Just Up The Dose

Sunday is Non-Medical Day

2009-10-04T08:00:00.000+02:00

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

2009-10-01T20:19:00.003+02:00

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!

2009-09-30T22:17:00.004+02:00

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

2009-09-29T22:20:00.000+02:00

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

2009-09-29T22:05:00.002+02:00

I Wonder What The Poor People Are Doing?

2009-09-27T20:42:00.005+02:00

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

2009-09-26T18:38:00.005+02:00

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

2009-09-25T07:00:00.000+02:00

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!

2009-09-24T09:00:00.001+02:00

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

2009-09-23T07:00:00.000+02:00

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

2009-09-21T08:00:00.001+02:00

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

2009-09-17T18:28:00.003+02:00

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

2009-08-30T18:03:00.003+02:00

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.

2009-07-25T11:19:00.003+02:00

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

2009-07-13T07:00:00.000+02:00

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

2009-07-06T21:32:00.005+02:00

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

2009-07-04T13:50:00.005+02:00

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

2009-06-30T14:46:00.003+02:00

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

2009-06-29T07:00:00.001+02:00

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

2009-06-26T13:04:00.004+02:00

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?

2009-06-24T06:50:00.000+02:00

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

2009-06-22T08:00:00.001+02:00

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

2009-06-17T08:00:00.001+02:00

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

2009-06-15T08:00:00.000+02:00

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

2009-06-10T17:59:00.003+02:00

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

2009-06-03T20:35:00.004+02:00

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

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SurgeXperiences No. 224

2009-05-30T22:11:00.001+02:00

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

2009-05-28T20:45:00.002+02:00

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

2009-05-27T08:00:00.000+02:00

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!

2009-05-24T08:00:00.000+02:00

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...

2009-05-20T08:00:00.001+02:00

...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.

Rugger

2009-05-18T08:00:00.001+02:00

One of the (very few) positive things about Saturday calls is that they mean I get to escape The Rugby. Working on a Saturday is a legitimate way to avoid spending the day sprawled on the couch (or fighting for table space in a pub) with The Adman, watching sweaty men jumping all over each other.

It is rather ironic then, that as winter sets in, rugby has become my chief source of Saturday work. There are apparently forty or so club rugby teams in The Crater and surrounds (not counting the prisons and schools), and so on any given Saturday there are in excess of six hundred grown men doing their darndest to inflict bodily harm on each other, whilst pretending that all they really want to do is get a little oblong ball over some arbitrary white line.

And inflict bodily harm they do. Last week I saw, in the space of two hours: two dislocated shoulders, a dislocated (and fractured) ankle, a fractured clavicle, a fractured ankle, plus multiple soft-tissue injuries. It's ok: reducing dislocations is very satisfying (the ankle is my personal favourite), and I'm a pop pro by now, but somewhat more annoying are the hangers-on. Do you really need your entire team to look on while I remove your head blocks? And is it really necessary for your girlfriend, mother and sister to stand stroking your head and murmuring 'It's nearly over, skaapie' while I apply your below-knee cast?

I'm all for sport - keeps them off tik and the heart healthy, eh? - but does it really have to involve quite so much contact? Can't there be more running, and less rolling about in a heap on the grass? Why do players often feel the irrepressible urge to punch each other? And why, after all of this, do these supposedly fine examples of masculinity turn into such cry-babies? Rugby and its allure has always been a great mystery to me, and I can't say that getting up close and personal withthe players has done anything to change this.

Picture Credits
Rugby Players
Originally uploaded by bluehawaiian

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

My First Blog Carnival

2009-05-17T15:40:00.000+02:00

SurgeXperiences No. 223 is up over at T's blog - Notes of an Anesthesioboist. Go check it out.

In a first for me, I'll be hosting SurgeXperiences here on May 31, so please everyone: submit your little hearts out! The theme will be 'My First Time' (in honour if the fact that this is the first blog carnival I've ever hosted), but don't feel too pressured to stick to it. Submissions should just have some kind of vague connection to surgery - anything that mentions cutting, stitching, bleeding, doping, stabbing, organs, limbs, tissue, germs or idiots is grand. Posts that mention pruning may also be considered.

Submissions deadline in Friday, 29 May - please send them to littlkaren@gmail.com, with the word 'Surgexperiences' in the subject header, or you can submit via here.

Looking forward to hearing from you!

Hangover Saturday

2009-05-10T18:17:00.005+02:00

Sitting in front of me was a rather shrivelled looking lady of seventy two, who'd woken up with a sore shoulder. The X-ray showed a dislocation, and I was busy making my notes before hauling her off to the procedure room for a reduction. I asked her how it happened (more and more this is becoming my style: diagnose first, ask questions later. This is not really a good thing), and she told me she'd tripped over a stone on her way home last night. Quite unlucky, I thought out loud. She nodded in agreement, and then said, 'But you know, doctor, it probably wouldn't have happened if I hadn't had so much wine to drink.' Impressed with her insight (usually somewhat lacking around these parts), I concurred and secretly thought 'You and me both, lady.' The call was thus far proving to particularly arduous, not because of the nature of the cases coming in, but because of the nature of my own hangover: I'd had a particularly pleasant braai with my friend The Annester the evening before. Morning after, however, not so pleasant.

Anyway, off the two of us tottered to the procedure room, where I spent about twenty minutes trying to get her five jerseys off and then to get her to lie down - all very difficult procedures to execute when your humerus head is in the wrong place. Once supine, she started praying loudly in a rather evangelical fashion - something along the lines of her being sorry for drinking so much and appreciating it if God would help her out a bit, etcetera. As I injected the sedation the prayer degenerated into a series of cuss words, perhaps revealing what she really thought of God, although in all likelihood it was just the midazolam talking. I quickly stepped out of my crocs (don't judge me) and braced my right foot against her chest wall and gave her arm a kind of a yank-and-twist (it's hard to describe, exactly), and thunk, in her shoulder went. Hooray! Another one to cross off my To-Do List! The lady gave a howl of pain and then a brief, evil-eyed glare in my direction, before falling into a deep, noisy sleep.

She woke up again, rather inconveniently, while I was trying to stop an eighteen-year-old girl from haemorrhaging to death via her radial artery (another story, for another day) .I glanced over at her and saw, to my consternation, that she'd wriggled her arm out of her sling and had it flung up above her head. Once I had the more urgent crisis under control I went over to her to ask how she was feeling, but instead of the outpouring of thanks I was hoping for, I just got more of the same twaddle about a sore shoulder. Taking a look at the incriminating joint, I noted with dismay that it was indeed dislocated again. This time I thunked her down onto the bed in a matter of seconds and heaved the arm back into place without any further sedation. Then I sat her up and strapped the arm tightly down, threatening to amputate the limb if she even so much as loosened the strapping. While doing this she gave me a kissie on my cheek, and said 'Thank you, sister,' but it was probably just the morphine talking.

Thanks to those of you who sent advice on how to reduce a shoulder when there's no man around! In all honesty, with the right amount of sedation it really is easier just to do it by myself... Men can faff so.

The more things change...

2009-04-24T08:00:00.000+02:00

Once upon a time, I was very afraid of drips. So afraid was I, in fact, that I dedicated an entire post to my fear, and used to always take at least three jelcos with me to the patient, telling myself that 'you don't go to war with only one gun'.

These days, I'm not so scared of putting up drips anymore, and it's more of an irritation when I fail than a relief when I succeed. Barring a really shocked, hypovolaemic patient, my first attempt at cannulation is probably succesful in about 80% of cases, when you include the really little ones like this.

(ELBW stands for 'Extremely Low Birth Weight' - this baby weighs only nine hundred grams.)

So, for the students out there: don't lose heart. Things do get better with some time and practice.

That's not to say, however, that you'll one day wake up to discover that medicine is easy. You just find new things to stress you out.

Boyle's Bitch

The machine above is used to administer anaesthesia. I consider myself reasonably intelligent, and I've managed to get a degree and all, but man - this thing still makes me break out in a cold sweat. It always has (anaesthetics was my Achilles' Tendon at varsity), and I suspect it always will. The various pipes and circuits confound me, the valves confuse me, the drugs and the order in which you have to give them dismay me, and it quite often takes me about ten minutes just to figure out how to switch it on. I've noticed there are people out there who have a knack for it (Eish, for example), who can be seen to be pumping that bag-thingy (I think it may be called the reservoir - my childhood anaesthetists always told me it was the 'Magic Balloon' and I still think of it as that to this day) between their knees whilst administering gas (but how do you know for sure that it's oxygen?) with their left hand, at the same time adjusting knobs and buttons at the speed of light with their right, and all the while jabbering away about Saturday's rugby and how they really feel about surgeons. That's talent, man! Respect.

Sometimes I look at consultants, and imagine they have glorious, untroubled lives, wherein they always know exactly what to do, and never have trouble doing it. This is probably not true. They probably struggle, just as much as the rest of us. But whereas we struggle with the little things: drips, ultrasounds, reducing ankles; they struggle with the big things: resecting brain tumours, defending lawsuits, paying off German automobiles.

And so: the more things change, the more they stay the same. The Fear is probably never going to leave me - it will probably just kep transferring itself to new activities every few months.

I won!

2009-04-22T16:50:00.003+02:00

When you kill a patient, you usually discuss it solemnly and confidentially at an M&M, and then try to put it behind you and hope that nobody tries to squeeze some money out of the whole sad affair. You don't ever brag about it and then enter a photo of the corpse into a most-pathetic-looking-corpse competition.

Not so with plants! I am very proud to announce that my tomatoes, who I'd like to think died of natural causes rather than at the hands of yours truly, have earned me a place in The Hall of Shame, making me its first winner! Rebekahn and Vivh over at Brixton Broads bestowed the coveted title on me this Sunday, and have even given me a prize: a donation made in my name to Food and Trees for Africa's National Tree Distribution Programme. This is very exciting - never before have I been rewarded for failure.

Go and take a look at Brixton Broads - Rebekahn and Vivh have a beautiful, wonderfully written blog all about gardening - reading it always makes me want to go outside and get dirty (although, as you can see from tragic tomatoes above, I don't seem to have much of a knack.)

Thanks guys, you made my day!

Cheese-kop

2009-04-20T08:00:00.000+02:00

In front of me is a black man, in his mid-twenties. The triage sister has written his main complaint in as 'septic head', and so far he's been subjected to an HIV and a syphilis test, both of which were negative. He takes his cap off for me, and sure enough, his shaved scalp is covered in thick, yellow goo. It's quite gross. It only takes me a second to decide I'm stumped, and call for backup. Luckily, The King is in the room next to me.

'Hayi man!' he yells on sighting the man's gloopy head. (Literally, hayi man means 'no, man', and is an expression of displeasure.) A heated exchange in one of the nine official languages that I don't understand follows, with Mr Septic-Head looking more and more subdued as it continues. After they're done, The King turns to me and shakes his head in disgust.

'Man, he knows: after you go cheese-kop*, you must put surgical spirits on to kill everything. This one, he put some stuff on that his girlfriend gave him.'
'Oh,' I say, 'so it's his girlfriend's fault then.'
'Ya man.' (shakes head) 'Women...'
He then suggests I dispense some Selsun Shampoo but says it probably won't get better until his hair starts growing back.

That's why I love medicine. You learn something new, every day...

*As I discover later, cheese-kop is the name given to the haircut when black men shave it all off.

100

2009-04-17T08:00:00.000+02:00

This is my hundredth post on Just Up The Dose! I know that for you more prolific bloggers out there, one hundred posts is nothing, but I've been blogging for just over three years now, two of which have been spent on this blog, and this is the first time I've stuck with one long enough to reach a significant milestone.

I thought I'd commemorate the occasion by compiling a list of my personal Top 10 (OK, some of these are a two-in-one, so it's more like a Top 12). Above all, Just Up The Dose is a collection of my memories, something for me to look back on when I'm older and have forgotten what these early days were like. Here are some of the posts that mean the most to me.

Student Years

I love reading these posts and remembering how massively different my life was as a student compared to what it is now. Barely any responsibility (and back then I thought I carried the weight if the world), many afternoon naps, and the sole prupose of having to store as much information as possible. Really... it was the life.

At Least We Get Free Food

My Years As A Med Student - Parts I and II

Internship

Ah, The Swamp: it chewed me up and spat me out, but I'm a whole lot stronger at the end of it all. Sometimes I look back on my two years of intenship and wonder what my six years of University were spent learning: it feels like everything I know, I learned after leaving school.

Diary of an Intern - Day 1 and Day 2

Stab Heart

FIFO

Tunnel Vision

Push Hard, Push Fast!

