Sunday, October 04, 2009

Sunday is Non-Medical Day

Check out my newest discovery: Smitten Kitchen. I know like, everyone knows about this blog already, but I have only recently discovered it (via Mel Content over on Boerewors). It's fantastic, absolutely fantastic. Food, food, and more food. Ah, bliss.

Crispy Chewy Chocolate Chip Cookies from Smitten Kitchen

Also being enjoyed this week is The Book Thief by Markus Zusak (still a number of paragraphs to go).

Lastly, don't forget to check out SurgeXperiences over at Survive the Journey today!

Thursday, October 01, 2009

When it's someone you know

There seems to be an unwritten rule that when you treat someone you know on more than a purely professional doctor-patient level, there will invariably be a complication or adverse event that almost never occurs otherwise. Your neighbour's kid is far more likely to develop anaphylaxis after you give him amoxil for his ear infection than the average patient, and if you have to do a lumbar puncture on a colleague's child, it'll probably be a bloody tap requiring a repeat in three days (even though you never get bloody taps anymore), and she'll definitely have a post-spinal headache, massively aggravating everyone's fears about meningitis. A fine needle aspiration done on a friend's lymph node is about a thousand times more likely to be lost by the lab than any other, and for some reason, it's almost impossible to successfully drip someone whose kitchen you've drunk tea in the first time round.

The Crater is one of those small-town hospitals where everyone gets real cosy, and we end up treating many of the other staff members, as well as their families. I've done rectal examinations on some of the cleaners, had sisters' nipples waved in my face, inserted a chest drain on one of the security guards (injured off duty), stitched up one or two of the admin folk, bandaged up sore nurses' knees, and have done some cosmetic mole and skin-tag removal on one or two of the clerks. As a team we've resuscitated, intubated and referred two of our sisters' mothers, one with a myocardial infarction and the other with a sub-arachnoid haemorrhage. On the whole, things have gone all right, but I always feel an added element of pressure when dealing with these people: maybe because their expectations of me just seem so much higher than the average patient's, or maybe because I know I have to look them in the eye every day if I mess up.

The place that stresses me out most of all though, is labour ward. Stressful at the best of times, this is taken to a whole new level when a sister's daughter is busy giving birth, which is something that happens quite frequently. I always find it harder to interpret the CTG or to feel calm about a bit of slow progress when I know it's a colleague's grandchild inside there just begging to get HIE and spend it's entire natural life in a wheelchair. Gah.

Last night, one of our casualties sisters became a granny for the first time. Her daughter was induced for having a prolonged pregnancy, and things went pretty well until the she was fully dilated. Then, all the midwives started stressing about the head that didn't really want to come down. There were no signs of CPD, so I told her to keep pushing (fingers crossed). Eventually it came low enough for me to cut an epis and apply a suction cap (anxiety attack just waiting to happen). She pushed, and I pulled, and after much screaming and straining a long head with bulging eyes appeared. But that was all. Let me tell you, of all the obstetric emergencies, shoulder dystocia is absolutely the most terrifying. It induces a cold sweat even in The Legend, who claims to have seen and done everything. I tried not to panic. The biggest labour ward sister leaned all of her weight just above the patient's pubic bone, while I wriggled a finger in down below the head and managed to hook it into an armpit. I pulled on this until an elbow and then a hand and then a whole baby appeared, bawling in a sea of meconium. It weighed 4.5kg, and was fine. Mom, of course, had a third degree tear, which I apologised about profusely, but fortunately know how to suture.

Sjoe, the drama.

Wednesday, September 30, 2009

Biggest Lipoma Ever!

Ok, I know it's not the Biggest Lipoma Ever, but it's the biggest one I've removed in my short career. You probably can't really get the scale from the picture, but it's about 10x7cm. (I didn't take a photo of the incision because, well, it's not my best work.)

The small thing on the left is the remains of a little sebaceous cyst removed from the same patient. I've yet to excise one of those without rupturing the cyst - perhaps I should add that to my To-Do List.

Tuesday, September 29, 2009

Time versus Money

My mom recently had a bit of an accident involving her knee and some over-enthusiastic chasing of a tennis ball down a court. It went the way knees usually go: first it was quite sore but expected to get better, and the next day it was really sore and the size of a melon. So she went to the orthopaedic surgeon.

There, he diagnosed a haemarthrosis and likely minisceal tear, and booked her in for an arthroscopy the next day. In theatre, he confirmed a tear of one of the meniscii, as well as a tear of one of the cruciate ligaments. He cleaned up and washed out a bit, then popped my mom into a brace, explained her options, and referred her to physio.

Although her knee did well with physio and the pain got a lot better over the next few months, it still felt quite unstable and tended to trouble her on longer walks or excursions. So, she went back to another orthopod (this one a knee specialist), who pencilled her in for another arthroscopy and ligament repair a few weeks later. This operation she had yesterday. It was done under spinal anaesthesia, and my mom could watch the whole thing on a big screen while the surgeon talked her through what he was doing. Today, she's home in bed, injecting her own clexane.

I guess the story isn't too remarkable, if you're the kind of person who's never had to use the public health services in this country. I mean, she had a problem, she went to the doctor, and it was sorted out. Isn't that how it's supposed to be?

It is, but for the vast majority of South Africans, things don't really work like that. We see a lot of knee injuries here in the crater - mostly rugby- and netball-related - and here our options are far more limited. We usually put them in a special bandage called a Robert-Jones for a while, give them a sick note, and some pain-killers. If things still look bad after a few weeks, we send a referral letter via the blood courier to the orthopods in The Valley, and hope for a speedy answer (that is, one that arrives within the week). They'll usually give us a date for their clinic a week or two ahead, and then once the patient is seen there they'll hopefully get squashed onto a scope list within the next month or two.

So, all in all, a woman with my mom's injury presenting to my hospital would have to wait much longer to have it sorted out than my mom did. My mom's medical bills are not negligible, but luckily she has medical aid that will help her with those. A patient presenting in The Crater would pay an arbitrary amount calculated according to how much they earned.

Perhaps to say that in the private sector you pay with your money, and in the public sector you pay with your time is oversimplifying things, but it is partly true. It is possible that in the public sector you sometimes pay with your health as well, but the specialists in the public sector are no less skilled than those in private - they're just less numerous. The higher morbidity in poorer communities is probably a result of complex socioeconomic issues, and not just of limited medical staff and resources.

With the new National Health Insurance plan, the government is hoping to make all South Africans pay equally, with a combination of time and money, to receive equal resources. I suppose it's a noble principle in theory, but considering the Department of Health's track record, it's just too terrifying for words. I value my time far more than I value my money, and am eternally grateful that I can choose which one I am going to give away.

Picture Credits
Time & Money
Originally uploaded by