The Candy Store

We get a lot of visiting foreign students at our hospitals here in South Africa. I don't know when the international elective first became commonplace (it's something the average South African student is still unlikely to experience, unfortunately), but since my third year I have met what feels like hundreds of students from all over the world: the United Kingdom, Belgium, the Netherlands, Germany, Australia, Mexico and the USA. I have heard it said that our Health Professions Council here doesn't allow South African students to complete rotations overseas because there just isn't enough exposure to the severe pathology and practical training that we have here. If this is true then so is its converse: visiting students are constantly shocked just by how severely ill a person without access to first world health care can become, and forever thrilled by the large variety of procedures and skills they're given the opportunity to try out over here.

Last night was Christmas Eve, and we had four elective students with us in the trauma unit: three Aussies and a Brit. They were like kids in a candy store. Never mind drawing blood or putting up drips, these kids were given free range to suture, insert intercostal drains and suprapubic catheters, fine-needle biopsy lymph nodes, give CPR, intubate, insert central lines, try out arterial lines, or try their hand at whatever else presented itself. One of the Aussie boys (who to my tired and jaded eyes looked about twelve years old, but was probably closer to twenty-two), while watching me help his friend put in a chest drain said, 'Man, this is awesome! We've done more here in a week than we've done in four years back home!'

And it's true - students do get to do a lot here. It's the way our training system works: chuck them in in the deep end, force them to learn the skills they'll need in the warzone that is the public healthcare system, and maybe by the time they graduate they'll be of some use out there. Our Belgian surgical consultant here always says 'A government trains the kind of doctors it needs', and South Africa needs doctors who can stitch up hardened criminals without effort and not bat an eye in the face of a ward full of near-terminal TB and HIV patients.

And for the most part, I think this training system is fine. Coming out of university, I felt competent with my skills, and comfortable that even if I wasn't quite clever enough to spot an obscure diagnosis or to fully understand the underlying pathology of a disease process, I'd know what the right thing to was in the acute setting, until someone with more knowledge and experience could be found to take over management.

But sometimes, I feel a bit sorry for the patients and students who are the victims of our deep-end training philosophy. Last night there were a few moments in the candy store where the kids, left to their own devices, overestimated the size of their ladels, and the gobstoppers went scattering and skittering across the floor and the kids, over-full on gummy bears and jelly beans clutched their aching tummies while tears brimmed in their eyes.

I didn't feel too bad about (and the students showed surprising resilience to) the groans of the repeat knife-violence offenders as chest drains were inserted under less-than-perfect local anaesthetic, but I got quite stressed when I saw the english guy boring a hole into a screaming eighteen year old, the student groaning and sighing himself as he repeatedly failed to get the tube in. On closer inspection he'd gone too superior and too anterior, and was trying to dissect through the thick pec major. I took over quickly and ended the agony. Later, the same student's frustration turned into abject misery as, in a moment of extreme tiredness at the end of his shift, he drove a contaminated needle through his finger whilst putting in a suprapubic catheter. We tried to make light of it, joking that you hadn't properly been to Africa until you'd taken a dose of anti-retrovirals, but he was struggling to see the funny side of it. The Aussie students decided to make tracks after spending three hours suturing one man's multiple scalp lacerations, only to find at the end that he was still bleeding pretty heavily from some, so that one of us had to step in and put in some heavy-duty stitches that the students just couldn't seem to get right.

Our way is a hard an gruelling way to learn things, and sometimes it's demoralising and exhausting, and not always good for the patients, but in the end we learn to get things done. South African elective, anyone? You (probably) won't regret it.

Fair 'n' Square

All medical students, at some point along the line (usually early in their course), will do an exercise in resource distribution. It normally takes the form of a riddle, in which you have one heart and five people who need a heart transplant. Each of the five people on the list have a bunch of redeeming and condemning qualities - you're given information regarding their age, dependants, alcohol or drug dependancies, jobs, and so forth. Then you have to decide who gets the heart. It's never easy, and never does an entire group reach a unanimous decision regarding the worthiest recipient.

I thought we could play this game on my blog. In this case, we have two contenders, and even though they're not competing for the same organ, they're still competing for resources. Who do you think is most deserving?

