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!

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.

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.

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 paulfongwm

Steekbardjie

I Wonder What The Poor People Are Doing?

I'm at the tail-end of a long weekend, which started on Thursday with a sleep-in on National Heritage Day and is ending this evening with a lazy evening by the fireplace (summer is on it's way, supposedly). These four days have been soooo good. We saw friends from far away for the first time in a year. The AdMan made me breakfast in bed. We walked Pepper on the beach, and we walked her in a forest. We drank beer and ate pizza at a pub, we braaid fish and drank whiskey at a friend's. I went to the nursery and bought pots, I planted seedlings and pruned my chilli-trees. I went to the shops and bought shoes, we went to a hotel and ate cakes. I caught up on CSI and started reading The Book Thief. So good I tell you, so good.

Hiding from some unexpected rain during a walk

Once upon a time, when I was young and stupid, I dated an Australian guy for a while. Whenever we were having a particularly lovely time, he'd always go, 'I wonder what the poor people are doing?' I wondered a few times this weekend what those poor bastards, my colleagues, were doing. It wasn't hard to guess. Examining perfectly healthy children, sweating over deathly ill ones, popping violently or stupidly broken limbs, draining abscesses, putting in drips and drains, listening to long sob stories, sighing over heart-breaking ones. And I didn't really envy them.

Pooped

Happy Hour

Saturdays in The Crater are unpredictable. Often they're busy, with a constant stream of patients with many complaints, ranging from the silly to the serious. Sometimes, they're eerily quiet, with only a couple of bored/paranoid moms bringing their snotty babies in for a bit of petting. At other times the morning is OK but the afternoon is crazy, as one battered rugby player after another is wheeled in for XRays and plaster. Saturday nights, however, are always, always busy. So busy, in fact, that an extra sister is always paid to 'moonlight', to allow the unit to cope with the very large number of people requiring suturing and care after other assault-related injuries. These people are called Die Bakleiers*, and really take up quite a lot of time.

In The Crater we're really lucky because the sisters do most of the suturing for us. The doctors' 'expert opinion' is only required in the more complicated or viscious-looking lacerations, and in those requiring extra intervention or procedures. This means that very often the doctor gets to have a good night's rest while the sisters slave away all night on die bakleiers. Like I said, we're very lucky in The Crater.

Not last Saturday, however. Last Saturday was bad - I spent the whole night patching bits of people together again. First, there was a lady whose face had been mistaken for a chew-toy by a bulldog. She was otherwise pretty and unscarred , and so I spent quite a long time trying to get things as neat as possible (no, the plastic surgeon wasn't interested). Just as I was bandaging her up and putting my tray in the sluice room, the ambulance brought another specimen in - a young guy who'd managed to wrap his car around a tree. He'd not sustained any serious injuries, but his face was a mess of superficial lacerations. From his forehead to his eyelids to his cheeks to his chin, and even to his knees, there was more than enough going on to keep me busy for more than an hour. Once again, I tried to be neat, but some unfortunate positioning of the cheek lacerations means that the guy's likely to bear a permanent and unfortunate resemblance to The Joker.

After this, there were a few drains and a few diversions in labour ward, but just before the sun came out and The Surfer came to relieve me, a sixty-something year old man came in with a 'scrotal injury'. I'm not sure what happened, because he didn't really want to tell me, but someone had managed to convert his underpants into a loin cloth, hacking open his left ball-sack in the process (I suppose the ball was actually the primary target, and not the underpants). Miraculously, his testicle had escaped injury, and all I had to do was sew the skin back together. D'you know what took the longest? Shaving that damn scrotum. It was wrinkly and stretchy and covered in hair. What a mission.

I know that people coming in requiring repair like this are meant to be victims, but it's hard for us to see them that way. The vast majority of die bakleiers come in highly intoxicated, and probably have a few victims of their own. Maybe we're all victims of some huge Happy Hour gone very very sour.

*The Fighters

Pimping

And so, as the end of the year approaches, it's time to start looking for a job. Like, a real one, that I need to submit a CV for, and will require an interview, and all those scary things. In medicine, you see, we're very spoilt: first we study for like a thousand years before being given three years of guaranteed employment (albeit possibly in a place that's not of your own choosing), but the point is that while most people are competing for jobs, polishing their CVs and pimping themselves in their early twenties, we don't start with that nonsense until we're nearly thirty. Unless you've really planned ahead. Which is not something I've ever been good at.

