Sunday, October 04, 2009
Thursday, October 01, 2009
Wednesday, September 30, 2009
Tuesday, September 29, 2009
Sunday, September 27, 2009
Saturday, September 26, 2009
Friday, September 25, 2009
Thursday, September 24, 2009
Wednesday, September 23, 2009
Monday, September 21, 2009
Thursday, September 17, 2009
Sunday, August 30, 2009
Saturday, July 25, 2009
Monday, July 13, 2009
Originally uploaded by ebola bebop
Monday, July 06, 2009
Saturday, July 04, 2009
Tuesday, June 30, 2009
half way line
Originally uploaded by r0b1
Monday, June 29, 2009
Friday, June 26, 2009
Cardiac arrest refers to the point when the heart stops, and as anybody with half a brain should know: heart stoppage is the end point of any disease process.
Therefore, all the hundreds and thousands of news articles that say Michael Jackson died of a cardiac arrest are wrong, and it's distressing to see that all those thousands of journalists don't know they're being duped. Something must have happened to have caused a cardiac arrest - a heart attack maybe, or a malignancy, or something. Everybody gets cardiac arrest right before they die. And then, when they stop breathing as well, it's called cardio-pulmonary arrest.
Just something to think about.
(This is my personal favourite '...was rushed to hospital...with a suspected cardiac arrest.' C'mon guys, either his heart was beating, or it wasn't. The suspicion ends the second you put you hand where his carotid should be.)
Wednesday, June 24, 2009
He had no other diseases that he knew of (although his blood pressure was sky-high), and said he hadn't injured the leg. I asked him when it had started, and he said he wasn't really sure, but mumbled something about 'the last All Pay day' (All Pay is kind of like the dole). This kind of disaster doesn't occur overnight, and so I pressed him a little harder - had his leg been dodgy for days, or weeks, or months? Shrug, mumblemumble. Finally I asked, 'When last did you walk by yourself?' and he just looked at me and said, 'You know, so long ago that I can't even remember any more.'
Let me get this straight: you're in what should be the prime of your life, and something so bad happens to your leg that you become bed-ridden, and you allow the situation to go on for so long that you can't even remember when it started? I'm pretty sure he was only brought to the hospital because his family couldn't take the smell anymore. Really, why did he wait so long?
This is a question South African doctors ask patients over and over again. Stage four HIV-sufferers who lie in bed for months before a family member hauls them to a clinic, people who allow huge burns to become septic before asking for help, men who walk on fractured hips and femurs for days before coming for 'a checkup', women who wait until their abdomens are full of pus before they tell someone about their 'discharge' - the list goes on. And patients can never give an answer, ever. They always just ignore the question.
For me, the most upsetting thing is that so many South Africans have such low expectations when it comes to quality of life, that they don't think there is anything abnormal about becoming bed-ridden at the age of thirty-five, or being pre-terminal at forty-two. Sometimes I wonder if they view hospitals in the same way that they did in the dark ages: a place to come to die. It makes our work harder, and more demoralising by far. I used to wonder if patients waited so long because our government hospitals are such terrible places to be, but really, they're not. Yes, you may have to wait a few hours to be seen, and the staff may be unfriendly, but after that you'll get a warm, clean bed and three meals a day. Surely that beats hacking your lungs up in some drafty shack with no running water? I would think so.
Monday, June 22, 2009
I've elected to start with Anatomy, and for that I'm studying out of Moore's Essential Clinical Anatomy (trying to keep things simple), and my trusty old Netter. Netter's atlas was first published shortly before he died more than twenty years ago, but I still like his beautiful drawings best - I'm not sure what others out there think?
Now, I just wish I'd payed more attention in that damn dissecting hall - I remember almost nothing of the insides of my cadaver, who was nicknamed Philemon (or maybe it was Phineus?), except the fact that he'd died post-colectomy, leaving a rather large and unfortunate gap in both his abdomen and my dissection experience.