Contender number one is 66 years old. She needs a new liver. She's very wealthy, and curently holds the position of minister of health in her country, where she preaches a gospel that includes beetroot and garlic as a cure for HIV. She has a criminal record, stretching back to the days when she stole from patients who stayed in the hospital she was superintendant of. She drinks alcohol on a daily basis, and continues to do so even although she's supposed to remain teetotal for six whole months in order to qualify for a liver transplant.

Contender number two is 21 years old. He needs dialysis and a new kidney, because he has an auto-immune kideny disease. He's poor, and lives with his large family in a township on the outskirts of a big city. He has finished matric, but has been unable to hold down a job due to his intermittent poor health. He tried a recreational drug once when he was sixteen years old, but never again.

If it was up to you, who would get the resources? Please vote in the quiz box alongside.

PS: In real life, Contender number one - our health minister Manto Tshabalala-Msimang - got her liver. She continued to drink wine with her meals even while in hospital, post-transplant. Contender number two died in our wards a few days ago after being rejected for dialysis and the renal replacement program due to his previous drug use.

Cartoon by Zapiro

Euphemisms*

In medicine, we like to use euphemisms a lot, and nobody does this better than the nursing staff. A common one is to tell the doctor, 'Such-and-such patient's condition is changing.' This means the patient is dead. When they call you to say, 'There's been an incident...', you know a patient has fallen out of their cot and is bleeding all over the floor from their scalp wound. When they say, 'I tried to contact you so many times...' it means that no patients received IV medicine on the last round because that particular nurse is too lazy to put up drips and couldn't be bothered to check who the doctor on call is and page them to do it for her. And, my personal favourite, 'The patient is restless': this means that some patient has developed a paranoid psychosis and is trying to murder the other ones in their beds (this usually happens in the early hours of the morning).

A few weeks ago, I responded to a call regarding a Restless Patient (RP), and upon my arrival in the ward I found a tiny woman who had been admitted with unstable angina weilding a fire extinguisher and threatening to blast anyone who came near her away. In varsity psychiatry they taught us that when faced with the aggressive patient, we should first try to calmly talk them down and then establish whether or not there's an organic cause for their psychosis. I tried to talk to the lady to establish what her problem was ('Murderers! Murderers!'). I then tried to rationally point out that tampering with a fire extinguisher was against the law and would involve a hefty fine for her (she lunged at me with its base). I asked her if she was feeling short of breath or had any chest pain ('You can't fool me! I'm not stupid you know!'). I then called security and asked the nurse to draw up a sedative. Security never arrived, but fortunately there was a male nurse in the ward who could wrestle the patient to the floor and pin her there while I put up a drip and injected. The last thing she screamed before passing out was 'Jou ma se poes!' (Non-Afrikaans speakers: this is quite a rude thing to say and refers to your mother's genitalia.)

Last night, I was once again called to deal with an RP at about 2am, this time in the male ward. Upon arrival in the ward this time however, I found a fairly unassuming man sitting on his bed and noisily working his way through a large packet of crinkle-cut chips. His bed was right next to the nursing station, and in this case, I realised that 'The patient is restless' meant that his midnight-snacking was interrupting the nurses' all-night napping. I asked him how he was, and he said he was fine. I asked him what day it was, and he answered corrrectly. I aksed him if he maybe wanted to finish his chips in the morning because he was keeping the other patients awake, and he said 'But I'm hungry. I'm nearly finished anyway.' I turned to the nurse and asked her if the patient had actually been agressive.

'Oh doctor,' she said, 'he has such big wide eyes and they are making me scared.' I looked over at the patient, and although his eyes were a little bulgy I thought they were more a sign of unfortunate genes than of murderous intent.

'Sister,' I said (trying to be diplomatic - she'd halved my sleeping time during the night with this call), 'I'm writing up a sleeping tablet for this man. Please only give it to him if he struggles to fall asleep after his meal.'

When I got here the next morning, he was tightly tucked into bed, snoring peacefully.

*Thank you toAllison for the spelling - I knew it looked wrong but just couldn't figure it out...