Anyway, I borrowed, the AdMan's CV a few weeks ago (it seemed a good place to start - he always lands plum jobs, but that may just be because of his natural good looks), and reworked it to suit my needs, and to make me look awesome. That's actually really hard to do, without making me look like an asshole as well. This CV I then cast far and wide, and kept my fingers crossed.

To date, only one hospital has gotten back to me, to offer me an interview for a post in a department I'm not particularly interested in. Still, considering some recent er, financial developments, I thought that a post in a lousy department was better than an unpleasant meeting with my banker, and went for the interview, which took place over the phone yesterday. It's the first interview I've had since applying for med-school, (not counting the one I had to gain casual employment at a bookstore as a student, where the manager was mostly just interested in my star sign and wether or not I was a homophobe), but they still ask the same questions. Why do I want to be there? Where do I see myself in ten years' time? What are my good points, my bad points? (Once again, that delicate line between awesome and asshole was approached, but I just told them that what I lacked for in skill I made up for in enthusiasm. They laughed a bit. Guess that counts for something.) They asked me one clinical question and didn't challenge my answer, so I guess that's OK too.

I know I'll eventually get to where I want to be, but sometimes I look down that long and winding path, and wish that there was someone who could just tell me exactly how long and how winding it's going to end up being. But there is nobody who can do that, so I suppose I'll just have to keep those fingers crossed, keep working, and keep pimping.

Picture Credits

Pimp Chihuahua
Originally uploaded by vssalazar

Happy Heritage Day!

Whether you call it National Heritage Day or National Braai Day, happy Day-Off to all South Africans (unless you're working, in which case... sorry guys. Maybe next year.)

Regardless, may we not forget who we are either as individuals or as a nation, where we came from, and where we hope to go.

100

Today it's one hundred days left until the end of the year! I know, I shouldn't be 'wishing my life away like that' (as sooooo many people have told me), but I am looking forward to getting back to The AdMan and to finally, finally being able to kind-of steer my own ship, and set my life on the course (I think) I'd like it to take. And, I'm a bit of a compulsive counter (stairs, stitches, hours-left-this-call, days until the next free weekend).

Anyway, for this last stretch, I have set for myself what is probably a stupidly ambitious task: One Hundred Posts in One Hundred Days. I don't know why I feel like I should do this, but I suppose I feel like I've really neglected my blog of late, and I'm also not too sure of what its future is, and so I feel like I should give it one good go, even if it is just for a short while. The posts won't all be awesome (are they ever?), and neither will most of them be long. But yes, my plan is to give it a go.

Over and out.

The See-Saw

Back in my student days, the department of Family Medicine tried to teach us how to modify 'health care seeking behaviour'. This refers to explaining to patients why they've presented too early or too late, or how to discourage them from coming to the doctor too frequently or too seldom. Intuitively, you would think that we'd rarely have to employ this skill, because most people are sensible, but that, in fact, is a myth. Most people are silly. Most people have absolutely no idea of when the most appropriate time to seek health care is, and so on the whole my days (and those of most of my colleagues) are a crazy see-saw between the hopelessly hyperchondriac and the stupidly stoic.

See, what the textbooks say, for example, is that you should wait about a week for your cold-slash-flu symptoms to go away before you go to your doctor. This is because most of these illnesses are viral in origin, and will resolve spontaneously after a couple of days, and we don't have any proper medication to treat them in any case - all the stuff that's going to make you feel a bit better can be bought over the counter. If it persists beyond a week, then maybe there are some bacteria in there that we can nuke with antibiotics (which you'll need a script for), and then you'll need to come and see us. Most people do not wait a week. They either wait about three hours (so that they've sneezed five whole times before coming to see me in the emergency room), or they wait about three months (so that they can no longer walk to their own toilet by themselves before someone wheels them into the back of the queue at the local clinic).

Common sense would also dictate, for example, that if you suddenly got a headache, you would take some paracetemol (also available over the counter, rather inexpensively) and see if it goes away. In my experience, people prefer to either present immediately, slumping weakly into my chair while cradling their sore noggin in their weak paws and claiming that they 'hate to drink tablets' (other than benzos); or to wait until their brain liquefies completely and a relative calls an ambulance to drag their febrile delirious carcasses into the emergency room. There really is no winning.