Wednesday, June 17, 2009
Two weeks ago I did the Basic Surgical Skills Course. It was fun - I got three days off work, and spent them practising various surgical techniques.
Pork trotters featured featured heavily on the course - we used them to practise basic suturing, foreign body removal, and tendon repair.
Other parts of the pig also came in useful: we did some bowel repair and anastomoses (above picture shows my friend Enzo being very happy that his end-to-side anastomosis didn't leak), and used pig aorta to practice vascular patches and repair (see below).
The final day of the course was the most fun - and frustrating - as we were exposed to some basic laparoscopic skills. This was a first for most of us, and was probably the most challenging part. I always hated assisting at laparoscopic surgery as a student, because it involved standing dead still for several hours while a frustrated surgical reg tried to extract a gall-bladder without hacking anything important off. Moving the camera the slightest fraction resulted in much shouting - a student's worst nightmare. Anyway, it really is quite hard - the toughest thing for me was trying to operate in 2D: it's really hard to work out how far away that thing you're trying to grab is. We practised cutting circles out of latex gloves , amongst other things. Mine is the one that has 'Karen' written on it - I blame the jagged edges on the cameraman ;-)
The course was enjoyable, and I learned to do a few things I hadn't been taught before, but it was also a bit frustrating - a lot of time was spent on really basic things like tying reef knots and inserting simple sutures. The degree I have is meant to be a Bachelor of Medicine and a Bachelor of Surgery, and I'm not sure then why it's compulsory to do a basic surgical skills course before undertaking any further surgical training.
The link above is to the Royal College of Surgeons' website in the UK -if you want to do the course in South Africa, well, you'll have to phone around, but it is run by the surgical department at most tertiary hospitals, and it's a lot less expensive than the price advertised on the UK website. If you're still fairly junior and are interested in persuing a surgical discipline the course will probably be of some use.
Monday, June 15, 2009
Stabbed? You were probably drunk and picking a fight. Diabetic foot? Shouldn't have eaten so many cakes. Asthma? Shouldn't have bought a cat. Your kid has asthma? You should stop smoking. Metastatic prostate cancer? Shouldn't have waited so long. TB-addled lungs? Ditto. HIV? Should never have had sex. Depressed? Should never have married that man. Broken ankle? Shouldn't be playing rugby anyway. Stroke? You obviously didn't drink your medicine.
It extends from the smallest, to the biggest things - I've had patients break their necks while sitting in the passenger seat of a car, and have heard doctors say it was their choice to get in with that driver. I've had babies die of gastro, and heard sisters tell the mother that they're lying about how long the history was, or about whether or not they boiled the water first. And when there's really nothing to pin on the patient, there's always another practitioner to blame: a sister who doesn't know when to refer, an irresponsible sangoma or homeopath, an overbearing mother-in-law.
On one hand, it's probably a symptom of the conditions in which we work: because we see the worst, we always expect the worst. But I also think it's a defense mechanism. The truth is that sometimes really, really bad things happen to ordinary people, and nobody wants to know that. So, it's easier to accuse said ordinary people of doing bad things, thus protecting yourself from the thought that the same fate may befall you one day. We're all terrified at heart.
Don´t point that finger at me!!!
Originally uploaded by rafallano
Wednesday, June 10, 2009
The patient, who lives on a farm about 70km from Crater Provincial, arrived and delivered at 9am, and said she'd started having contractions at about 3am. When the pain started, her husband wrapped himself in some warm clothing and stepped out into the minus three degree outdoors, and walked the half-hour to the farmhouse. There, he found out the telephone was broken. He wasn't offered a lift to a neighbouring farm, and so trudged on for another hour or so, until he found a telephone, from where he called the ambulance. The ambulance then took four hours to arrive, and another one to get back into town.