There's a knife in my head

The photograph above is of the back of a young woman's head. She presented herself to casualties in the early hours of yesterday morning, and yes, that's a knife going into the one side of her head and coming out the other. The emergency medicine registrar on call that night (who obviously hails from some dull suburb where people don't routinely attack each other with the cutlery), got quite excited about the whole affair and wanted to refer her immediately for a CT scan and neurosurgical opinion, but we convinced him to first do an X-ray and see if we could help her out at our level.

We did the right thing, because as you can see from the X-rays above (sorry - the picture quality's not great), it would take a lot more than a piece of steel to get through this lady's thick skull. One of the casualty officers removed it quite easily and then sewed her up again. He asked her if she wanted to take it home, but she just cried a bit and said no. I suggested he put it in a little bag in case she wanted to press charges later and the weapon was needed as evidence in a court of law (I imagine this is what happens in civilised places like Canada, or Norway, perhaps), but everyone just looked at me blankly. Evidence? Court of law? Not in South Africa, it seems.*

I did ask her what happened, but she didn't really answer me. Hopefully the issues had been sorted out by the time she got home.

*If there are any South Africans out there better versed in the law than I, perhaps you could tell me what we are supposed to do with evidence harvested from a victim's body?

'Refreshed'

I've been on holiday: not just from blogging, but on a real-life one, including beaches, inconvenient weather, a long road-trip and many games of Risk.

Is there anything more horrid than the first day back from holiday? I can't imagine so... Just when I'd finally overcome my automated 6:30am wake up time and hard started sleeping through till when the sun was nice and properly up, I had to set my alarm again and get up before anyone else. After lurching about the house in attempt to get ready, I squashed myself into that vile thing known as rush-hour traffic, and fought minibus taxis and luxury german cars for a little bit of space on the road, and then arrived at work late, and sadly, without my stethoscope.

The hospital was a nasty adjustment: I'd spent the last weeks enjoying natural sunlight and my eyes took strain under the passage flourescents. The most pungent smell on my hollies had been that of sunscreen, and my nose blocked itself in self-defense at the reek of poo and pee in the ward.

And then while I was wading slowly through the thirty patients whom I'd never seen before in my life but had somehow, in my absence, become 'mine', someone came up to me and said 'Oh, Karen! You're on call today! Oh... you didn't know? Well, you better go get some food - looks like it's gonna be a big one!'

We took forty patients - a new record. I need a holiday...

Tunnel Vision

Tunnel vision is something that happens to all doctors, even though they'll adamantly deny it's something they could ever be accused of. It refers to how a practitioner's diagnostic ability becomes impaired by habit - how seeing a particular disease process particularly frequently prejudices us to making that diagnosis whilst perhaps missing something less common with a similar presentation.

A good example is a case that happened here in my first month as an intern: a diagnosis of abdominal tuberculosis (very common around these parts) was made in a youngish and chronically ill female. It was only six days later, when it was discovered that her haematocrit (a measure of the number of cells in the blood) was dropping alarmingly that someone thought of doing a pregnancy test. A few hours later we were unzipping her belly to remove a ruptured ectopic pregnancy, six days' worth of blood gushing out onto the theatre floor and running out under the doors. Tunnel vision: a physician, used to diagnosing several cases of abdominal TB a day, didn't even think of a slowly leaking ectopic as a cause for a distended and painful tummy.

A few weeks ago, I was also the victim af tunnel vision in a most dramatic and embarrassing fashion. I was in casualties interviewing some patient or the other, when a screaming banshee of a lady pushed a wheelchair up to me and started yelling loudly at me. The wheelchair contained a chubby middle-aged woman who was, well, gasping. I asked her whether her chest hurt or whether she was short of breath (yes, I know, rule number one of patient interviewing: never ask leading questions). She told me she was short of breath and I wheeled her over to Asthma Corner and strapped an oxygen mask onto her face. I know this was silly, but I really just wanted to get her out of the way so I could carry on with what I'd been doing before. I then told the casualty officer that there was some lady in the corner who might be having some unstable angina (something that, as a medical intern, I see very often), and then asked a nurse to get her into resus when a bed opened up and to do an ECG ASAP.