I find (and this is really just based on half-hearted observation and not on any kind of scientific audit, so please don't go threatening to sue me), that on the whole the early presenters tend to be middle-aged and slightly wealthier, and are more likely to be first-time mothers, first-time grandmothers (regardless of how many of their own children they've safely ushered into adulthood), prisoners, or in a crap job. Late presenters are more often very young or very old, very poor, and sadly, non-english- or afrikaans-speaking.

I don't know how to fix it. Everyone complains about it, from my friends in rural South Africa to bloggers in urban America. It's probably an epidemic we health-care professionals have ourselves created, and one we'll never escape. All I know is that it means my day alternates between boredom and irritation, and frustration and depression - two sides of a coin that will never land the way I want it to.

Picture Credits

Winter See Saw
Originally uploaded by morningsunstudio

Seestah

The other day I was chatting to a lady whose leg I was about to amputate*. I explained how I was first going to give her an injection in her back, after which she would feel a warm, heavy feeling in her legs before they went to sleep**. Then, I explained, I was going to make a semi-circular cut just above her knee and remove the leg, and that she would perhaps feel some movement and maybe hear some disconcerting sounds (the hacksaw is never pleasant to listen to), but that she would feel no pain and would probably have her first good sleep in months. Afterwards she'd go back to the ward and have lunch and as soon as her pain was improved the physiotherapist would start working with her, and everything would be just fine.

She nodded calmly and seemed to listen carefully through all of this, and then at the end said, 'Yes sister, that's nice, but when is the doctor coming?'

Now, I know. I shouldn't let this kind of questioning bother me anymore, but sometimes it is a bit irritating. Yes, I am short, and I look five years younger than what I am (in a bad way), and all the other doctors here are big strong Afrikaans men (except for the one big, strong Zulu). Maybe it is a bit confusing for some of our more elderly, rural patients who last saw a doctor en route from their mothers' vaginas, and didn't know that girl-children are now allowed to go to university and obtain degrees. Perhaps some people need a loud, tall man to make them feel safe, and a soft-spoken, gentle girl to change their bedpans.

I don't dislike being called Sister because I think I'm better than the nursing staff, or deserve more respect. I can tell that for many of the patients the word slips accidentally out of their mouths, just as many of the more down-trodden non-white farm workers reflexively call me 'Mevrou', (which is somehow worse), but that they still appreciate my expertise (if you can call it that, at my level), regardless of my gender. What really bugs me, is the way some patients assume my knowledge and skills are inferior to those of my male colleagues. It's massively sexist and hugely ignorant. I hate it when I spend quite a lot of time and effort on a patient, and go to great lengths to try to help them and inform them and empower them, and then they frown and tell me they'd like to see the doctor. I get really angry when a patient is seen by a male student (who asks me for advice, and who I help with procedures), and then comes back ten minutes later asking me 'where the doctor is so I can get a sick note'. I loathe the way patients will finish a consultation with one of my colleagues, turn around and walk the few steps to me (usually busy with another patient) and ask me to call the farm to send someone to fetch them. Aaaargh!

I know that the healthiest way of dealing with my irritation is just to laugh it off. I remember one Sunday morning, in my first year of internship at The Swamp, presenting the night's stabbees to my registrar. There, they were in the habit of calling me nursie. 'Nursie!' they wailed, 'I need to pee!' 'Nursie, it hurts, man!' 'Nursie, can you phone my mother?' I was so used to it, I didn't even hear it any more.

'Don't you just love being called Nursie?' laughed my reg. I must've looked a bit downcast, because then he said, 'Don't worry, in a year or two you'll be slicing these bastards open and nobody's going to be calling you nursie then.'

And he's right.

*Yes, another one to cross off my list.

**In true Saffa style, we do the whole operation on our own here.

I Know It's Been A While

I've been away for a long time, I know. I was (trying to) study, and this blog was not a priority in that time. Anyway, now my exam is over (fingers crossed) and I'm back. To those of you who still visit, thank you.

Here's Pepper, echoing my thoughts on Pathology.

See y'all soon.