Into the Dark

My First Time

Community Service

It's still all so new, and sometimes still so frightening - what can I say? Here's the intro.

The Cosmonaut

The Local Dialect

2009-04-16T08:00:00.000+02:00

(Apologies, non-Afrikaans speakers, you won't get this, but it doesn't translate well)

We had a nice little old lady who kept coming in with a ridiculously low haemoglobin (kind of like a measure of how much blood you have in your body), requiring repeated transfusion to correct. We knew she most probably had a malignancy somewhere, but had thus far failed to find it, or any source of bleeding for that matter. Then one day, she came in pouring blood from her vagina (this is not normal in a seventy-year-old).

We knew she'd been up to the valley for a 'scope' or two, but various administrative problems, miscommunications, name-spelling errors and so forth had resulted in the loss of the scope reports and any insight that they may have provided. I couldn't believe that in our hunt for cancer we'd forgotten to look in her uterus, of all places, and so thought maybe she'd had a scope of that (known as a 'hysteroscopy'), as well as of her colon (known as a 'colonoscopy').

And so I embarked on the arduous task of trying to extract from the patient where exactly the camera had been inserted. 'So Tannie,' I said. 'Het hulle die kameratjie in die voorste gaaitjie of die agterste gaaitjie gesit? Of al twee?' (Nice Little Old Lady furrows brow in confusion.) 'Tannie weet mos, daar... voor? Of... agter?' (Brow furrows deeper.) I wave my hand vaguely in the direction of my crotch. 'Voor?' And then in the direction of my bum. 'Of agter?'

And then Nice Little Old Lady (pretty flower-patterned skirt, lovely dusty-pink cardigan, neat little clutch-purse gripped firmly in both little hands) says, 'Jirrrrre dokter, ek weetie, maar hulle't dit seker in my hol ingedruk, he?'

No further questions, thanks.

Epilogue:

After doing an endometrial biopsy on the patient we asked her to come back in a week's time, but she never did. When she came back this weekend, three weeks late and down to an Hb of 3, I asked her why she'd missed her scheduled follow-up. 'Ag dokter,' she answered, 'ek het geweet julle wou net weer in my doos krap, en ek was nie lus nie...'.

Best Week Ever

2009-04-14T08:00:00.000+02:00

This week I am feeling supremely proud of myself because last week I nailed two serious clinical diagnoses, and the most sophisticated tool I had at hand was an X-ray machine.

This first was Ms X, whose cousin brought her in because she'd woken up with a headache and was acting a bit more obtuse than usual (she's apparently not very easy to get on with, even at the best of times). So anyway, Ms X is in her mid-thirties, and she's quite scrawny and looks a bit rough-around-the-edges. She was acting a bit strangely (napping on the waiting bench, and then flinging her arms and head down on my desk to continue her snooze while I was trying to interview her), and her neck was as stiff as a board. In this part of the world, the sum of these three things (skinniness + acting weird + stiff neck) almost always means HIV and some kind of opportunistic central nervous system infection, and generally we'd just pop a needle into their spine to get a diagnosis, but in this case a little voice whispered in my ear 'Wait.' On closer inspection, she had not even the hint of a fever, a slightly elevated blood pressure and when prodded enough she could vaguely explain that the headache had come on quite suddenly. So I called up Civilisation, and spent ten minutes trying to convince the guy on the other end of the possibility that she'd had a sub-arachnoid bleed. Eventually he conceded that maybe they could give her a scan, 'just to make sure', and off she went. Two days later, she wasn't yet back, and I called Civilisation up again. After many switchboard detours, I finally got through to a sister in the neurosurgery ward, who confirmed that Ms X had in fact had a bleed, and was being prepared for an angiogram as we spoke. Woo-hoo, Karen!

And then my second super diagnosis for the week was on Baby Y - born at around 32 weeks gestation (around... hmm.. sevenish months?) at 1500g, she'd vomited everything she'd been fed in her first 24 hours of life, and had failed to make a poo. When we put in a nasogastric tube we drained dark green fluid, and her X-ray looked like this:

Ya ya, I know the diagnosis is really obvious now, but I've practically spoonfed y'all each little puzzle piece. Anyway, I called Civilisation up again and told the pediatric surgeon I thought I might have a case of duodenal atresia*. I was quite unsure of myself though, and said he could send the kid right back if there was nothing wrong with her. 'Don't be stupid, Karen!' he yelled. 'There's obviously something wrong with her! Send her at once!' (This was quite a pleasant change from the attitude of the spinal unit folks).

Anyway, the next day Civilisation called me back (d'you hear that? Civilisation called me!) to tell me that Baby Y had jejenal atresia**, that they had operated, and that she was recovering nicely in ICU. What I'd seen on the X-ray had confused me a bit, looking almost like a double-bubble sign, but not quite (Bongi could probably explain why it isn't one, if you really want to know), and the reg told me that it was in fact a triple-bubble, so that although my diagnosis wasn't spot-on, it was only a couple of centimetres off.I'm trying to maintain some modicum of modesty, but it's quite hard.

*Kind of like a blockage of the small intestine, because a part of it doesn't grow.
**The same, just a bit further down.

How to lose 'friends' and alienate people

2009-04-08T08:00:00.002+02:00

One day one of the local (private) GPs phoned to tell me she had a really sick little baby. 'He's terribly dehydrated!' she wailed. 'His little fontanelle is all sunken, and his eyes too!'

I think what she hoped for/expected me to say is 'Oh shit! A severely dehydrated baby! Send him over on the double - I'll wait for him at the front door!' Instead, what I said was, 'Gosh, he sounds really sick - does he have a drip up?'

What I hoped for/expected her to say was, 'Duh, I've got the line up and have already given the first bolus and am calculating the maintenance fluid as we speak' but instead she said, 'Oh, um, we don't really have the equipment for that here... You know, like Darrows and stuff.' (I suspect what she meant was that the nominal fee she'd charged didn't go so far as to cover any actual contact with the patient, let alone the use of anything that cost more than fifty cents to dispense).

Anyway, I think what she hoped for/expected me to say was, 'Aw, shucks, that's OK then - send him over, we'll just do all the hard stuff for you over here', but instead what I said was, 'You really should rescusitate the patient before transfer - these small babies crash really quickly. You don't need Darrows - just bolus with normal saline.' (Which is true - I've seen more babies abruptly die from severe gastro than I'd care to remember.)

What I then hoped for/expected her to say was, 'Oh ok, no problem!' but instead she said, 'My nurse is going off duty now - she'll bring the baby over in about ten minutes... You guys can just get all that stuff ready so long.'

Maybe I wasn't assertive enough or something, but in the end her twenty years or so of practiced laziness trumped my two years or so of trying to get referral units just to do the basics before transfer. The baby arrived half an hour later, sans drip, shocked and acidotic as hell, and we spent the next hour resussing like demons.

Ultimately, the entire interaction was just mutually frustrating and dissatisfying. I came off sounding like a big bossy cow, and she came off sounding likea big lazy cow, and I suspect that now Mrs GP and I will have trouble pretending to like each other, something we'd managed to do quite well up until that point.

Picture Credits

Cow Kuh vache vacca vaca koe mucca
Originally uploaded by Urs Wachter™

Ka-Pow

2009-04-06T08:00:00.000+02:00

Just when I thought I'd never again experience the same satisfaction I did as when I drained my first abscess, a guy came in with an SVT. OK, he didn't actually come in with that - he came in with bronchospasm and then we whacked him with various drugs until he developed an SVT, but that's a technicality.

Anyway, there he was, heart going gudunkgudunkgudunk at three hundred per minute (that's roughly five times the normal), and dropping his blood pressure. I was farting away with valsalvas (asking the patient to make like he's making a poo) and vasovagal manoeuvres (rubbing his carotid arteries) when The Surfer came in and screamed 'What are you doing man? Shock the bastard!' (The patient wasn't really a bastard but we talk this way in The Crater because we are Hard Core.)

So, The King loaded him up with midaz while I lubed the paddles and pushed the sync button. Then I stuck them on his chest (directly onto the skin - we don't have that fancy machine they've got on ER where they can shock you through your T-shirt without you catching fire [snigger]) and yelled 'All clear! Charging!' (I felt a bit like Meredith Grey here, and flicked my ponytail accordingly, but mine isn't as long as hers), and then Whomp!

The patient grunted a bit as his back arched off the bed (exactly like in ER). We looked over at the screen: beep - beep - beep - at a respectable hundred beats per minute, in sinus rhythm.

Cured, hurrah! And with maximum dramatic effect to boot. Ain't medicine grand? True, we had to send him up to The Valley afterwards for further investigation, but we all felt like superheroes for the rest of the day.

Monday, Bloody Monday

2009-04-03T08:02:00.000+02:00

I was driving back to The Crater one Monday morning (on the weekends that I don't work, I go to Civilisation to visit The AdMan), and was just rounding the second-to-last corner before town when I happened upon a body lying in the middle of the road. Running towards me from the other direction were a bunch of men in overalls - he'd just flown off the back of a lorry. Statistically speaking, this had to happen sooner or later. South Africa has several thousand road deaths per year - with these figures it is highly likely that each of us will at some point in our lives be the first on the scene of an accident. You just have to hope that (a) you're not actually a part of the accident and (b) nobody is too badly hurt.

This guy was badly hurt. I put the palms of my hands over his ears and my fingers around the back of his neck to stabilise any possible C-Spine injury as we moved him to the edge of the road, but as I did this his major injury became apparent. As we carried him, hot, sticky, bright red arterial blood pulsed out of his ear and over my hand - a textbook skull-base fracture, and a massive one at that. He was still breathing when we lay him down, but it was already agonal, and his pupils were dilated. I called The Surfer to ask for help - we were only about three kilometres from the hospital and I knew he'd get there with tubes and bags quicker than an ambulance would, which I called immediately after - but I was already pretty sure it was a lost cause.

So we stood there and waited, and watched his gasps become more dramatic and less frequent (one of the Hollywood myths I detest the most is that of The Instant Death - there is no such thing). Around this time some other guy stopped and told me we should turn him on his side because he was drowning in his own blood (hope flared briefly inside me - was it really possible that we could fix this with a bit of suction?), but really, I knew better. The arterial spray was thinning out to a dark venous trickle, which followed the other six litres of the guy's blood across the road. A few minutes before The Surfer arrived he took his last breath - at this point my only option would have been to start mouth-to-mouth, but his faced was covered in blood and I had no guard. I don't think it would've helped much anyway.

The Surfer arrived, and then a few minutes later a police car was there, and then shortly after that the ambulance appeared. I went home to shower - there was blood everywhere: my hands, my hair, my jeans - and the ambulance took the body to the hospital where The Legend signed the death certificate and the rest of the men from the lorry were debriefed.

There really was nothing I could have done - the man sustained a fatal injury the instant he hit the road, there was nowhere for me to compress, and I had no tools with which to resuscitate him. And although I couldn't personally have prevented his death, it was preventable - he shouldn't have been riding on the back of an open lorry up a winding mountain pass, with no seatbelt on or even a roof over his head. When will we learn?

Picture Credits

Smashed egg
Originally uploaded by Dusan Bartolovic

From Dusk 'til Dawn

2009-04-01T14:41:00.000+02:00

On a good call, I'll get to leave casualties at around one or two am and go home to bed. On a bad night, I'll get called by labour ward an hour later for an emergency caesarean section. It's usually when I'm traipsing between labour ward and theatre, trying to spy on casualties without being seen (and therefore being asked to do something) myself, that I see wierd and funky shit going down that doesn't happen in the daylight hours.

For example, I once passed there at four am, relieved to see the place deserted. But then, on looking a bit further in, I saw a patient I'd managed earlier in the evening, who'd been in an MVA*. Although he had no major injuries, the soft tissues of his face were very swollen, and his puffy eyes were squeezed shut. He'd vomited all over his own clothes, and when I passed casualties later, the nurses were obviously trying to get him into a clean gown. They'd managed to strip him bare, and with his giant, swollen head and tiny previous-TB-times-many body, he looked exactly like a man-sized lollipop, with a long dangly penis in the middle. In addition to this, he couldn't see too good (closed eyes and all), and he kept bumping into tables and chairs and squealing nurses, as they tried to get him to sit on a chair so that they could scrub him down and then gown him.