The baby came out in a fountain of meconium, floppy and with quite bad respiratory distress. Luckily, the mom didn't seem to have ruptured her uterus. I'll not bore you with the details of the six-hour neonatal resus that commenced - lots of fluid, attachment to the CPAP machine, inotropes, endless blood gasses - but in the end, we managed to get the baby onto the mother's chest with nothing but nasal prong oxygen for transfer to The Valley (for some reason, putting an intubated neonate onto an ambulance has become akin to signing its death certificate). He was crying and hungry by the time he left - good signs.
It just amazes me that in the twenty-first century, a woman's story of her labour can still sound like something out of a Thomas Hardy novel. Despite massively sophisticated communications systems, a good infrastructure of roads and a well-developed emergency response system, there are people out there who still have such hugely limited access to help, and that disasters still occur because of it.
Originally uploaded by Rob Scumaci
Wednesday, June 03, 2009
Everything is relative
One day during the visit, my granddad and I walked up to the admin building to check for post. To get there we walked through a communal dining hall and past the frail care centre.
'Now,' said my granddad, 'take a look at these people. They're really old. I think some of them must be more than a hundred!'
The people we passed were, indeed, very ancient looking. Many of them were in wheelchairs, some couldn't feed themselves, and others had fallen asleep mid-meal (my grandparents never do that). But when I really took a closer look at them, many of them were probably not much older than my granddad, and some were quite possibly younger.
In fact, when I think of many of my patients, despite the fact that they're chronologically a few decades behind, they're biologically ancient compared to my grandparents. At 82, my granddad still goes for a two-hour walk every day, and plays bowls twice a week, but many of my fifty year old patients are unable to walk to the corner store. My grandmother still cooks two hot meals every day (plus pudding) and cleans her own house, while many people I know who are twenty years younger than her rely on their children for full-time care.
Of course, there are many reasons for this - although my grandparents have 'lifestyle' diseases aplenty (diabetes, hypertension, ischaemic heart disease), both access and education have meant that they've been optimally managed from very early on, unlike many of my patients. They haven't had to spend the bulk of their lives toiling at hard manual labour, they definitely don't have HIV, and have never had TB (and even if they had, it would probably have been picked up before it destroyed both their lungs).
But, it just goes to show: the number of years you've lived is just that: a number. Don't be fooled into thinking that your birthday defines how old you are. It's what you're able to do with that should-be youthful body and mind that counts.
Old people on Daytona Beach
Originally uploaded by Natasha Hirtzel
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Saturday, May 30, 2009
My First Time
As this is the first blog carnival I've ever hosted, the theme for this week is 'My First Time'. Thanks to everyone who sent submissions, and to those of you whose posts I've used without asking permission - thanks as well. Let's get cracking!
Bongi, from Other Things Amanzi, tells us about his first trip into submandibular gland territory, and how the experience still leaves him feeling nervous years later. He also tells a story about teaching a fresh orthopod to do an unassisted trache in ICU. This post is also a good example of why surgeons and anesthetists will never be the best of friends, in spite of all the time they're forced to spend together.
Dr Alice from Cut On The Dotted Line had a good post this week, about assisting and being taught by a very thorough but very patient vascular surgeon. For me, new and difficult surgery always reminds me of my violin-playing days, and the exhaustion I would feel after trying to get to grips with a new and difficult composition. Dr Alice must have been toast by the end of this day - but she handles it with her usual optimism.
In varsity, the only practical thing the neurosurgeons ever taught was how to drill burr-holes: a life-saving procedure used to relieve pressure on the brain caused by a bleed after trauma. Personally, I hope never to have to use the workshop's power-drill on a patient, but kudos to this Australian surgeon who recognised serious pathology and had the balls to do something drastic about it.
In this video Dr Barry Rich shows how he performs a no-needle/no-scalpel vasectomy. I wish I could offer something like this to my patients, who all seem to be terrified of any form of surgery. 911Doc from M.D.O.D. shows us what it looks like when a small-caliber bullet goes through a brain (don't worry - no blood 'n' guts, just an X-Ray). This post is also an impressive survival story.