Yesterday morning I arrived in casualties, to find it filled with about ten women, all wailing and staggering about and flopping out of wheelchairs. Each of them, without exception, weighed in excess of a hundred kilograms, and while some were kitted out in the brightly coloured overalls of the surrounding fruit-processing factories, others wore printed dresses and wraps, and with their bright red teary eyes, the whole effect was that of an over-full jar of jelly babies.

The words 'motor-vehicle-accident' hung in the air, and The Legend was grumbling about the difficulties of dealing with trauma in er... overweight... individuals. We then had a brief discussion about whether or not it was better to be fat when in a car accident: looking at all the round ladies, I suggested that their adipose tissue may have been protective: they were probably wedged into whichever vehicle they were travelling in quite tightly, so that on impact they probably didn't move much, and just kind of bounced off of each other anyway. The Legend thought that I might have a point.

What transpired in the end was that there had indeed been a car accident, but that none of the ladies had actually been involved. The accident was in a different town, far away from them, but a man to whom most of them were related in one way or another had been killed. His body went to the forensic mortuary, and they all brought themselves, weeping and staggering, to the doctor for 'Injections'.

The Crater is the first place I've worked where people routinely present themselves immediately post-bereavement to an emergency unit, but The Legend says it's nothing new. He says that usually they want 'an injection', and thinks it's a cultural thing, although I can't imagine that hospital beds and benzos have been a part of the traditional mourning process in the Xhosa culture for many years. Anyway, The Legend gave each of them a miniscule dose of lorazepam (the ethics behind that are questionable, but for another day), and a sick note. The doctor's notes pretty much all read:

Patient recently lost relative.

Is sad ++

P: lorazepam 1mg IM, sick note

I don't know what the moral of the story is. Have we forgotten what grief is, or that it's a normal emotion? Do we really believe that all kinds of pain and discomfort should be alleviated by drugs, if possible? Is this story important? Who knows.

Kwashiorkor

At about 3am on Saturday morning I was trying to get a history out of a non-compliant epileptic with whom I had no language in common, when I heard the unmistakable wailing of a woman who has just discovered her child to be lifeless. A few seconds later a staff nurse came running out of the gastro ward with the floppy body of Yoliswa, a two-year old kwash we'd had with us for a few days, in his arms.

Kwashiorkor occurs in abundance in The Crater and South Africa as a whole because the bulk of the population is dirt poor and people don't have enough money to provide their children with even the most basic nutrition, even though we live in a highly fertile country where the trees hang heavy with fruit and the land is full of livestock, and politicians do million-dollar arms deals even though we'll never go to war, and they grow fat in luxury while the people who voted them in die from starvation. Anyway, you'd think it would be really easy to treat, but unfortunately it has a poor prognosis. We lose many, many children despite aggressive treatment of their opportunistic infections and intense re-feeding.

So here was Yoliswa, small and swollen, with no hair and ulcers all around her mouth and neck and armpits, minus any respiratory effort or pulse. We commenced CPR and miraculously, after one cycle, she resumed her trademark high-pitched kwash-cry, grimacing in pain from our chest compressions. I called her mom into the room, and started preparing for a blood gas, when her crying stopped and the complexes on the monitor started disappearing. Out went the mom and back onto her chest we jumped, but this time thirty minutes of pushing and bagging and adrenalin-injecting produced no results, and at about 03:40 I called the resus off.

We tidied Yoliswa up: pulled out her ET tube, picked up the broken adrenalin vials, pulled the monitor stickers off her chest and put her jersey back on, cleaned her bum and put it in a clean nappy, and wrapped her in a sheet. We called her mom in who, like the non-compliant epileptic, understood no language that I or any of the nursing staff spoke. We tried to explain in English and Afrikaans and Sign Language, our hands open in the universal gesture for 'I'm sorry', but she still didn't get it. Eventually we called in a security guard to tell her that her baby was dead. The wails of almost an hour previously resumed.

After that, I had to get back to the epileptic. I stalled by washing my hands over-thoroughly, wondering what the best way to restart the frustrated conversation would be. I like my job, but sometimes it's just all too depressing for words.

Picture Credits

grind
Originally uploaded by ebola bebop

I Told You So

This guy came in on my call on Saturday, complaining of a sore neck. Even the AdMan, who's never read an X-Ray in his life, could spot the pathology, but I've made a big red arrow for you in any case. What you're seeing is a C-spine dislocation: bad news.