And then, a few nights ago, we were all overcome by the most ridiculous coughing spasms as we pushed a patient into the passage leading towards theatre. There was much shrieking and so forth coming from casualties, and so while second-on-call put up the spinal I went to see what all the fuss was about. There, I found the sister in charge with a towel wrapped Jihad-style around her head, shoving patients out the front door.
'What's going on?' I spluttered, over the screams and wretchings of stabbed men and gastro babies and abdominal pain ladies and urinary retention old men.
'Oooooh, doctor!' she hollered, 'there was a terribly onbeskofde patient and the security guard had to open his tear gas!' (Onbeskof is like rude, only worse).

Later, once everyone had calmed down, the pepper had settled, and everyone had been nebulised, I managed to establish that the security guard had detonated a can of Mace after somebody accompanying a patient had attempted to stab him when he refused to allow the person into the unit. I gather that after this incident (pepper spray not being so good for post-TB lung, our most common disease here, after all), the guards were given those mini cattle-prod things to defend hemselves with. A few days later The Buckle was busy in a room down the passage (also at 3am, or thereabouts), when he heard the frantic tapping of running feet. This was followed by 'Gzzzt, gzzzzt, gzzzt' and then 'Eina!', as the guard finally caught up to his errant charge (Eina is like ouch, only worse).

*Motor Vehicle Accident

Help!

2009-03-29T15:29:00.000+02:00

Last night, my worst nightmare came in: a C-spine injury. I found her lolling about on a stretcher, no hard collar, no head blocks, no trauma board, no nothing - just a note from the ambulance saying she'd been in a motor vehicle accident. I noticed a scalp abrasion, and then prayed like hell that she was just being aspris, and refusing to move her legs because of some perverse compulsion to be obtuse. But when I wrenched a piece of her calf skin so hard I left marks, and she still didn't bat an eyelid, I had to acknowledge the worst. She only had sensation from above the nipple line up, and x-rays showed a big step-off between C6 and C7. For y'all lay folks out there - her neck was essentially broken.

And so started the big telephone marathon. I called The Valley, they told me to call Civilisation. I called the neurosurgeon at Civilisation, who told me to call the Spinal Unit at a sister hospital some way away. I called the Spinal Unit, who were full, and referred me to to the respiratory unit, who were also full, and referred me to neurosurgeon number two. Neurosurgeon number two told me he couldn't help, and that I should call neurosurgeon number one back. Neurosurgeon number one called his consultant, and then told me the consultant said that the patient could just as well lie in The Crater waiting for a Spinal Unit bed as she could in Civilisation.

'Ok...' I said, 'but what should I do for her over here?' I've never, ever had to manage a C-Spine injury before.
'Oh,' he said, 'just keep her in the hard collar, give her some pain meds and some heparin, and pressure care... Do you have one of those nice mattresses with the ripples there? [no!] Oh well, then just turn her every three hours...' And so I left it till the morning.

In the morning, I called the Spinal Unit again. My patient was still breathing, but was using her abdominal muscles a lot, and was struggling with secretions. I got a registrar there who had never been to The Crater, or anywhere like it. 'Can you arrange an MRI there? Can you put her on CPAP? Is she on a bowel regime?'

no!
no!
no!

She sighed a long-suffering sigh, and said she'd call me back. Three hours later, I hadn't heard from her, and I called The Valley up again. They took pity on us, and accepted the patient. Hours later, the reg from the Spinal Unit called me up and said she thought they could maybe help out later in the week. I explained about the patient's deteriorating respiratory situation, about our various other limitations, and about how The Valley said they'd take the patient from me. 'But why haven't you intubated the patient?' she yelled. 'Why haven't you gotten the physio to help with the secretions? Whywhywhywhywhy?' I was too tired to explain about the fact that we have no physio here, that I was all alone and there was nobody to help me intubate somebody with a broken neck - quite a tricky procedure - and that it was actually quite difficult for me, in any case, to judge just how bad the patient's condition was. After all, I don't work with these kinds of patients all day every day, like she does, and when I'd called the specialist the night before, desperate for help, he'd told me to just let the patient 'lie there' with a pair of DVT stockings.

Post phone conversation, my morale at an all-time low (I also had to break the bad news to the patient at around this time), I called the orthopod at The Valley. He's worked in a Crater before, and hasn't forgotten. 'It's OK,' he told me, 'you've done everything you can at your level. You don't have the help you need to tube her, and you don't have the machines you need to ventilate her. You've done your best, and we'll take over from here.'

I know that when you work with a certain thing all day, it becomes hard to understand why dealing with that thing isn't second nature to other people. I also know that it's highly frustrating to deal with people who don't really know how to properly manage certain medical emergencies, when really they should. But at the same time, there's nothing more terrible when, at your hour of most extreme need, you call somebody begging for help, and then get given vague and non-specific advice that leaves you with an even sicker patient and a grumpy referral centre the next day. In addition to knowing a bit more about the acute management of spinal injuries now, I also learned something last night I hope never to forget: what it's like to be completely alone and helpless, with nobody interested in your problem until it's too late.

Image from here

Hicks

2009-03-26T15:20:00.000+02:00

On Saturday, the Helicopter came to take a patient away to Civilisation. As I walked into Casualties, Jonny (the resident homosexual staff-nurse) said to me, 'Ooooh, Doctor, go check out Talldarkandhandsome in the back there.'

I could tell they were different the second I set eyes on them. It wasn't just the clothes - they wore bright red jumpsuits instead of the usual industrial green - but also the way they totally took ownership of our small resus room. They were busy transferring some intubated dude onto an emergency trolley ('Stab neck,' The Soup murmured to me.) One of them was indeed tall, dark and handsome, and he was barking questions at the sister. 'What was his pre-transfusion Hb? What FiO2 have you got him on? Are you sure there are no arterial injuries?' he snapped, far more authoritatively than the usual giggly, fussy paramedics I'm used to here in Craterville. With him was a woman not much taller than I, who had long blonde hair that shone like gold, and knew exactly how to operate the emergency trolley - something that's always been completely beyond me. But the moment I knew they were really different, was when they started wheeling the patient out the back door, and not the front like usual. I dashed out after them, and there it stood: huge and red and gleaming in the bright Saturday-morning sun: The Helicopter.

Jonny, not missing an opportunity to get as close as possible to Talldarkandhandsome, helped him lift the trolley up over a curb to get it to the helipad ('Ja,' said the Soup, 'you guys should build yourselves a ramp there..' I'm not sure who this was aimed at - surely if it's his hospital... and his helipad... it would be his ramp to build? Anyway.) They pushed the patient over to the chopper, and then they performed some complicated manouevre that hoisted the patient up next to the pilot (who bore quite a resemblance to the object of Jonny's affection.) Then, Talldarkandhandsome and Shinyblondehair climbed into the aircraft themselves, and strapped big earphones over their heads. At this point, not wanting to look like a sad country hick, I tried to walk nonchalantly back into casualties. The Soup and I fiddled about aimlessly in there for a few seconds, listening to the sound of the propellors picking up speed, and then the The Soup said, 'I really like watching those things take off.'
'Yeah, me too...' said I. We ran back outside.

The Helicopter was just beginning to lift off, it's tail pulling up before it's nose came off the ground. Higher and higher it went, and Shinyblondehair looked down at us and waved. We waved back, craning our necks, and staring after it for as long as possible. Within fifteen minutes it would be in Civilisation. I know I'm not, but I still felt like a bit of a sad country hick.

Picture from here

Licence to Cut

2009-03-23T15:17:00.001+02:00

In Civilisation, us interns used to fight over who got to do caesars. This was mostly because caesars are fun, but also because we knew that once we found ourselves in our own little Crater somewhere, we'd have to do them on our ace. In Civilisation, however, interns never, ever got to do them without at least registrar supervision, and even the medical officers first had to get their Licence To Cut (kind of like a driving licence - this was obtained by safely performing a caesar under the supervision of a consultant) before being allowed to operate on their own.

Coming to The Crater, I was pretty sure I'd cope on my own, but asked The Legend to do just one with me before my first big call, so that I knew I'd be safe. Things are quite different in The Crater - more... casual, if you will. In Civilisation, a registrar with like a hundred years' experience puts up the spinal under super-sterile conditions (often under consultant supervision), and then monitors the patient intensively while another registrar from a different specialty who, with the help of a scrub sister and and assistant or two, rips the baby out and hands him/her to yet another registrar who checks that the neonate doesn't have two heads and seems to be breathing ok.

In The Crater, The Legend puts up the spinal. Then he explains to the staff nurse about the two drugs he has drawn up. The first drug is call The Stuff in the Big Syringe, and is for Blood Pressure. The second drug is called The Stuff in the Small Syringe and is for After The Baby's Out. Then The Legend goes and scrubs, and then he does the whole operation with only the scrub sister to help, occaisionally telling Staffie to inject some of The Stuff in the Big Syringe if the monitor is making too much noise. If it really makes too much noise (ie: is broken) he tells her to switch it off. Then he chucks the baby at the labour ward sister ('Staffie! Inject The Stuff in the Small Syringe!'), who is more than capable of making sure the neonate doesn't have two heads and making damn sure it breathes properly herself.

In Civilisation, you have to do the operation an exact certain way. Like, you have to always use a certain number of instruments to clamp the edges of the uterine incision, even if the clamps are not really holding on to anything important and are kind of getting in the way anyway. And, you have to use a certain number of suture lengths, even if you don't need all of them and end up throwing half-lengths away, because it's protocol. If you don't do it this way, you are not licensed to cut. In The Crater, The Legend, supervising my first caesar, was more than happy for me to do things the way I'd learned in Civilisation, even if it wasn't his own special way. 'As long as you do it properly,' he said. This sounded reasonable to me. (When I asked him if I had a Licence to Cut he just looked at me blankly).

I'll be honest, I'm not especially comfortable doing the spinal and the caesar and the baby resus all by myself (even although I know I'm not a true Saffa Doctor until I have). But confidence is important, and it's something I feel that The Crater cultivates, and that Civilisation often seems to crush.

The labour ward is now sort-of my job, and I do a caesar almost every day. Sometimes I'm still surprised to find myself doing them - two years ago, I was still a bit nervous about suturing something as simple as a sheath. What's next? Laparotomies and thoracotomies, I hope!

The First Day

2009-03-19T15:14:00.000+02:00

My first day at The Crater was New Years' Day. The King, The Legend and The Surfer tried to make out like this was The Soup's idea, and The Soup was away on leave so he wasn't there to make out like it was actually their idea. I think it was everyone's idea. Anyway, on the afternoon of the thirty-first, I waved goodbye to my Swampy and Civilised friends, had a fairly quiet new-years' eve with the AdMan, and then left at the crack of dawn for The Crater the next morning. Coming off-shift was The Legend, who gave me a whirlwind tour of the town ('Algemesaal! Sub-akutesaal! Kraamsaal! And ongevalle... you came through there at the beginning...') Then he shoved a big trolley at me and told me to get cracking with the round. This is where the first big shock came - Afrikaans notes! I can speak and understand the language OK, but the reading, well, it goes a little slower. And the abbreviations are all totally different - HRK, NSG, RV, MVO - huh? I was very slow - The Legend saw thirty patients and I saw six. I think this might've made him a bit worried about the year to come. He then plonked me in Ongevalle (casualties) and wished me luck. And then, for the first time ever, I was all on my own. The Legend said I could call him... if I really needed to (I took this to mean 'Don't call, please', although ended up calling later anyway to ask about some broken bones). He did invite me to a braai at his place in the evening though.

The first thing that became apparent about The Crater is that people fall down there quite a lot, and they fall hard. Most of my morning was taken up with diagnosing and popping* various fractures - some guy who'd 'fallen' onto another person's face with his hand, and broken the base of his thumb; another who'd 'fallen' onto some guy's hand with his face and broken his jaw; a young girl who'd 'fallen' onto a 'log' and fractured her clavicle; and then, the only story I really believed, a little old lady who tripped over the curb on the way to new-years' day drinkies at her son's house, and snapped her tibia in half. In between all of this were various other problems - the usual HIV-with-diarrhoea-for-three-weeks ('But why did you come today?'), incomplete miscarriages, people with pains that start in their leg and then travel a path that bears no resemblance to the layout of the nervous system to the neck, dronk-verdriet** stabbees, and pooping babies. The only relief was that the sisters did all the suturing, something that never, ever happened in The Swamp.

By three pm, I hadn't stopped moving, and was hungry and thirsty. There was still a huge pile of folders waiting for me, and I had to get through them by five - I was told that The GPs (who cover weeknight calls for us) would not see any patients who had arrived before five. One of the nurses came to me with a spare plate of patient food and a mug of Coke, and sent me to A3 - the indecent assault room. This was the first time I'd ever eaten government-issue hospital food in my life, and damn it was good.

