Vohra has organised monthly seminars where he has encouraged the students and house officers to present and discuss excerpts from literature that ties together medicine and the human stories that we so often do not hear over the presenting complains of our patients due to a dearth of something as basic and as essential as empathy, compassion, and kindness.

That, and my own personal experiences as a student, a patient’s attendant, and an almost doctor (am I even ready?) have ascertained one thing: the vicious cycle of ‘I-had-it-rough-so-shall-the-younger-ones’ does not stop at diabolic social norms and customs usually handed down in the ugly disguise of ‘tradition’ from one generation to another, but also plagues our professional circles where one side chooses to override the other. We not only need to talk about uprooting this thorny bush, but we also need to take practical, effective steps to do so. The subject of ‘ethics’ should have enough importance to be the ticket to your own graduation ceremony.

Actions speak louder than words. Let’s get going, shall we?


the little secrets of life

7:20 PM | 1 August 2019

Five years ago when I started medical school, I had expected to learn the truth about human life – how we breathe, how we eat, how we sleep. Literally. But what I have stumbled across is far, far greater than that. I’ve learnt how we feel, why we feel. The little secrets of life, you know? Yeah. And how a dua – a heartfelt prayer – works.

We sit on the prayer mat and raise our hands in supplication and cry our hearts out, our foreheads kissing the ground, our souls trembling. We utter our hearts’ deepest, darkest desires. Then we get up from the prayer mat and we expect heaven to have been laid right before us, right away! Not so fast, people! Not so fast!

It’s a process. Slow and steady, usually. Also awe-inspiringly quick, sometimes. A fetus takes nine months to grow into the baby that the mother gives birth to after a tiring labour. I’ve seen duas being answered like that. I see it now, too. I see the ease in the difficulty. “For indeed, with hardship will be ease.” (Surah Ash-Sharh [94])
It’s amazing how I can even see it. Another one of those hugs from God, you know? Pour in a little love, a faith that loves to play hide-n-seek, also throw in an ounce of fear – “what if my prayer isn’t answered?” – and lots and lots and lots of patience: that is your dua. And then the magic begins to show itself; a  few trips here and there, maybe a disaster or two, a couple of heartbreaks and a huge river of tears later..it happens! At the perfect timing, in the perfect way. Perfect here is synonymous to His will, okay?

And so it’s happening! It’s happening and I am in happy awe of how beautifully He is managing the universe! The little ants who get their sustenance; the chirpy birds; the poor cobbler at the end of the lane. Me. You. Us.

We all have such a beautiful relationship with God. He has little secrets with everyone, all of us. That’s so incredibly fascinating, is it not? How He brings ease into my life will be very different from how He sends a hug your way. But the interesting bit is that we all see it. Not always. Just sometimes. And in those “some” times, lies the secret to all of our time on this little planet.

Everything wonderful is on the way. Yeah? Yeah.



The Glasgow Coma Scale

| 9 June 2019 |

During our end of rotation exam, the spot for neurosurgery had a question on epidural hematoma. The question was a case based CT scan image, asking us to state the GCS of the patient, the radiological findings, and the subsequent management plan.

The Glasgow Coma Scale (GCS) is the scoring system used to describe the level of consciousness in a person following a traumatic brain injury. It evaluates the eye, verbal, and motor response of the patient. In simple words: from a total of 15, the lower the score, the worse it is.

As a doctor-to-be, I often find myself wondering how the world would be if there was a consciousness scale for basic human qualities like kindness, empathy, compassion, forgiveness, mercy. Would we have been as concerned if the ‘score’ was low? Would we have made friendships and nurtured relationships on the basis of this score? More importantly, would we have really believed in the credibility of this score to establish how “alive” a person really is, how “conscious” they are, how “healthy” they are? Will the heart and soul ever win over all that the eyes merely see?

This black and white film illustrating an important organ of the human body is more than that if you choose to think about it. If you choose to think about it. Drifting through the mundane motions of life – waking up, eating, going to work, paying the bills, filling up the car’s tank, all of those worldly tasks – the desire to worship through love and kindness drowns in the darkness of fear and confusion and “what will people think”, and we’re left with nothing but an emptiness that tires us. Tires us because our scores are low. And because they are low, sometimes, the sunrise stops becoming the alarm clock for another happy day of happy miracles; and when the foamy waves hit the shore, you only see them too late – going back, not rushing to hug you.

If only medicine had the cure to that. If only.

brain MRI
Source: Google