Guess what he'd been doing? Yep, playing rugby.

Yes, I know, rugby is how modern-day man vents built-up testosterone that would normally have been used to hunt saber-toothed tigers and challenge neighbouring cave-men, but that doesn't make the sport any less dangerous. I'm just saying, is all.

Saturday Posting

Sorry guys... I know it's been a while since I've done any proper medical posting. The usual things have been going on: yesterday a woman presented with a dislocated jaw. Nothing unusual there, except that it had been dislocated more than a month ago (by my flatmate, The Dentist... hey these things happen...), but ya, why did she wait so long? Who knows. We couldn't get it back in, and she went off to Civilisation so they could give it a go there. Also this week: a man with a tumour that had been growing on his jaw for a year, full of maggots; and a nineteen-year-old (who already had a five-year-old at home) who was induced for PET and delivered a 3.5kg baby boy, even though she swears she had no idea she was pregnant.

We did end up striking, for a whole two hours yesterday morning. This basically entailed a press release that said we were going on strike, and then we saw all the patients anyway. The strike was called off yesterday - our demands have not been met, but the DoH agreed to reinstate the doctors in KwaZulu who'd been sacked if we agreed to go back to work. Does this mean They have won? Probably. I'll tell you next month.

And, I got a puppy! Two weeks ago I found her shivering outside one of the clinics in the neighbouring township that I do 'outreach' at once a week. Someone had dumped her there and thrown rocks at her. She couldn't stand up by herself and had a temp of 40. I took her to the vet who drained a big abscess behind her ear, and de-wormed and de-flead her. In the two weeks I've had her her body-weight has doubled: she now weighs three whole kilograms. Here she is:

Her name is Pepper. Before you ask: she is a Pavement Special, or a canus africanus, if you want to be fancy.

And then, I'd just like to direct y'all to a lovely blog I discovered via my old friend Arcadia: 66 Square Feet. Marie Viljoen is a fellow South African living in New York, who designs gardens for a living. Her blog has nothing to do with medicine, and is beautiful, just beautiful. Go and have a look.

Half Way

Tonight at midnight I'll be halfway through my community service.

Whenever I run a race (something that happens far less often than it should these days), I love getting to the halfway mark because after that I can tell myself that all I have left to do is so much less than what I've managed to do so far.

On the one hand, I'm glad that the year is going so quickly: I miss The AdMan and my Civilised friends, I miss Civilisation's restaurants and malls and movies, and I miss being surrounded by a large network of medical people, instead of being an outsider who occasionally needs to tap into the network for help.

On the other hand, I'm enjoying The Crater: I like my work (and the work-load) here, I like getting to know individual patients and families in the small community we look after, I like my colleagues, and I like the hospital staff. Also, I don't like wishing parts of my life over: time already disappears so quickly, it would be a shame to want it to go even faster.

Anyway, here I am. It's been an interesting six months: I've learnt a lot, and grown a lot. I hope the next six have as much to offer.

Picture Credits
half way line
Originally uploaded by r0b1

My Five Cents' Worth

A blog by a South African com-server would not be complete without some comment on the current doctors' strike. For those readers who are not from these parts, or those who are not really sure of what the story is, it goes a bit like this:

Around this time last year, the government promised all doctors in the public sector a significant increase. That is, not one that would make us rich, but one that would at least put us on par with other professionals in public service. A year later, we're still waiting. The significance of this reaches more deeply than our pockets: it's not only about the fact that we're not able to purchase homes and so on, but also that because South African doctors are paid so poorly, many of them simply opt to leave either the public sector, or the country entirely. This in turn puts a far heavier workload on the shoulders of those who remain, who then end up offering a sub-optimal service. In addition, the government is not only stingy about doctors' pay: they're stingy when it comes to health care in general. Most hospitals are poorly equipped and generally badly staffed. Even in places where doctors are willing to work, many posts have been frozen, due to 'budget issues'. There are not enough beds for all the patients that need them, and not enough theatre time for all the procedures that need to be gotten through. Sometimes the pharmacies run out of vital medicines - anti-retrovirals, antibiotics, pain-killers, to name a few - and often the depots run out of basic equipment, such as plaster of paris and alcohol swabs and drip sets.