At five pm, there were still about fifteen patients to see, and then one of the sisters told me an indecent assault case had come in. I'd been shown the rape kit many times in my student years, as well as as an intern, but had never actually had to examine one of these patients before myself. The victim was a little younger than me, but was surprisingly calm about it all, and fired the story at me in rapid Afrikaans which I occaisionally struggled to follow, but which nevertheless sometimes left my ears burning. At this early stage of the year I was still trying to be really polite when I asked questions, and I cautiously asked her when last she 'lay' with her 'partner' (in Die Taal, of course). She stared at me blankly.
'You know... sex... boyfriend...' I muttered.
'Oooh, wanneer laas het ek en my outjie genaai?***' I blushed. 'Gister? Ek dink?'

All in all, it doesn't take that long to examine a victim of indecent assault, but those little boxes! Oh my word! Each swab taken has to be folded into a little triangular box that requires a manual to figure out. And there were what seemed like gazillions of little packets and papers and swabs and sterile-water droppers... Once again, I was slow. By the time I was done, it was six pm, and I sms'd The Legend to say that I was really sorry, but that I wouldn't make it to the braai.

Moments later, he and The King were right there, in Ongevalle. Within fifteen minutes they'd laid waste to the remaining folders, were shoving my hand-bag at me and telling the sisters to call the GP. This is probably the nicest thing a colleague has ever done for me - if it wasn't for that, I would've been there until seven. Doctors, for all their supposed comaraderie, seldom do each others' work.

At The Legend's house, I was given the most giant T-Bone steak ever, and pile of salad and potatoes that I failed to finish. Afterwards The King took me to my new flat, for which he had the key. All that was there was my new bed, propped up against the wall, which he quickly helped me assemble. I wish I could say I collapsed into it and slept like a baby, but The Crater is really, really hot, and there's lots of water around, and I spent the night trying to dodge the killer mozzies that were dive-bombing me. I got up much earlier than I needed to the next day, and went and got insect repellant and a toothbrush (I'd left mine in Civilisation). And so, the year began.

*Applying Plaster-of-Paris (POP)
**A crying drunkard
***There is no good English translation for this

The Cosmonaut

2009-03-15T15:07:00.002+02:00

And so here I am* - my final year in compulsory government employment: Community Service. Com Serv means different things to different people. To some, it means a painful wrenching away from their families and loved ones, and a year of exile in a town with an unpronounceable name that doesn't appear on major maps. To others, who find devious means to escape the forced exile, it's a year of mind-numbing boredom, as they languish in a clinic or a rehab centre or a TB hospital, doing work they care nothing for but that nevertheless allows them to go to the mall as often as they'd like. And to yet others (the lucky ones, I think), Com Serv is one final grab at freedom - one last chance to live it up in a place they would normally never get to go to, practising cowboy medicine they've never seen before and, beyond their duties at work, free of the entrapments and confinements of adulthood that bind all those living in The Real World.

I'll be spending my Com Serv year in a place we shall call The Crater. It's a bit of a compromise: whilst I didn't feel I could face a year comprised solely of clinics, I also didn't feel I could beat a path deep into the bush, leaving my boyfriend (the AdMan) all on his own. The Crater is a small farming town about 150km away from Civilisation, and so while I get to (pretend to) be a cowboy in place that was previously only a small signboard pointing away from the highway to me, I also get to dash home on the weekends to eat sushi. It's perfect.

The hospital in The Crater is district-level: slightly more basic than The Swamp, where I worked as an intern, which was a secondary level hospital. Our immediate referral unit is in a place called The Valley, and only the truly complicated or tertiary-level cases get sent on to Civilisation. Although I was in the heart of Civilisation only a few months ago, I get nervous when I call there now. I'm scared they'll hear my Craterish voice and read my Craterish notes, and sigh in snooty despair. I know this is a silly way to think.

I'm not alone in The Crater - there are five other doctors who work here with me. Firstly, there's The King. I don't know why he's still in The Crater - he comes from a massive coastal city as far removed from where he is now as Paris from Pofadder. Nobody here speaks his home language, except his flatmate, an old high school friend who always has money despite the fact that he seems to do nothing but sleep all day (we'll call him The Hustler). Whenever we ask The King why he's still here he says, 'I'm chilling, man.' Then, there's The Buckle - my fellow cosmo (short for: community service medical officer). He grew up around these parts. Before we met him, we don't remember ever diagnosing buckle fractures. Now, we see them all the time. They also seem to occur more frequently in patients he's busy treating. Whenever this happens, it is cause for much hilarity.

There's also The Legend, and The Surfer. The Legend is called that, because last year whenever I told people I was coming to The Crater, they'd say, 'Oh, you'll meet the Legend man! He runs his own ARV clinic and can do a hysterectomy and a hip replacement and he cycles like a thousand kilometres a week! What a legend man!' The Surfer is a little bit miserable in The Crater, because there is no sea here. But he knows a lot as well, and doesn't take crap. If you do something stupid, he'll tell you, but always manages to be quite nice about it.

And the final two characters (for now) are The Dentist and The Soup. The Dentist is my new flatmate, and as the name implies, he's the local government dentist, staying on for an extra year after his own community service. He's Muslim, which is new for me - I've never actually lived with a Muslim guy before - but he's always really cool about the rest of us getting drunk and falling down. He drives back to Civilisation every weekend as well - everyone he knows in the world is there. The Soup is the boss. He does all the usual boss things - go to lots of meetings, decide who's hired and who's fired, etc - but he also does some clinical work. He lives next door to me.

And so, Karen Little goes from regular student blogger/whiner, to infrequent intern blogger/whiner, to cosmonaut. I'll try to be more regular and whine less this year.

*OK, I know I'm only starting the story three months in, but internet access proved to be a bit of a challenge in The Crater. Small towns, y'know...

Sunday

2008-11-02T15:56:00.003+02:00

Ok, I confess, I've been feeling a bit uninspired of late. I've been staring at my computer screen for close on half an hour now, and the only story I can think to tell y'all is the one about the little girl in my ward who coughed up a ten centimetre worm while I was examining her this week. On seeing it wriggling about on her pillow, she cackled in delight and then shoved it back into her mouth. Luckily I got a hold of its tail (or it may have been its head - I didn't really look closely enough to make sure) before it disappeared completely from whence it came.

And well, that's not a very long story. So I thought I'd tell you about a very good book I read last week, called Blood Kin. You may have heard about it already - it's written by a South African gal called Ceridwen Dovey, and won the Alan Paton award for fiction this year.

Blood Kin is set in a fictional country, the name of which the reader never learns, and tells the story of the barber, chef, portraitist, (and their significant female others) of the President, who are all taken prisoner when the government is overthrown in a coup. The book reads quickly, easily and beautifully, and skillfully explores human nature, and how the more things change, the more we stay the same.

Dedication

2008-10-26T22:56:00.002+02:00

I spoke in an earlier post about how often people I had been treating were abandoned by those who were supposed to love them, and were many times left to die lonely, undignified deaths in hospital beds far away from their homes. In the Swamp, it was sometimes hard to see the good in people, and difficult to believe that we truly care for and value each other.

In Civilisation though, it seems there's a bit more compassion to go around. The nursing is better, the doctors more dedicated, and the relatives seem more concerned. In the Swamp, we all worked hard, and did our best, but everyone just seemed so burnt out and jaded the whole time, and the relatives all seemed defeated and exhausted. In Civilisation, everyone is just as tired, but somehow always have just a little more to give.

The people that really deserve credit though, are the mothers (and a few of the fathers). When babies get sick, they can stay in hospital for a really, really long time. It's not just the HIV babies that linger: TB, heart and chronic lung problems, malignancies, congenital malformations ad many other disorders can keep kids hospital-bound for weeks and even months. I'm almost done with my eight week paediatric rotation now, and there are patients in my ward who were there before I came and will not yet have been discharged by the time I leave. And most of them have a dedicated mommy or daddy standing by, sitting and sleeping on a chair night and day, only leaving the ward to go shower or buy coffee, learning how to feed their children through nasogastric tubes, wiping up their vomit and holding their hands through each painful procedure, dressing them in layers of fresh clothes after rubbing each nook and cranny with aqueous cream. I've seen parents choose to give up their hard-found jobs in order to stay with their sick children, or move thousands of kilometres in order to find the best medical care.

Not all parents are good, obviously - the abandoned and abused children are manifold as well. But it's good to see, in a society that for the most part seems selfish and cruel, that we do have some sort of survival instinct that compels us to care for ouryoung, at all costs.

Picture Credits
Aicha and Fatima (Koundara, Guinea, West Africa)
Originally uploaded by ccarlstead

Born in a Chair

2008-10-06T13:13:00.004+02:00

It was 2am, and for once, quiet in the maternity hospital. There were about three women contracting away in labour ward, but they weren't due to be examined in the next few hours, and there was nobody waiting to be seen in the admissions suite. We were sitting around, talking nonsense, when we heard the ping of the elevator. The whoosh of the doors was followed by the kind of screaming that can only mean one thing: a baby's about to pop out from between someone's thighs.

I cautiously poked my head around the corner, to see what was coming my way, and it was as I suspected: careening towards me was a clenching/shrieking lady on a wheelchair, pushed by her sweaty, bug-eyed husband, yelping granny following closely behind. Admissions Sister, sensing an impending delivery in which she wanted to play no role, planted herself firmly in the doorway and yelled, 'You shall not pass!' Gandalf-style, one powerful arm pointing towards labour ward. Bug-eyed husband did a quick U-turn and pushed his wife through the first labour cubicle's door, leaving a trail of bloody dots in his wake.

In and out, and in and out, and in and out of labour cubicles he ran, apologising over his wife's screams to the labouring women he encountered in each. Finally we met up in the fourth, me yanking on a pair of gloves, his wife screaming now at top notch.
'Stop screaming!' I screamed, 'Get out of your chair and climb onto the bed.'
'But it's out, it's out!'
'OK, stay in your chair!' I yelled, picturing baby bungeeing from vagina to floor. Bug-eyed husband kneeled down in front of her and yanked at her pants. He pulled them down over her thighs, and there was a sudden, total silence, as we all looked at the small human squished between its mother's legs and the wheelchair. Everyone held their breath as I reached down and picked it up, and then...
'KwaaaaaaaaaaAAAAAAAAAHHH!' - the best sound in the world: a healthy baby. I snipped the cord and handed him to even-more-bug-eyed dad, and the mom hobbled over to the bed so that I could deliver the placenta.

And so you see, Amanzimtoti, sometimes it does happen just like in the movies :)

What would you tell your children?

2008-10-03T17:39:00.003+02:00

When I was busy applying to University, many people tried to dissuade me from studying medicine. They told me all the true things: that I would often have to work through the night without sleeping; that it would be years and years before I could even think about specialising in what I was interested in, let alone have my own practice; that I would catch nasty diseases from my patients; that I would be studying or working or trying to fit some sleep in while my friends and family had fun without me. I didn't listen to them. I guess at age 16, all those things just sounded... glamorous. And, I naively thought I really loved all people and wanted to help just everyone.

The other day a friend and I were trying to decide what we would tell our children of they wanted to study medicine. It wasn't all that easy. See, in addition to the truths mentioned above, there are other things about medicine, especially South African (or, I guess, any third world) medicine that you will only really understand when it's too late. For example, once you've finally completed your six years of routine humiliation at the hands of countless personality-disordered consultants and registrars, you'll be sent to some place far away from your home and very possibly not of your own choosing, to be abused and humiliated for a further two years as an intern. Just when you've settled into this new place - gotten comfy in your new house, moved in with/married your life partner - the government will once again move you to some backwater town with an unpronouncable name and no tarred roads to practice something that vaguely resembles medicine, but only in the crudest sense of the word.

In this backwater town, you will realise that, actually, you can't change the world when there are a bunch of idiots ruling it, and you'll watch in despair as mothers and babies and all sorts of other people die or become crippled from things you know are perfectly treatable, if you only had some basic drugs and resources at your disposal. You'll become more and more frustrated as half of your patients die as a result of laziness or plain stupidity, and the other half as a result of ignorance and corruption, and you'll wonder why it's called 'community service' as you have no service to offer your patients. You'll forget that you originally became a doctor so that you could cure people (mostly because a cure is as rare as a rabbit in Antarctica) - if you're lucky you'll maintain your strong sense of compassion, but if you're human it'll probably be, well, annihilated as you become completely swamped by people who just want things from you all day long and never seem to be interested in sorting their problems out themselves. After a year (or two, it now looks like) of this, you can go back to wherever you want, but you may very well end up slaving away at something thankless and unfulfilling as you wait for a post in something you really like, which you may or may not get.