Another new and fancy invention that I've never seen in this part of the world is the CardioARM: a robotic arm that can get into those hard-to-reach places in a very non-invasive fashion. I always wonder if a machine like this is going to leave me jobless one day.
Breaking The Ice
Drunk people in a casualties are virtually always a pain in the ass. Most of the time I just wish they would go away and stop ruining my evening: I seldom think about what their behaviour will mean to them afterwards. The Annester, from No Cure For Stupidity takes a look at a severely intoxicated fifteen year old: it's the kind of thing you can only pray your own children never do to themselves.
People always ask me what I think of the latest influenza-or-whatever scare, and I always say the same thing: thousands of people die from various parasites and a particularly nasty retrovirus in Africa every day, and only a few isolated activist groups seem to be freaking out about that. The NHS Blog Doctor takes a look at this issue over here. In another post from 911Doc on M.D.O.D., we see what happens when resources get rationed. This is a story that seems so typically South African, I can barely believe it comes from one of the Lands of Plenty.
Rlbates from Suture for a Living puts what mus be a very painful topic for her into perspective with a reiew of an article on the risk of stroke during coronary artery bypass graft.
Ben Goldacre is one of my newest heroes - in this column in The Guardian he debunks yet another bit of media pseudo-science hogwash.
The End of the Beginning
We all relate to patients differently. Pauline Chen thinks medicine brings out the mother in her, while Make Mine Trauma Struggles with the consequences of getting involved.
And then, two posts I've included for sheer funny-value: Mel Content from The Boerewors Emergency Medicine Chronicles tells us about his first day back at work, and Doctor Grumpy shares a terrifying rep encounter. Enjoy!
And that's SurgeXperiences no. 224 - I hope you enjoy the twenty-one posts above as much as I did!
setting out on virgin territory in Greenland
Originally uploaded by rosieandelvis
Originally uploaded by skipgoforth
Breaking the Ice
Arctic Circle, breaking ice and a polar bear
Originally uploaded by Steve from London
The End of the Beginning
Originally uploaded by andrew_mo
Thursday, May 28, 2009
She arrived sometime in February, quite late one day. She was in her late thirties, pregnant, had a distended tummy and got really upset every time someone touched it. We soon had her consented for a laparotomy and were wheeling her off to theatre.
I should perhaps now mention that this case also offered The Buckle the chance to try his hand at his first unsupervised general anaesthetic. Getting her to sleep wasn't too hard (it never is), and I noted with relief that he'd managed to hook her up to the machine in a way that seemed to work out (I was of no help - as mentioned before, I suck at anaesthetics). Soon I had the patient opened up and was digging away in her pelvis.
It's fortunate that they patient asked me to ligate her fallopian tubes as part of the operation, as these kind of just dissolved between my fingers as I hunted for her stray pregnancy, which was not to be found in either one of the tubes, ravaged as they were by repeated pelivic infections. Instead, it was firmly wedged between her uterus and her rectum (this space is known as the Pouch of Douglas), and had put out tentacles of endometrium and... stuff... all over the rest of her pelvis. It was as I realised this that the muscle relaxant given to intubate her wore off, and her abdominal muscles clamped shut, making it rather difficult for me to get in.
'Uh, Buckle...' I murmured, 'do you think you could relax her a bit?'
'Hmmm...' he answered, and left the room. A few seconds later, bright red blood started to pour out of the abdomen and drip onto the floor (the sucker wasn't sucking fast enough). The scrub sister looked at me and raised an eyebrow.
'Buckle!' I yelled, 'this woman is bleeding and I. Can't. Get. In. Do something!'
He came back in, jabbering on the phone to The Legend (far away, in The Valley), who seemed to be explaining to him how to give a muscle relaxant and then how to make sure it has worn off. Buckle injected something and a few seconds later I'd regained access to the pelvis.
