FIFO

The other day, I sent a fourth year student to draw blood on a patient waiting to go from casualties to the ward. A short while later, she came back to me and said, 'Um, doctor,' (both words I've become extremely unfond of), 'I can't get blood on that patient...'

'How many times did you try?' I asked her, knowing that at her university the students didn't seem to believe in the rule of three (that is, try three times before referring upwards).

'Well, only once,' she squeaked, 'but then the patient stopped breathing and I couldn't feel a pulse anymore.'

I went over to see the patient, and sure enough, she was recently deceased. We hadn't expected her to do well, and so wasn't for escalation of management, and as such I didn't commence a resus. I made a note in the folder, pulled the sheet over the head, and then wheeled her trolley over to a small cubicle in casualties, where I parked her next to another patient who had recently moved to the ward upstairs. I turned around to see a nurse pushing another corpse-laden trolley towards us and said 'Sorry, I was first! You'll have to find another space for that!' (The cubicle only has space for two trolleys.) The nurse pretend-pouted and we both started laughing. Then I looked up and saw the fourth-year staring at me like I'd just drowned her kitten. 'Erhem,' I cleared my throat sheepishly, 'that lady was really, really sick, we didn't expect her to make it...'

The head of surgery here and sort-of deputy superintendant is a large Afrikaans man. An ex-provincial rugby player with creaky knees and a recently-conquered addiction to cigarettes, he never actually specialised in surgery, but just became extremely good at operating whilst spending years in the bush, sewing people back up again after they'd hacked each other apart with pangas. Sometimes we like to moan to him about the horror and general craziness we're forced to deal with on a daily basis, but he just laughs loudly and yells, 'In this place it's FIFO, people! Fit In or Fuck Off! If you want a cushy fucking job you can move to that bloody place on the hill and fill in fucking forms all day!'* (referring to the academic hospital down the road from us). 'Fitting in' refers to many things: coping with intakes of more than thirty patients, doing seven evacs in a row because nobody in this town knows how to use contraception, doing your friend's ward work for them because they're having a bit of trouble fitting in themselves, and becoming blunted to the illness and death we see each day.

With a mortality rate of between fifteen and twenty percent in the medical wards, most of us interns have, after eight months, become very used to patients dying. Sometimes we laugh it off, and most of the time we just don't think about it too much. We're 'fitting in' really well. And it's easy to forget that other people, especially the students, do not yet have the same defenses we do. Sometimes I feel sad when I think about how blunted I've become, and I wonder if it has somehow made me less human. But then I think, if I cried for every patient who passed away, I'd need a constant intravenous infusion just to cover my fluid losses. I guess, as much as we try to deny it, life is a bit cheap in Africa, and it's something we adjust to all too quickly. It's not right, but when faced with two choices - tough up or die crying - what do you do? FIFO.

*Whilst he may sound absolutely brutal, we all adore him: he lacks the sheer nastiness of other consultants many of us have worked with. If he can see you're really upset, he'll put his arm around you and pat you on the back and say, 'I'm really impressed with how you managed this situation. These people are really fucked up when they come in. There's nothing more you could've done,and I think you did really well.' (These kinds of words, I believe, are rare in the medical profession).