But even with all this in mind, I can't imagine myself doing anything other than medicine. Maybe that's because, eight years later, I don't know anything else. But, it's also because there is nothing else quite like medicine. I will always have a job, and there's no part of the world in which doctors are not needed. I seldom have to do anything that really bores me for more than a few hours at a time, and I never have to wear high heels to work. I can leave when the work's done (and ok, often the work just never ends, but when it does come to an unexpected early finish, there's nobody punching a time card and forcing me to stay until five). And, every now and then, I do actually get to cure someone, or someone says a heart-felt thank you.

So, what would I tell my children if they wanted to study medicine? I'd just try to be honest, I guess. It's unlikely that anything I say will change their minds once they're made up anyway.

The Good, the Bad and the Ugly

2008-09-29T22:40:00.003+02:00

September 2008

The Good

South Africa's new Minister of Health - Barbara Hogan. Her previous experience is all in economics and finance, she has no medical or para-medical degree, and her main claim to fame is the nine years she spent in prison, but hey, as long as she's not Manto, it must be good, eh?

The Bad

It's bad, but in a really good, funny way: the criteria you have to meet to consider yourself a bona fide Saffa doctor. Dr Skakhi is a newish South African blogger about town - check him out.

The Ugly

My ankles and midriff - two years of calls in hospitals colonised by fleas have left me scarred for life. If I were a model I would sue... someone.... but then, if I were a model, I probably wouldn't be spending the early hours of my mornings sitting on flea-infested chairs or trying to catch ten minutes of sleep under flea-infested blankets, now would I?

Spring

2008-09-24T18:56:00.002+02:00

Every year, as Spring rolls around, I am reminded of how very much Medicine is like gardening. See, in both cases, you start out with this small dried-up thing that looks pretty useless. First, you tuck it into a nice warm bed - plants like a little patch of soil but I've noticed that humans prefer a nice firm mattress covered in soft linen. Then, you give them water: you can just kinda splash it in the general direction of the plant, but sometimes with humans you have to be a bit more invasive and set up a system that pours fluids directly into their circulation.

They both need lots of nutrients - plants are lucky in that they can suck up a lot of the minerals they need from their beds, but sometimes this needs topping up with something nice and stinky, often from an animal's bum. Humans on the other hand can't absorb their nutrients directly from their environment and need to ingest them a few times a day. Some humans like stinky nutrients as well, but a lot don't. Sometimes they're really behind and need to do a lot of catching up - in cases such as these we can give them concentrated minerals and vitamins in tablet form.

Then, there's pest eradication. Plants and humans need to be protected from pests and predators, and need to have some resident ones removed. Unfortunately in humans it's often not possible to resort to the nice eco-friendly methods we can use in plants, and generally have to use all sorts of toxic chemicals to make sure they become and remain germ-free. These chemicals can be administered in many different ways - we can use the watering-system to pour them directly into the human, or we can give them to the human to ingest with their nutrients, or rub them all over their skin. It really just depends on the pest and the human. Sometimes it takes some skill to correctly identify a pest and to recall the most effective method of eradication.

When your plant/human starts to flourish again, it may require a short period of support before it can stand on its own. A stick wedged into the soil and a few peicesof string will often suffice for a plant, whereas a walking frame or the wheelie-table next to the bed will probably work for a human. Both may need a bit of external input - you may have to train your plant around its stake and your human may need some instruction in the art of mobilisation. There, fortunately, people specially trained just to help them with this.

And then, one day, you'll be rewarded. Your plant will suddenly become covered in lovely leaves or brilliant flowers, and your human will give you a big smile or surprise you with intelligent conversation. That's when you know it's fairly safe to turn them out of the greenhouse/hospital, and let them go at it on their own.

Picture Credits
Seedlings Common chickweed
Originally uploaded by tico_bassie

Regret

2008-09-19T11:24:00.000+02:00

The bread-and-butter of my internal medicine rotation last year was TB. I saw it in every shape and form, and knew how to hunt for it in every organ, system and cavity. In busy weeks, my reg and I would diagnose up to ten new cases a week - with five teams in the department, this meant that up to fifty new cases a of TB were being diagnosed each week, just in the small hospital I was working at. And in all that time, in all those patients, how many times did I tell someone to take any small children they had in the home to a clinic for TB workup and prophylaxis? Not once. It never even entered my mind to do that. It seemed like it was enough just to prove the diagnosis and then refer the patient on to the relevant primary care facility. I didn't really think about the people they'd be passing their AFBs on to once they went home.

Now, I'm rotating through paediatrics, and am seeing the truly tragic consequences of an overburdened health system that just always seems to fail those who can't protect themselves. The ward I'm working in at the moment is, at any given time, the temporary home to several previously super-healthy children who have fallen prey to TB, and it's really, really horrible.

It's supposed to happen like this:

1. I diagnose TB in Ms A. I start her on treatment, fill in her referral form, as well as a notification form.
2. A copy of the referral letter is forwarded to Ms A's local clinic, and the notification form goes to a local health authority.
3. An employee of the local authority visits Ms A in her home, screens all of her family members for TB, starts those who are infected on treatment, and the rest on prophylaxis.
4. TB is wiped out in that family, and everyone goes on to live happy, healthy, long, productive lives.

What really happens, is this:

1. I diagnose TB in Ms A. I start her on treatment, fill in her referral form, as well as a notification form.
2. A copy of the referral form stays in Ms A's folder, which gets filed somewhere and never looked at again. The notification letter gets sent to a local health authority where it gets put in a big box with a hundred thousand other notification forms, and never gets looked at again.
3. Ms A fails to go to the TB clinic, and they never hunt her down, because they never got a referral form to say they should be expecting her.
4. Ms A hacks up AFBs all over her super-cute, well-grown, HIV-negative two-year old brother (Little B), who never gets TB prophylaxis because nobody has ever offered it.
5. Little B gets TB Meningitis, which fries his brain so completely that he ends up blind, spastic and on a tube-feed for the rest of his life.
6. Everybody lives long, unhappy, unproductive lives: Ms A ends up on a disability grant because of her debilitating post-TB bronchiectasis, and Mrs C (mom to Ms A and Little B) can't work because she has to stay at home and full-time-care for Little B who, well, like I said, is blind, spastic, and on a tube-feed.

And it could all have been so easily prevented...

These days, whenever I diagnose TB, I tell all my newly-diagnosed patients to take any small children or old people they might have in the home to the clinic to be tested. It seems such an obvious thing to do, but it never occurred to me before to do it - I very naively thought the system would have it all sorted out. How wrong I was.

Crawling out of the Swamp

2008-09-11T19:57:00.000+02:00

For the last rotation of my internship, I have been shipped away from the district-level hospitals I've been working in since the beginning of 2007, to an awesomely fancy tertiary centre, where I'll be doing my pediatrics rotation. Now, I've learned to do (what I thought were) all sorts of impressive things at district level - insert an intercostal drain, perform a caesarean section, remove an appendix, cure TB, diagnose fibromyalgia - but I must confess: in this new place, I feel a bit like an amoeba that has just crawled out of the swamp and is trying to blend in with the multi-cellular organisms, hoping they're not going to notice the glaring differences between us.

The Swamp is different to Civilisation in so many ways, starting with the size. Where the Swamp only had four wards and a caravan selling slap chips, Civilisation has, well, actually I don't know how many wards, but it has seven floors in each of its four wings and a special cafeteria just for doctors! And in Civilisation... you can get any investigation or intervention you could dream of for your patients - it has an MRI machine and gastroscopes and cath labs and a nuclear medicine laboratory and a special ward for people for people who breathe through a pipe in their neck and a special clinic for people who have cerebral palsy, it has dieticians and physiotherapists and counsellors and crisis rooms and an intensive care unit and and and... it just goes on. All the Swamp had was a CT scanner that didn't work too good in the rainy season and a social worker. And the best part about Civilisation is that you never have to beg/perform sexual favours to get any of these investigations/interventions for your patient, and they all get done, like, today!

Another huge difference between the Swamp and Civilisation is the spectrum of disease. In the Swamp, most people are diagnosed with either Stab Chest, HIV, TB (or a combination of the two), Ruptured Ectopic Pregnancy, Unplanned Pregnancy, or Substance-Induced Psychosis. In Civilisation however, wow - it just blows your mind, the things you can get. Neuroblastoma, thalassaemia, malaria, biliary atresia, tracheo-oesophageal fistulae, sickle-cell anaemia, juvenile conduct disorder, Prader-Willi Syndrome - once again, the list just goes on. And the treatments available are really different as well. The Swamp only has a selection of maybe six antibiotics, half of which need to be co-signed by a consultant, but in Civilisation any old ~~fool~~ amoeba can just go ahead and prescribe Amikacin if the fancy strikes them.

I've always thought that House was the biggest load of rubbish, and that (a) nobody has weird diseases like that and that (b) no patients have entire teams of specialists dedicated to solving their diagnostic mystery, who subject them to a billion special investigations a day and have the ability to remember all the features of obscure syndromes at the drop of a hat. But Civilisation has proved me wrong. It really is like that out there - I've just developed such a murky, fuggy view of things from spending too much time splashing about in the mud.

Picture Credits
Beaver Swamp
Originally uploaded by Baab1

Screaming for morphine is always suspicious

2008-09-08T08:09:00.000+02:00

If you enter casualties on a wheelchair pushed by your long-suffering sister, wailing whilst you flap both arms in the air, and then slither to the floor Cousin Boneless Chicken-style before loudly vomiting up a tablespoonful of saliva, don't be surprised if everyone in the unit is suddenly avoiding eye-contact and has found some other really important patient to attend to.

You see, if you look over to the patients who we know to be in truly excruciating pain - the young girl with the ruptured ectopic pregnancy, the middle-aged man with the perforated peptic ulcer, the little old lady with the fractured hip - you'll notice they all have something in common: they're being extremely quiet, whilst doing their very best not to move a muscle. If whatever's biting you leaves you with enough energy to ululate loudly enough for the folks over in the psych ward (a unit we're beginning to suspect may be more suited to your needs) to hear you, it probably ain't biting that bad.

Moreover, if you suddenly scream, 'Oh god, it hurts so much, somebody give me some MORPHINE!' - well, you're probably gonna get bumped to the very back of the triage queue, where nobody can hear your screams (except your long-suffering sister).

The Dee-Gees

2008-09-04T08:16:00.001+02:00

(Or: Why Family Medicine was hard for me, Part II)

In front of me I have a newly diagnosed Type II diabetic. Type II DM is not a great thing to have (in fact, I spend many an idle hour wondering which I'd rather have: diabetes or HIV), but for the moment she's not in bad shape. She doesn't have any target organ damage yet, and if she remains well controlled she should pretty much be able to go on with life as usual (minus the daily slice of cake). I break this good news to her, expecting - what, to see tears of relief perhaps? I don't get these. Instead she looks at me and asks, 'So can't I maybe get a disability grant then?'

ARG!

There are a few conditions that may make it difficult for you to earn a living. Examples of these are:

1. Refractory epilepsy
2. End-stage cardiac failure or post-TB bronchiectasis
3. Amputation of one or more limbs
4. Severe intellectual impairment
5. Stage 4 HIV (aka AIDS)

If you suffer from one of these, the government might see fit to supplement your income with a 'Disability Grant' (DG for short).

However, conditions such as:

1. Vague, non-specific, intermittant backache
2. A fractured ankle
3. Gastro-eosophageal reflux
4. Ingrown toenails
5. Chronic Monday-itis

are unlikely to render you permanently incapacitated, and so barring a catastrophe (see some of the dread diseases above), there's no reason the average, honest, hard-working taxpayer should have to support you for the rest of your life.

Thankfully, I never have to actually assess people for DGs - there's a special doctor who does that and only that all day (I suspect his salary is where most of the health budget goes- I sure wouldn't do that job for what they pay me now). But in the primary care clinic, I'm the first one they see, and so the first one they ask. Much of the time, the people doing the asking actually do have jobs, and it just makes me really angry. The last time I checked ,the monthly DG was around R1000 (that's about US$130 or 70 pounds), which is about half of what my boyfriend and I spend on groceries every month, and we don't even have a team of sprogs to feed (although, to be honest, we don't have to eat a tub of Woolworths chocolate fudge ice cream a week either). Why, why, why are (some) people so utterly lazy that they would rather live on the breadline that work a perfectly decent nine to fiver?