I don't know - at some point I did pull a little foetus out, which was about the size of my thumb, and I got lots of POC* out, but most of the stuff I just had to leave in there because every time I touched it it just started bleeding again. She was also bleeding from the edge of her uterus, where one of her frayed tubes had torn off, but I just stitched a bit of broad ligament over that and it stopped. After much sweating and cursing the pelvis finally seemed dry, and I closed up. What seemed like a very long time later, Buckle managed to get the patient to open her eyes, and there didn't seem to be any evidence of hypoxic brain damage. Three days later she was still haemodynamically stable, her abdomen was soft,and she was discharged.
All in all, it was not the most elegant anaesthetic or laparotomy, but I think it was OK for a first-time-solo. I've done a few ectopics since then, and they were all very straightforward by comparison.
What did you recently do for the first time? Either tell me in the comments section here, or write a post about it and submit it to Sunday's edition of SurgeXperiences via here.
*POC - Products of Conception
Wednesday, May 27, 2009
5. Have not even the foggiest about your medication
Karen: I see you're HIV positive. Are you on ARVs?
Patient: [blank look]
Karen: You know? Tablets for HIV?
Patient: [nods slowly]
Karen: OK, which ones?
Patient: [blank look]
Karen: Did you bring them with you?
Patient: [shakes head. coughs/groans/answers telephone to avoid further questioning]
OK, you're 90 and you're demented and you can't really remember what kind of medicine you're on for your blood pressure. That's acceptable. But if you're thirty, healthy, pregnant, and HIV positive, and you're not really sure whether or not you're on ARVs, or which ones you're on, or when last you took them? This is life and death man! Take some freaking responsibility!
4. Answer the telephone while the doctor is busy with you
There are thirty people behind you in the cue. The doctor is busy taking a history and trying to get to the bottom of this very complex problem you've come to see her about. Your phone rings. Do you:
(a) Answer it
(b) Push 'reject'
(I would suggest you choose 'b' if you don't want me to throw you out and tell you to go to the back of the line)
3. Refuse to believe that your child does not have life-threatening pneumonia
Your kid's temp is 37.4 and there's snot pouring from his nose, making his breathing rather nosy. Other than that he's been running around the casualties like an Easter Bunny on speed for the last hour, and cackles in delight every time I try to listen to his chest. He is not dying. Trust me. He has a cold. It's going to be ok.
2. Refuse to believe that your child has a life-threatening pneumonia
Your kid's temp is 39.8, he's breathing at a rate of 70 per minute, is desaturating on room air, can't feed because of his respiratory distress and has a multi-lobar pnuemonia on chest X-ray. No, you can't take him to go and fetch your All-Pay today, or on the seventeen hour bus trip to the Transkei, because then he will die. Trust me.
1. Grab the doctor
I'm busy drawing blood/putting up a drip/packing your bleeding schnozz/examining you intra-partum/injecting local anaesthetic into your wound, and you choose to make your discomfort known by grabbling my wrist/thigh/waist/breast. Doctors HATE it when you do this. We KNOW we are doing something either painful or uncomfortable to you, and we are not doing it because we are mean or sadistic, we are doing it because we have to. Grab the sheet, bite your lip, bite your finger, whatever, DO NOT hurt or otherwise invade the doctor's space. In my audit of, um, five other doctors/final year students, they all listed this as the most annoying thing patients do. We really, really dislike it.
SurgeXperiences here on 31 May. Send your submissions to email@example.com - put 'SurgExperiences' in the subject bar.