Now, doctors are saying: we will no longer be the representatives of this system. We did not create it, and we do not condone it.

There have been many protests and marches over the last few months, but last week it finally got all ugly as doctors in Kwazulu Natal went on strike and crippled health care services in the province, followed soon after by doctors in the Eastern Cape, Western Cape, Free State and Gauteng. Right now, the Western Cape is only running emergency services - all clinics and elective procedures have been suspended - but they threaten to down tools completely on July 3 if their demands are not met.

It's a very sticky ethical situation. The public is suffering, and there is a good chance that people will die as a consequence of the strike. On the other hand, the public suffers massively and thousands of lives are lost every day as the government continues to under-fund and mismanage the health care system. The doctors striking say that they are doing it with the bigger picture in mind: they believe that if their demands are met it will mean better care for all in the long run. The tragedy is that we live in a country where extreme measures are needed before any attention is paid.

In The Crater, we're not striking - we're the only source of emergency care in a hundred-kilometre radius, and it really would be unethical to strike. But I would like to say that I support the strike and am grateful to my colleagues who have been brave enough to take action - and put their jobs on the line - for the sake of us all.

Cardiac Arrest Is Not A Disease

This may seem a bit callous, and is perhaps a bit off the point, but I would just like to say that cardiac arrest is not a disease.

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.)

Why Did You Wait So Long?

On Sunday I arrived on call, and found casualties saturated with the unmistakable smell of Septic Leg. The source was a man who at thirty-six years of age seemed far too young to be in possession of a rotten limb, and he was in bad shape: pale and sweaty and septic. His leg was a shocker (and I've seen a few) - it was bloated and green, with a large chunk of black stuff hanging out of the side of his foot. When I squeezed his calf near his knee, bloody pus oozed out of a sinus near his ankle. Nasty.

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.'

What?

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.

Starting Again

I've registered to write an exam in August, and so last week I picked up a textbook for the first time in almost three years (ok, not counting ACLS last year). It was a strange and frightening experience.

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?

In a kind of pavlovian response, I strongly anticipated the smell of the formalin and cadaver when I first opened the cover but, seven years after leaving the dissecting hall behind, the smell is well and truly gone. I thought it had soaked into the pages for all eternity, but it's true what they say: nothing lasts forever.

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.

Basic Surgical Skills

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.

Finger-Pointing

It's a curious syndrome, the Blame-The-Patient one. It's one that many doctors and nurses that I work with suffer from, and refers to a state of mind wherein you believe that anything that has happened to a patient must be their own fault.

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.

Picture Credits
Don´t point that finger at me!!!
Originally uploaded by rafallano

The Dark Ages

This morning a lady who was booked for an elective caesarean came in and delivered a severely distressed, underweight baby on the ambulance trolley, before we could transfer her on to a bed. She was booked for a caesar because she'd had two already - the risk of uterine rupture during labour becomes quite high in this case, so we try to avoid it.

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.

Picture Credits
(Never) Alone
Originally uploaded by Rob Scumaci

Old

Everything is relative

Last week I visited my grandparents, who I don't get to see very often. My granddad is eighty-two, and my grandmother is seventy-eight. They live in a little retirement village near the seaside, and they always seem really old to me. They do things that people who are getting on in years do: brush their false teeth with hibiscrub instead of toothpaste; fall asleep roughly every two hours, regardless of surrounds; count their tablets into little boxes at the beginning of each week. They think things that ageing people think: everything 'instant' is bad (instant oats, instant cornstarch, instant messaging); that the golden age of music came and went about fifty years ago; that no meal is complete without pudding. They don't hear too good anymore, my gran has quite an impressive tremor, and my granddad (who really shouldn't be driving) always switches on the windscreen wipers instead of the indicator, even though he's had the same car for nine years.

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.

Picture Credits
Old people on Daytona Beach
Originally uploaded by Natasha Hirtzel

PS: Follow me on Twitter! Click Here

SurgeXperiences No. 224

My First Time

Welcome, to surgeXperiences no. 224! SurgeXperiences is a fortnightly blog carnival that rounds up recent surgery-related blog posts and news items, with a couple of general medical stories thrown in for good measure.

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!

Virgin territory

Is there anything more exciting (or terrifying) than using a knife to reach into a part of a human being that you've never reached into before?