Makeover

2008-09-03T12:33:00.002+02:00

Behold my lovely new header! It was sent to me by my good friend, The Electric Orchid Hunter (whose beautiful and fantastic blog has long been the subject of my envy). The person who designed the header can be found here:

(clickclick)

These days of course, we don't just drill into peoples' heads willy-nilly, but only if they're unlucky enough to have been clubbed over the head with a cricket bat/quart of Black Label/train carriage, and have developed some problems as a result. This happens more often than you would expect round these parts.

Also, Bongi from Other Things Amanzi has bestowed an award upon me! He has given me the Arte y Pico award, which is an award passed from blogger to blogger, as each recipient passes it on to five blogs they believe contribute significantly to the blogging community. At this point in time I have only one blog I would like to pass it on to, and that is (the above-mentioned) Eclectic Epiphytes and Electrophoretic Epigrams. I'm not passing it on here because the author gave me a header, but because his blog really is truly beautiful and wonderfully written.

Arte y Pico Rules

You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
To show these rules.

The Good, The Bad and The Ugly

2008-08-31T12:51:00.004+02:00

for August...

The Good

It's been around for ages, but I only recently discovered it via Blogs of Note: M.D.O.D. It's a plus plus funny medical blog by a group of doctors in the US. There are a few posts about American football and politics inbetween the medical posts (subjects I know very little about and am quite bored of, respectively), but the doctor stuff is hilarious. Some particularly good ones can be found here, here and here.

The Bad

The woman who phoned the ambulance to take her to the clinic last week because 'her piles hurt'. Dontcha know there are people dying out there?

The Ugly

The tampon that got inserted in March... and removed by myself at the beginning of August. That blue string is there for a reason, gals - it's a long, dangly reminder of the potentially super-stinky foreign body in your vajayjay!

Snot en Trane

2008-08-29T12:01:00.003+02:00

The other night, my first stabbee for the evening arrived in casualties approximately ten minutes after I did. He got himself our immediate attention by seating himself at our desk and leaking blood all over one of our nice new chairs, and so we soon had his perforated body scooped up onto a trauma trolley and on the way to the resus area. It was around about this time that a large switchblade fell out of his pocket.

The man wasn't too badly hurt - he had about five lacerations for me to suture and needed an intercostal drain. But, oh my, did I struggle. It started with the IV lines: while I was getting the stuff together my reg yelled 'Make it an orange!'
'NOOOOO!' yelled Mr Stabbee, 'Not the Orange!' (I began to suspect that this patient was going to be difficult just for the sake of it - there was no way that he, straight off the street, could even know what 'an orange' referred to - a large intravenous cannula [he was losing quite a lot of blood].)
And then, drawing up the lignocaine, 'NOOOOoooooo OOOOhohohohohonOOOOOOO.... Don't put that in me please....'
And then, injecting the lignocaine, 'OHHH my god ithurtsithurtsithurts, stop, pleeeeease...'
And then, holding up the scissors to cut the sutures, 'AAAAAAHHHH!!!!'
(It was at this point that another helpful intern slipped a bit of morphine into Mr Stabbee's drip, causing him to be a bit more quiet but also, unfortunately, somewhat more floppy).

I don't know whether or not this guy was guilty of any crimes (although he did object quite strongly when we offered to call the police), but I guess I thought that someone who carried a large switch in his pocket would be a little tougher. Maybe it's like the surgeon (who was busy patching someone up in the next cubicle) said: 'If you play with knives on the street, you come to hospital and you cry.'

Picture Credits
switchblade
Originally uploaded by williamwats

Head, Shoulders, Knees and Toes

2008-08-23T10:10:00.006+02:00

My Family Medicine rotation has not been easy for me. I think this is because I just don't know most of the the things Family Physicians seem to be born knowing: what to say when a patient asks you if she should divorce her husband, the name of the disease that makes the left side of your scalp tingle when you read the paper, why somebody would arrive at the clinic at 5am, wait six hours to be seen, and then wait two hours in the dispensary queue, even though they know all they have is a cold. But mostly, I don't know why it hurts.

And trust me, everything can hurt. Your head, your left ear, your right eye, your shoulders, the tips of your fingers, your kidneys, your stomach, that little spot just below your belly button, your big toe. Your bum can hurt when you go to the toilet, your knees can hurt when you climb the stairs, your back can hurt when you sleep on your left, your heart can hurt when your husband shouts at you. The Pain can move: up your arm, down your leg, around your chest. And The Pains are more important than any of your other health issues, like the fact that your sugar is more than three times the upper limit of normal, or that you smoke sixty cigarettes a day, or that your untreated condylomata can no longer be contained by your underpants. It's The Pains, The Pains, that are the worst.

I only have the skills to do so much - prove that you're not having a heart attack, exclude an ectopic pregnancy, confirm that you don't actually have multiple drug resistant TB of the spine. And then I'm... well... at a big, terrible loss, that leaves you grumpy and sighing and tutting as you limp out of my room. I know: it's not you, it's me. Last week I went to a community rheumatology clinic with an MO who has dedicated her life to The Pains, and she always knows exactly what to do. Make them bend this while you rotate that... oh, it hurts? Ta-daaaa! It's inflammation of the Sub-something-or-other Bursa. The treatment? Rest and anti-inflammatories, of course! And, failing that, a little jab with a little steroid here or there.

I really look forward to the Knowledge that comes with Age.

The Ethics of Blogging

2008-08-22T14:22:00.005+02:00

Anonymous commenter number whatever left this comment on a recent post of mine, entitled Failure:

'I hope to god this is made up, otherwise you just breeched patient confidentiality.'

This comment left me with the bad feeling in my tummy that anonymous comments often do, usually because many people who comment anonymously have bad or nasty things to say. But, it got me thinking. Am I blogging unethically? Am I violating patient confidentiality when I describe my encounters with patients or things that happen while I'm at work?

I'd like to think not. As much as I criticise anonymous commentors, I myself blog anonymously - Karen Little is not my real name. Although my readers know from which country I hail, because I think that knowledge is important to understanding some of my posts, I've never named any of the institutions I've worked at, or the city I live in. I never use real names on my blog, and try to avoid detailed descriptions of patients that may render them recognisable. It's true - once or twice I've slipped badly, and people have guessed who I was talking about or have pointed out that the photos I posted were, well, not really mine to publish, and I've deleted or changed those posts. But maybe, even though I've taken all of these measures, I am still an unethical blogger and I do violate confidentiality in some small way with each of my posts.

There's been a lot of fuss about this lately, as I discovered when I Googled the topic - the BMJ recently published an article* dealing with the very subject, based on a study published in The Journal of General Internal Medicine. The article quotes:

'..."blogs are a growing part of the public face of the health professions.They offer physicians and nurses the opportunity to share theirnarratives. They also risk revealing confidential informationor, in their tone or content, risk reflecting poorly on theblog authors and their professions."'

On the subject of anonymous bloggers such as myself, the article said:

'..."anonymous" medical bloggers who provide informationabout their location, subspecialty, or other personal detailsinadvertently reveal their identity to patients, colleagues,or other members of the public. In some cases, patients describedin these blogs may be able to identify themselves.'

The article didn't presume to offer guidelines to bloggers, but did quote:

'"Unfortunately, no professional organisation has taken the initiativeto provide guidance on this issue. As the number of medicalblogs grows, professional organisations, medical educators,and the blogging community must address the challenge of thisnew medium by setting guidelines and standards for what is appropriate."'

The thing about blogging is that it isn't policed, and there's nothing stopping me (or any other blogger) from saying whatever I want about whomever I want without permission. Unlike medical journals, which require studies and articles to meet certain ethical requirements before being published, the only person standing between my printed word and I is, well, myself. It's up to me to decide what is ethical to say and what isn't, and how far to push the boundaries of patient confidentiality.

Anthony of Black Triangle takes a very firm stand on the matter. He says:

'It is quite clearly unacceptable to be the subject of a blog post without consent. There is a difference between health care professionals and others. We should be trusted. We are invited in by patients to share the most intimate of problems. They trust us not to share those problems with others, without their consent.'

And, he makes the case that no public benefit is really being served by posting stories about patients on a blog, that blogging our stories gives voyeurs the opportunity to 'rubberneck on the net', and that there is often a conflict of interests as medical bloggers are paid to tout products.

It's a touchy subject. I'd like to think that my blogging is not unethical, but I'm really not sure anymore. In medical ethics we subscribe to the principles of beneficence and non-maleficence. I don't think my blog hurts anyone, and so I think I'm non-maleficent. But am beneficent? I can't honestly say I blog for good - looking back over my posts for the last year, I've written many stories about patients but, as in the case of my post Failure, my frustrations are more often with the system within which I work than the patients themselves, and I use the stories to highlight these - but is it really for good, or is it just a glorified form of venting? I don't make any money off my blog (unless you count the 4p I've made from recommending my favourite fiction on Amazon), but I do like it when people respond to what I've written, so maybe I'm just another one on the hunt for popularity. I've said before that blogging is often a form of debriefing or closure for me, but maybe it's highly unfair for me to seek closure in the way that I do, making private stories public.

What do you think?

Reference:
Study highlights challenge of patient confidentiality in medical blogospheres
BMJ 2008;337:a1043

My First Time

2008-08-16T19:00:00.003+02:00

Obstetrics: those were cut-throat times. There were so many reasons to shaft your colleaugues: to get as few calls as possible, to get the least unpleasant calls. To attend as few actual deliveries as possible, thereby avoiding as much poo as possible, as many placentas as possible,and as much cleaning up as possible. To get the easiest clinic, the shortest ward round, the longest lunch break. But most of all, in obstetrics, we shafted each other to get the most caesars.

The caesarean section: the operation that happens by the thousandful every day in every major city in the world. I won't say it's an easy procedure, but on the right patient and under competent instruction, even the clumsiest intern should be able to manage one himself. I don't know why we were so obsessed with doing as many of them as possible. We claimed it was because we were terrified of what would happen in the Bush next year (when we're shipped off to the darker parts of the country to provide the Community with Service), and we were expected to do them by ourselves. But really, I think we just wanted to do them because they're fun, and we each wanted to do the most of them because most doctors are congenitally competitive bastards who just need to win at everything.

Oh, the things we resorted to - sneaking into the consultant's office to manipulate the roster seconds before it officially went to press; slipping into theatre when the designated intern for the day was five minutes late, and then refusing to budge; buying the scrub sisters chocolates, cokes and pies to get them to agree to scrub with us. It was lowdown and ugly. And our energy wasn't focussed only on shafting each other, but also on buttering up the registrars as much as possible, so that they would be willing to take a step back and teach. We had to earn their trust before they would hand over the scalpel - proof that we could tie knots, provide decent fundal pressure, and suture the skin neatly enough for the new mom to be able to wear a bikini again were essential if we wanted to earn the sacred title of 'surgeon'.

But, eventually, after enough knot-tying and fundus-squeezing and enemy-making, we were all given a chance. I still remember my first time like it happened a heartbeat ago. I spent the day assisting a reg who finally decided, after eight hours of hard retracting, that he liked me enough to let me do the last one. I scrubbed up, and took my place on the patient's right, as apposed to the assistant's lowly left, and helped the scrub sister clean and drape. I picked up the knife, and gingerly cut through the skin. After an age, I'd finally dissected down to the sheath. The reg stuck his finger in to show me where to cut and I put my blade down and... 'GAAHHHHHHhhh!' The reg clutched his spurting finger to his chest, a little hat of latex glove hanging off the tip of it. I stood aghast as he yanked his gloves off his hands, and then held them under the tap and scrubbed as hard as possible. But the scrub sister yanked me out of my reverie with a 'Come now girlie, there's still a baby inside there.' She assisted me for the rest of the procedure, showing me how to pull the baby out, where to put my stitches and how to make sure there was no more bleeding.

Luckily, the patient was HIV negative, so I only ruined my reg's finger, and not his life. And, despite my clumsiness, he still let me operate with him many, many times again, and of all the interns who did obstetrics with me, I did the most caesars. (Not that it's a competition, of course.)

Failure

2008-08-11T15:05:00.002+02:00

I was just about to go on my tea break when a male nurse came rushing into the trauma unit, clutching a big bundle of blankets. 'Somebody help me!' he yelled, 'This baby isn't breathing!' I stood up, knocking my chair over backwards, and asked him to put the baby on the bed. It looked about three months old and was still warm, but was indeed not breathing and had no pulse. It also had that murky look about the eye which in my (limited) experience usually means that the creature before me is no longer of this world.