I went back to my patient and fiddled around there for a while. The next thing I knew, chubby wheelchair lady was standing in the middle of casualties, oxygen mask dangling uselessly around her neck, screaming 'Oooooooh! I need to pou-pou!' I noticed with interest that the crotch of her tracksuit pants was looking rather full, and that her belly was indeed rather round, but more uterus-shaped than excess-abdominal-fat shaped. I was still processing all of this new information when the casualty officer whipped her onto a stretcher, wheeled her into resus in the place of a drunken stab victim, ripped off her pants, and pulled a crying baby boy out from between her legs. I stood slack-jawed and amazed - I really hadn't seen that coming.

I was, naturally, the laughing stock of casualties for several days thereafter. In a small hospital, it's amazing how rapidly a story like this can spread: within an hour everyone had heard the tale of the intern whose unstable angina turned into an unstable vagina.


Well done, me.

The Tagging Game

About three weeks ago, I was tagged by the fabulous Ing, but I never even noticed until earlier this week. Anyway, in a brief Sunday-afternoon digression from standard medical blogging, I shall play the Tag Game.

The rules:

1. Post these rules before you give your facts

2. List 8 random facts about yourself

3. At the end of your post, choose (tag) 8 people and list their names, linking to them

4. Leave a comment on their blog, letting them know they've been tagged


The facts:


1. At the end of my second year of university, I went to London for two months, where I worked in a warehouse that packed stock for Marks & Spencer. There my job was to hang clothes on a rail before they were put on a truck and taken to various stores. I earned more doing that than I do now as a qualified doctor in South Africa.

2. I have a love/hate relationship with Nigella Lawson. Today I attempted to make her chocolate and raspberry pavlova (see: Forever Summer) from scratch using a recipe of hers, and my flatmate and I whisked egg whites with a hand whisk (I don't have an electric one) for a full hour before being left with something liquid that tasted a bit like meringue but could not be moulded into something round that could be placed on a baking sheet. Today I hate Nigella. In her book, How To Be A Domestic Goddess, however, she has an entire chapter on pies, which I love a lot, and they're all awesome, and her pastry doesn't flop. Love/hate.

3. When I moved down to where I currently stay, I transported a pair of orchids in my boot (the journey took two days). When we got here, they were brown and hard but I firmly believed that a bit of water and sunshine would perk them up in no time. It was only three months later, when The Electric Orchid Hunter finally confirmed that they were well and truly dead that I could bring myself to throw them away.

4. I was once threatened with litigation because of a post on my first blog, Sort-Of Here. (It wasn't a medical post - it had something to do with the bookshop I was working in at the time). Ever since then I try to be as anonymous and non-specific as possible. It was a really scary experience.

5. Excluding my textbooks, I own about two hundred books. I know that's not all that much - my flatmate owns about seven hundred.

6. I get really stressed when I think about my career, because sometimes it feels like it's going to take me forever before I can start specialising, an at other times I feel like I'll never have enough time to do all the things I'd like to before I settle down to one specialty.

7. My favourite blog of all time is sill Jungle Jane's, even though she doesn't blog all that often any more.

8. When I meet new people and they ask what I do, I always say 'I'm a doctor'. Sometimes they then say 'Oh... so what exactly do you do?' This question confuses me a lot, because I thought everyone knows what doctors do. So I have some pictures on my phone that I show people who ask questions like that, so that I can explain what doctors do. Here's an example of one:

(Yes, that's a Leatherman-type tool on his head)

This photo was taken by my friend Anne who lives nearby. Apparently the patient was referred up to a tertiary hospital. She's not sure what happened to him after that.

Ok, that done, I'm gonna tag the last eight people to comment on my blog who have blogs of their own.

1. Ash, who celebrated her five-year anniversary in the Netherlands two days ago

2. The Electric Orchid Hunter, who is the cleverest peron I know

3. Make Mine Trauma, of Intraoporate, who really seems to work extremely hard

4. Bongi, of Other Things Amanzi, one of the few blogs I check every day

5. Jason, who is High on Drugs

6. Alison Cummins, of the brand new blog Transparency

7. Nathan, of A Jolly Company

8. Wendy, even though I know she doesn't want to play this game.