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.

Maiden Voyages

There were a couple of interesting articles this week on surgical simulators. The first comes from the Beeb, and tells of how a team of London surgeons first did a dummy-run of a carotid stenting using the Angio Mentor, which recreates a 3D model of a patient's anatomy using CT scan data. The question to ask is: are surgeons who practise on simulators better than surgeons who practise on humans? This post from Al Fin suggests they are. He also suggests that even apes can be trained as surgeons - an idea I've heard before. I remember one of my consultants at varsity saying 'You can train a monkey to be a surgeon, but that doesn't mean you can teach it manners.' I can't remember why he said that, but he was probably being disparaging about one of his registrars. He was an extremely unpleasant character.

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

We all need people who have the courage to talk about things that are less than pleasant. This harrowing essay featured on The Kitchen Table was written by a trauma surgeon in Iraq - this is one of the most impressive submissions this week. The surgeon, John P. Pryor, was killed on his second tour of Iraq, and I suspect the world has suffered a loss.

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

There's so much negative said about medicine in The Blogosphere, it's a relief when people have good things to say about the profession. Ane from Meeting the Monkey and The Annester from No Cure For Stupidity talk us through the bad and the good, and tell us why they ultimately love their jobs - read Ane's account here and The Annester's here.

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!

Picture Credits

Virgin Territory
setting out on virgin territory in Greenland
Originally uploaded by rosieandelvis

Maiden Voyages
RMS Titanic
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
Finish Line
Originally uploaded by andrew_mo

The First Ectopic

I could hardly wait for my first ectopic to arrive at Crater Provincial Hospital. For all the fun and games that go down here, we rarely get to do any really exciting surgery - ectopics are pretty much as hectic as it gets. And for those of you in the know, these days ectopics are very rarely exciting anymore: diagnosed at an early stage they can be removed with a minimum of fuss and drama, and it's actually a really easy operation to perform, provided you're fairly comfortable with tying knots. What I was hoping for was a proper African ectopic - someone who'd last menstruated three months previously, had been having abdominal pain for the last four weeks, and had developed palpatations from her anaemia - you know the kind where you just have to ask why they waited so long (a question invariably answered with a shrug).

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

How To Make The Doctor Cross

I try not to complain about patients toooooo much, seeing as they are my bread and butter, but I have to admit that they do often sometimes annoy me. In a bit of a rant, here are the top five things (in ascending order of importance) that patients do to make me angry:

5. Have not even the foggiest about your medication

Typical exchange:
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]

AAAARGH!

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.

Don't forget!
SurgeXperiences here on 31 May. Send your submissions to littlkaren@gmail.com - put 'SurgExperiences' in the subject bar.

D'oh!

Yesterday, one of the sixth year students gave a woman a pneumothorax whilst attempting a pleural tap on her. This is a recognised and described complication of the procedure, although I've never seen it happen before. What probably contributed was the fact that he used a large grey jelco instead of a small black needle, as recommended - rookie error. Anyway, we just made lots of fun of him and then dealt out his punishment: inserting an intercostal draining on a rather nice little old lady, who could've been his grandma (he'd popped that lung good and proper - no oxygen and monitoring for her, I'm afraid). As you can imagine, he felt really, really bad, and it put me in mind of some of the really dumb things I've done before.

One story involves a little girl who came in with very severe gastroenteritis - by the time I saw her she was in shock, and soon developed seizures due to her hypernatraemia (see - too much salt is bad for you). Anyway, I gave her valium, and then some more valium, and then a bit more, until she stopped fitting (the wisened old hounds out there may see where this is going already). Then I called The Valley to refer her. The person on call there for paediatrics asked me to repeat the blood gas in a bit and then call again - apparently people with a pH below a certain number aren't allowed to go on an ambulance (and severe gastro makes you very acidotic, to put it simplistically). Whatever. When I was done on the phone, the nurse came to tell me the kid's sats were falling and no amount of fiddling with the probe (first-line management for desaturation, obviously) would get them up again.

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

Picture Credits
The Simpson's D'oh
Originally uploaded by Sangre de Chivas!

It could be worse...

...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.

Don't forget!
SurgeXperiences here on 31 May. Send your submissions to littlkaren@gmail.com - put 'SurgExperiences' in the subject bar.