I yelled for a bag-valve-mask, and within moments one was in my hands. This speed was impressive, but unfortunately the mask looked designed for a premature neonate, and was only about big enough to cover one of this baby's nostrils. I started chest compressions as I asked for another one. Out of the corner of my eye I could see the nursing staff first reaching to give me an adult mask (bigger than the baby's head), then trying to attach an adult bag to a baby mask, then dropping the baby mask... In my head the teaching of the basic life support course I'd been on a few months ago ran through my head: '...it is very important to give effective breaths (that make the chest rise) for infants and children during CPR.' I took a deep breath, bent over, and started mouth-to-mouth. The chest rose twice, and I started compressions again.

This is not a story with a happy ending. I was the only doctor in the room for most of the resus, and I watched in despair as the nursing staff in the unit tried to do chest compressions - stroking the sternum more than compressing it - and then squeezed oxygen into the atmosphere as they failed to get a seal around the baby's mouth when I delegated the airway in an effort to help with compressions (later I would discover we weren't even squeezing oxygen out of the bag - in the madness nobody had attached it to the oxygen cylinder). After I got the baby intubated another doctor arrived, and I watched hopelessly as he tried to set up an intra-osseous line with an ordinary needle - there were no intra-osseous sets or even spinal needles in the unit. He called it a few minutes later and then sent me off for my tea, the smell and taste of dead baby still in my mouth.

There is so much to recoil at in this story - the way the mom had brought her baby to the clinic that day because she was looking a bit feverish, and then noticed that she was no longer breathing as she stood in the queue at the tuckshop to buy herself a pie; the way I had to give mouth-to-mouth at a busy trauma unit in a very first-world city; our clumsy, haphazard and ultimately futile attempt at resuscitation; the way I had to break the news of the death to the mom and dad in a large linen storage room because the unit has no debriefing or counselling area. I don't understand why public-sector nursing staff in this country have such poor skills when it comes to things like CPR, which is something even high-school children can be taught to give effectively, and why the units never seem to have the proper equipment: it's like the health institutions don't care about their patients enough to train their staff properly and invest in decent tools. I'm also anxiously awaiting the day when I can manage an emergency situation like a resus, without looking back and wondering if it was a failure because of me and my own shortcomings.

Picture Credits

PlasTIco the Kewpie
Originally uploaded by iamsored

Eats flesh, smells bad

2008-07-31T16:52:00.000+02:00

The anaesthetist is saying that he's never seen so much nec fash before in his life. In ten years, and across four continents, he'd only ever seen three cases. But here, in six months, he's lost count already.

Nec fash: doctor-speak for necrotising fasciitis, the flesh-eating bug disease. I know you've all seen it before: on ER, Grey's, and even on Scrubs. On these shows, the diagnosis of this condition is accompanied by much hoo-ha, hubbub and hysteria. Here, we just sigh and say, 'Of which part?'

Nec fash is not pretty. As the name implies, it starts with a bacterial infection, and ends with the destruction and death of the fascia - the bits of stuff between tissues like skin and muscle. It spreads fast - what starts as a zit next to your anus that you were too embarassed to tell anyone about today ends in the stinky liquid destruction of your entire perineum the day after tomorrow. The only way to treat it is to debride: to cut and cut and cut until all the rotten bits are gone. This sometimes has to be done several times over, as little pockets of nasty that are missed at the first operation continue their spread. Very often, it's fatal.

We don't know why we have so much nec fash here, but I believe it's the fault of the unholy trinity of untreated diabetes, genito-urinary sepsis and poor sanitation that plagues the poor population we treat. The majority of the nec fashes we see are in diabetics, and usually start as perianal or suprapubic abcesses that just spread and spread and spread. In university we were taught that the complication of not properly draining a perianal abcess was fistula formation, but here I've learnt that although that does happen, a far more ghastly consequence is massive sepsis and death.

Genito-urinary sepsis results in a nec fash that has its own special name: Fourniere's Gangrene. Two groups of people tend to get it: highly active young men with too many girlfriends and the STIs that come with, and not-so-active quadriplegic people who get sepsis from their in-dwelling catheters. We had one of the former in our wards for a long while. When he arrived, the intern who saw him (and happened to be suffering from a bit of compassion fatigue) immediately said, 'Boetie, you must stop sleeping around, and you must use condoms.'
The patient looked at him and laughed. 'I have five girlfriends, and they all like skin-on-skin!' (Really, I kid you not.)
Compassion-fatigued Intern looked at him and said, 'Well after this, you won't have a scrotum anymore, so I wouldn't be too proud of myself.'

Sometimes, nec fash is not as glaringly obvious as others. Once, a man came in about ten days post-appendicectomy, complaining that he wasn't feeling too good and that his wound was painful. Clinically he was a bit septic, but the wound didn't look too bad from the outside. But when the PMO (of the creaky knees and FIFO fame) came to take a look at him, he said, 'You see that dirty-dishwater kak draining from the wound? This is nec fash - he needs to go to theatre now.' And sure enough, nec fash it was - the man ended up being debrided all the way up to his armpit, after which he enjoyed a lengthy ICU stay (this all freaked me out a bit - nec fash isn't supposed to be a complication of appendicitis, is it? Was it something we did? Maybe Bongi can help me there.)

Is there a moral to this story? Probably not for you, dear reader. But it does reinforce the message we try to get through to the population we treat, the one they seldom seem to get: don't wait so long - it's better to come sooner than later.

Into The Dark

2008-07-27T15:23:00.000+02:00

Love of mine

Someday you will die
But I'll be close behind
To follow you into the dark

No blinding lights
Or tunnels to gates of white
Just our hands clasped so tight
Waiting for the hint of a spark

If there's no-one beside you
When your soul embarks
Then I'll follow you
Into the dark

- I Will Follow You Into The Dark
Death Cab For Cutie

One of my duties as an intern is to certify patients dead when they pass away in the wards at night. In medicine this usually happens once or twice a night, the disease burden in this area being what it is.

It never fails to amaze me how few relatives of deceased patients I see. Occasionally I'll see a forlorn husband clutching a plastic bag containing an old skirt and a pair of sandals, and a handful of times I've had to console a heartbroken sister or daughter. But for many of the patients who finally succumb to their TB or cryptoccocus or PCP, I see no relatives or friends either before or after they die. As I pull blankets and sheets over their cold, curled up, and sometimes filthy husks, I marvel that of all the indignities AIDS inflicts on its sufferers, the one that is the most tragic - banishment - is one that people inflict on each other.

I have many things to be grateful for, but one of them, however maudlin it may be, is that if I were to die soon, it wouldn't be alone. If I had to slowly pass away in some hospital bed, there would be someone beside me, and there would be someone to say goodbye to me before I was wrapped up in plastic and taken away.

For Further Management

2008-07-23T15:31:00.002+02:00

Last night I was on call for family medicine in a small district hospital that is only supposed to accept stable patients who need some in-hospital TLC. When I'm on call there I'm completely on my own - as an intern I'm always meant to have supervision, but this 'supervision' is in fact thirty kilometres away and quite unlikely to come out except in the direst of circumstances. I've had many nightmare calls there already trying to resuscitate dehydrated babies, but those are in another story.

So, last night, I get a call from the locum doctor at the clinic telling me he wants to send me a pre-terminal patient for some 'TLC' - the victim of a gunshot neck eight months ago with subsequent right sided paralysis. I accept the patient - we look after lots of pre-terminal people there. Forty five minutes later, I get a panicked call from one of the nurses saying an extremely ill patient has just arrived, that the paramedics are waiting on hand, and that she's not sure what to do. I rush off to see the patient.

Now, there are different types of pre-terminal patients. There are those who have a known and named terminal illness (such as cancer), where a decision has been made by a specialist and the patient and his family to withdraw treatment. Secondly, in this country we have patients who come in ravaged by a monster unnamed by the patient but known to us - HIV - and a quick look at someone in the terminal stages of this disease often makes it apparent that heroic measures will not benefit anybody. And then, there are patients who were actually fairly well prior to their presentation at the clinic, but who are pre-terminal in the sense that if somebody doesn't do something now they will shortly take a long leap into the hereafter. The patient I got last night was one of these.

There he lay, in my tiny, ill-equipped admissions unit, surrounded by his distraught wife and young children, panicked nurses and frustrated paramedics, dying. The paramedic told me that when they'd arrived at the clinic the patient had been pushed behind a curtain, and that the doctor there told him not to attach any monitors for the journey and that he wasn't for resus. I asked his wife what the doctor had said, and what her husband's condition had been like before yesterday: she told me that he'd been not-too-good but also not-too-bad, and that the doctor at the clinic had said, 'You never know, he might get better.' An active decision to not resuscitate was never discussed with her.

And so, I did the only thing I really thought my conscience could bear: I intubated him. This proved to be extremely difficult and I had to enlist the help of the paramedic (when, oh when, will I become one of the smooth, Zorro-type creatures shown so often on TV?). His heart rate dropped off terrifyingly and he stopped breathing, but after a few minutes of bagging he stabilised again. We put him on the ambulance and sent him somewhere better equipped to deal with him. I doubt he's still alive today.

I really hate it when other doctors don't take responsibility. The referring doctor's letter said that he was 'for further management' - but in this case, further management clearly included some major intervention and referral to a specialised centre. If upon seeing the patient the doctor had decided that he would shortly pass away and that intervention would not have been beneficial, he should have kept him at his clinic, instead of sending him on to another place so that somebody else could watch him die. I've talked about the euphemisms we use in this profession before, and I think I've finally decided on my least favourite one: 'for further management'. All it ever seems to mean is 'I don't really know what to do with this mess here and I'm not really interested anyway, so I'm sending it to you to sort out.' Not cool guys, not cool.

Picture Credits
Light at the end of the tunnel
Originally uploaded by mlsnp

Push Hard, Push Fast!

2008-06-25T18:12:00.000+02:00

This weekend I did the Advanced Cardiac Life Support course, designed by the American Heart Association. This involved giving up one of my precious few weekends off as well as about a quarter of a months' salary to go and spend three eight-to-six days learning about the best way to try to bring someone whose vitals organs have abruptly conked out back to life.

It was totally worth it. Prior to this weekend my resus skills included (1) chest compressions and (2) lurking in the background while a bunch of frantic worker bees who seemed to know what they were doing took care of things. Our course instructor was amazing: not only do I now finally understand the ECG (yes, all you medicine nerds out there, I'm a little slow), but I am also no longer terrified of the defibrillator. The weekend started with basic life support - giving breaths, doing chest compressions, and so forth - and then escalated into the full-on orchestration of a hard-core resus. Over the three days the seven of us on the course were repeatedly given scenarios to act on, and took turns to be team leader, chest compressor, airway manager, drug giver and defibrillator. As we pounded Resus Annie's chest and filled her body with fake medicine we screamed 'Come on people! Push hard and fast!' We also repeatedly failed to scream 'I'm gonna shock, stand clear!' (that old ER favourite), thereby killing about a dozen imaginary bystanders in the process.

You can then imagine, with all this thumping and adrenalin pumping, that when I got home and our elderly neighbour asked my boyfriend if I could come around as she needed some help, I dashed over fully prepared to give her thirty of my best. But instead of lying pulseless on the floor, she was sticking her tongue out at me. 'I was sucking joob joobs earlier, and now my tongue just won't stop bleeding. What do you think I should do?' I inspected the offending appendage and found it to have a small cut at the end. I told her the bleeding would probably stop shortly (for this piece of advice she gave me a whole slab of Beacon Forest Fruit and Nut - yumyum!) and then mooched on home.

Medicine isn't always exciting, but I'm glad that I'm now just a little better equipped to deal with it when it does pick up the pace.

Image from here off the blog From The Outside Looking In

No Fixed Abode

2008-06-12T23:20:00.000+02:00

Call them what you will - vagrants, tramps, beggars, bergies - every town has them, and sooner or later, every one of them will get ill enough for someone out there to actually notice, and they will be brought to hospital. And the rule is, once a person with No Fixed Abode has a foot in the door of a health care facility, it is only with superhuman effort and perserverance that you will get them out again. It's not surprising, really: if you were displaced from a hard, cold sidewalk with a dustbin as your grocery cupboard, to a nice soft hospital bed in which you were served three luke-warm meals a day, you'd probably also do your darndest to remain in that position. Moreover, most doctors do actually have hearts, and I know of none that would cast a homeless person recently ill back onto the street with nothing but a packet of oral antibiotics and a few good wishes.