Sunday, May 24, 2009
Now, there's a certain protocol when it comes to status epilepticus. First, you give valium, at a very small, specific dose. Then, you repeat that dose of valium, once, after which you move on to another drug. There's a very good reason for this: valium is a benzo, and benzos have the unfortunate side-effect of respiratory suppression. In this case, I'd made a few major errors, the first being that I'd been a bit casual with my actual dosing, giving two mils here, then three mils there... You try and work out what 0.2 times 13.5 is and then how to get that out of a ten milligram vial and dilute it into an injectible volume while there's a fitting toddler and screaming mother in front of you! Then the second-line drug was O/S*, so I just gave some more valium instead. Eventually, she did stop fitting, but sadly also stopped breathing. So, we bagged and bagged and bagged. At some point the paeds person called me back and asked for her repeat blood gas, which now showed a respiratory acidosis (a sure sign that someone's not breathing). There was a bit of an awkward silence after I read it to her. Then she asked, 'Is she actually breathing?'
'Well, haha, funny story that...' I started.
Anyway, I bagged for about an hour and a half, and the kid was OK in the end. I won't do it again.
I can't decide if the next story is worse, or not as bad. In this case the patient's life was never at risk, but I had to eat serious humble-pie. What happened was that I had to take a cast off a patient's leg, for a wound inspection or something. For this we use an oscillating blade which, as my untechnical mind understands it, can only cut through hard, firm things, like plaster of paris, and not through soft squishy things like human tissue. I always demonstrate to the patient beforehand that the blade can't cut them, by pressing it down on my own hand while it's on. Because of the vibration, however, it does generate quite a bit of heat which can be uncomfortable. So, I set to work on the guy, and pretty soon he was wailing and moaning and trying to push me away.
'Stop it!' I complained. 'I know it's uncomfortable, but it can't hurt you!'
'Eina eina eina eina!' he shrieked.
'Oh please, man!' I shouted, 'we use this thing on children and they don't scream as much as you!'
So as you can imagine, it was a bit embarassing then, when I finally got the cast off, to see that I 'd made a long cut all the way down his shin, from his knee to his ankle, which was bleeding rather actively and also had some plaster and orthopaedic wool embedded in it. 'Oh my gosh!' I yelled, 'this machine is totally broken! That's never supposed to happen!'
Actually, as The Legend explained later, it can happen rather easily if you saw over a place where the skin is stretched tightly over the bone - like over the tibia - which is why you're always suposed to open leg casts on the side. Nice one, Karen.
See, it's like I told Fred, student of the pneumothorax fame - there are two ways to learn in medicine: either from the mistakes of others, or from your own. Lucky are those who learn from the mistakes of others, and those who are perpertrators should just damn well make sure they don't do the same stupid thing twice.
*Out Of Stock
The Simpson's D'oh
Originally uploaded by Sangre de Chivas!
Wednesday, May 20, 2009
...if you think you're having a bad day.
Yesterday, an unbooked lady* came in to labour ward and promptly delivered a pair of slightly premature, low birth-weight twins. Surprise!
Once she was cleaned up, the labour ward sister did her booking bloods, and it turns out she has syphilis. Surprise surprise!
After that, we got the pret-test counsellor in and... you guessed it... she has HIV as well. Surprise surprise surprise!
Now, she has to spend at least two weeks in hospital while her twins get fully treated for her syphilis, but probably longer as the smallest one has to gain 400g before she qualifies for discharge (you or I may be able to do this in one sitting, but it takes a prem ages). She's also going to get an extremely painful injection in each buttock once a week, for three weeks. She then has to hope that ARVs do actually work out for her, and that she doesn't die a horrible, undignified death a few years from now, leaving aforementioned twins with nobody to raise them (assuming that they somehow dodge the virus and survive their first five years of life - she's chosen to breastfeed, and took no antenatal anti-retrovirals), because her partner/infecter is absent.
So, cheer up. It could be worse.
*An individual who didn't see fit to pop into a clinic once she realised she was pregnant, or at any stage thereafter.
SurgeXperiences here on 31 May. Send your submissions to firstname.lastname@example.org - put 'SurgExperiences' in the subject bar.