With the above in mind, then, it stands to reason that we get to know our No Fixed Aboders (NFA) pretty well, and that they tend to stand out in our memories against the thousands of patients who quickly pass through our lives. I have several that I'll never forget: Winston 'belonged' to my friend Iwan when we were students, and like to hoard food. Each morning when Iwan pulled the blankets back he would find his patient cuddled up to a sausage roll or a packet of slap chips. Early last year I had an NFA called Ann who managed to break her leg in a drunken stagger across a road one dark night. A lot less friendly than Winston above, she would meet my daily enquiries after her health with a standard response of 'Fok jou man.' Just this weekend I made aquaintance with a man called Yusuf, who had been scraped off the street by the police after being beaten up. He had a broken arm, but also a nasty pneumonia which earned him a ticket into the medical ward. Smelling of a combination of urine, wet dog and fynbos, he was immediately set upon by a pair of nurses armed with aprons, masks, gloves and a large bowl of hot, soapy water. After stripping him down and sealing his clothes in a plastic bag, they viciously scrubbed his emaciated body from head to toe and then tucked him into bed. By the time we got to him on the post-intake round, all that was left to be seen was a little lollipop-head poking out of a pile of hospital linen. 'Jissus man,' he told us, 'you've got nice blankets in this place hey.'

The question to ask is, how does an NFA happen? Even in this country where millions live below the poverty line, there's no reason for an individual to have no shelter whatsoever, and moreover, to have no friends or family at all. In her book The Glass Castle, Jeanette Walls describes how her parents chose to remain homeless, even when they didn't need to. There may be other people like that out there, but intuitively it seems wrong that the bulk of people out there living this way chose it for themselves.

With regards to Yusuf above, our consultant suggested hunting for signs of schizophrenia or other psychiatric illness, saying that many homeless people suffer from an undiagnosed or poorly managed psych disorder. 'You never know,' he said, 'a handful of haloperidol may be all you need to turn this man's life around.' I remain dubious. A vast number of the patients who arrive in our wards are there due to a combination of a medical problem and a severe social problem. Unfortunately, social issues seem, in many cases, almost impossible to treat.

Picture Credits
Homeless in Sugamo 2
Originally uploaded by the_jim

The Big Oops

2008-06-09T12:44:00.001+02:00

It happens to all South African doctors sooner or later - the accidental pricking of their own flesh with a used needle, the careless splashing of blood onto an open wound or into an eye - followed by the great worry: is the patient I was working on HIV positive?

Recently, it happened to me twice, except I didn't have to wonder whether or not the patients were positive - they were. The first time was probably my fault. It happened while I was frantically trying to get fluids into a tiny baby before she died of one of the developing world's biggest baby-killers: diarrhoea. I was all on my own at the district-level hospital I'm rotating through, and the last time I'd done paediatrics was more than two years ago, as a student. I failed and failed and failed to get a drip up, and the baby was rapidly approaching the point of no return, and so I had to resort to doing something I'd never done or even seen before: insert a big, hard needle into the baby's shin bone so I could could give her fluids directly into her marrow. I don't know when during the whole messy business it happened, but at some point I took my gloves off and got my finger, recently slashed open from some inept butternut-cutting, covered in HIV positive blood. Silly, I know. This was a fairly low-risk injury: the cut was already healing up when I splashed myself, but I decided to start prophylactic ARVs anyway.

Two days later, however, something happened that wasn't my fault and definitely called for ARV prophylaxis. I was drawing blood on a man known with HIV and TB, now sporting a deep vein thrombosis as well. He wasn't confused and he understood what I was doing, but for some reason after I had the needle in his arm he decided to start waving the said limb around in an effort to show me where his veins were. Everything went slow-mo as the needle fell out of his arm, tumbled downwards, and then somehow slipped through one of the tiny holes in my croc to impale itself in my foot. His eyes went wide. 'Oh... Sorry...' he mumbled. I had to go and sit in the doctor's room by myself for a while after that. I told one of the other doctors there about the incident but she just laughed at me - we're far too blunted when it comes to this kind of thing.

I'm halfway through my course of ARVs now: two weeks down and two weeks to go. It hasn't been that bad, although about a week after I started I got flu and I frantically called everyone I knew to see if they thought I was seroconverting. I feel better now though, and I guess I'll just have to keep my fingers crossed and hope for the best.

Picture Credits
Can I take your Blood
Originally uploaded by Şinner Photography Ψ

Some South African Perspective

2008-06-05T17:23:00.000+02:00

During my very long blogging hiatus, I managed to do many things, which I won't go into now, but may tell you about later. What I also did was read many books, two of which were quite medical and quite South African, so I thought I'd tell you about those.

In his new book which addresses, as the title suggests, the HIV epidemic in South Africa, Jonny Steinberg travels to rural Eastern Cape to visit some MSF-run ARV clinics. There he meets Sizwe (outside of South Africa this book is know as Sizwe's Test), a young and successful shop owner in a small village in Lusikisiki. Three-Letter Plague deals very well with many social aspects of the disease that people like me (that is, white, urban doctors) really just don't understand. From the deep tribal and rural superstition that shrouds the way people perceive AIDS and prejudices them against strange western methods and medicines, to the South African government's warped stance on ARVs and the manner in which they should be distributed, to the way rural poverty and disenfranchisement have changed sexual behaviour and family structure, the book touches on the multiple barriers between the average HIV-sufferer and what should be fairly simple treatment. Three-Letter Plague is an eye-opener: even for those who have little or no interest in HIV, it sheds light on a part of our country that few of us understand or even know about, and underscores the gravity of the epidemic in an emotionally restrained and non-sensational fashion.

Karma Suture is told by Rosamund Kendal through Sue Carey, an internal medicine registrar at a busy hospital in Cape Town. This book is a quick and entertaining read, even if it isn't a great work of literature. It is extremely realistic though - reading it was, for me, almost like being at work - I bought it because somebody told me that if my boyfriend read it he'd gain some perspective into my life (although you'd think this blog would do that all by itself. Anyway.) The elements of the story are fairly predictable: Dr Carey is hardworking but over-tired and uninspired, and her personal life is the collateral damage in the battle that is her job. During the course of the novel she re-discovers compassion as a friend of hers is diagnosed with lymphoma and becomes severely ill and she finds herself on the patient's side of things again. She takes stock of her life and realises she needs to look after herself and pay attention to her friends, whom she has been neglecting. The book shows the unglamorous, frustrating and often depressing side of medicine in a way that is simple, human, and often very funny.

What really amazes me is how few doctors seem to read anything other than textbooks, journals or the heating instructions on instant meal packages. Out of all the doctors I asked, only one person had read (or even heard of) any of the above books - an HIV specialist who'd read Three-Letter Plague. Moreover, when I asked people about Karma Suture, most of them misheard me and said 'The Karma Sutra? No Karen, why would I read that?' which leads me to believe that very few doctors are having sex either.

The Candy Store

2007-12-25T14:28:00.000+02:00

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

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

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

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

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

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

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

Fair 'n' Square

2007-11-09T20:13:00.000+02:00

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

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

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

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

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

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

Cartoon by Zapiro

Euphemisms*

2007-11-05T08:42:00.000+02:00

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

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

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

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

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

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

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

There's a knife in my head

2007-10-23T15:28:00.001+02:00

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

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

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

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

'Refreshed'

2007-10-22T18:27:00.000+02:00

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

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

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

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

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

Tunnel Vision

2007-10-01T09:37:00.001+02:00

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

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

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

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

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

Well done, me.

How I spent my Friday night

2007-09-16T18:19:00.000+02:00

Sometimes I really feel like I don't get paid enough for what I do.

It's Friday night, and I'm at work (problem number one: it's Friday night, and I'm at work and everyone else I know is at a braai/pub/party watching South Africa squash England), and I'm seeing a patient who's been moaning 'help me, help me' for the last three hours, trying to work out what his problem is.

It turns out he has several: he's had three previous strokes, and he's extremely spastic on his left side. He also has bladder outlet obstruction, and therefore can't pee, and his suprapubic catheter has fallen out, so he's been backed up for three days. But his most pressing problem, as he informs me, is his bum.

'What's the matter, sir?' I ask him, 'What do you need help with?'
'My bum, my bum,' he moans.
'What about your bum?'
'It's sore' For some reason he then elects to pull my hair.

I notice in his folder that nobody's ever tried to establish why he has outlet obstruction, so I decide to do a rectal on him, as an enlarged prostate might be blocking the pipes. This is where I discover problem number two: a nappy full of poo. The nursing staff is already overbusy, so I decide to take the nappy off and clean him up myself. I do this sort-of ok, and then try to wipe away the one last piece of stool lurking at his anus so I can do my PR. What comes away is a baseball-sized chunk of faeces, followed by a river of overflow diarrhoea (definitely problem number three). Mr Help-Me breathes an immense sigh of relief, while I desperately fight my gag reflex, and deposit the prize in the bin. My concern for the nursing staff's over-business vanished, I inform a nurse that he's soiled the bed and ask her to clean it up (my respect goes out to all nurses out there: you definitely don't get paid enough to do what you do).

After the nurse has cleaned up, I go back to Mr Help-Me. I notice he's still leaking a bit PR, but feel his prostate anyway (ten points to Karen for thoroughness). I then prepare to put his suprapubic back in: a suprapubic catheter involves boring a hole through the skin, muscle and bladder above the pubic bone. It's pretty painful, but the patients you perform this procedure on can usually be counted on to thank you profusely afterwards, as they've usually got two or three days worth of urine stuck inside.

Mr Help-Me, however, does not thank me at all. He instead smacks me repeatedly over the ear with his good arm (problem number four), yelling 'Eina! Jou moer man! Fok, jou donder! Bliksem!' (I'm sorry, there is no english translation for this kind of cussing) for the duration of the procedure. After the catheter's in, and his urine's streaming out, I ask him if he feels a bit better. He looks at me blankly. 'My bum is sore,' he says. I decide to go check out the next patient.

I hope you all had a good weekend - don't forget to check out Surgexperiences 104, a surgical blog carnival, hosted by Bongi over on Other Things Amanzi this week.

Drama Queen

2007-09-13T16:11:00.001+02:00

A few months into my surgery rotation, I reached a point where I could confidently do small procedures by myself. Uterine curettage, drainage of a variety of abcesses, washouts of compound fractures: these were all things I could do without supervision, things that the registrars in my department were happy to leave me alone with. I was also happy to do them, because I hoped that for every fifty uterusses I scraped out, and every hundred bums I decompressed, I'd be allowed to do something a little more interesting: remove an appendix perhaps, or suture a small hole in some bowel.

That's why, one Thursday night, at about eleven, I told my registrar he could could go to bed while I cleared up the rest of the list. It was full of the kind of cases that give these kinds of lists their special name around here: poes and pus. Yes, I know that's disgusting. And yes it's true, doctors are more foul-mouthed than the bartenders at your local drinking hole when you're not around to hear them.

I did a few evacs, I drained a breast abcess, and at about 1am I drained a Bartholin's abcess. A Bartholin's is a tiny but exquisitely uncomfortable thing that will only affect you if you're unlucky enough to be female: it's an abcess that grows from the Bartholin's glands on the vulva. It's a small thing, and we see two or three of them a week here. I drained and marsupialised this one without too much ado, and went to bed.

At six, I got up to do my morning round, and went to check on my patient's wound, hoping I could discharge her at the same time. Imagine then my dismay when I took off her bandage and removed the gauze plug I'd placed a few hours earlier, and she started hosing blood all over the bed. In retrospect, she wasn't hosing at all, and had in fact only sprung a minor leak, but I was still young and fresh and often had difficulty judging the severity of a given situation. As I squizzed closer at the drained abcess in the bleak ward light (the majority of the lightbulbs have been stolen - This Is Africa), I could just make out the steady blink of an arterial bleed.

Now, fellow doctors, students and laypeople, what's the first thing you do when you see something bleeding? That's right - you put pressure on it. That's not what I did. I panicked. The first thing I saw when I saw that blood was my registrar's livid face as I told him I'd managed to exsanguinate a patient via her labia minora. The second thing I saw was the clips and ties we use to tie off bleeders in theatre. I rushed to casualties for a suture pack and ties. I rushed back to my patient, to find she'd managed to soak an entire linen saver and sheet with her blood. I felt cold sweat running down my back as I groped blindly with my artery forceps in the tiny hole on her vulva (really tiny - about half a centimetre across), my patient yelling and cursing me as I failed repeatedly to catch the bleeder. Eventually conceding defeat, I took a deep breath and called my registrar.

'Yes?' he mumbled.

'Uh... remember that Bartholin's I drained last night?'

'Not really...'

'Well, I just took off her bandage, and she's hosing all over the bed.'

'Have you tried compressing it?'

'Um...'

'Oh, for God's sake Karen , there are no vessels down there important enough to have a name. Just stick another gauze down there and push on it while you count to three hundred. Stop being such a damn drama queen.'

I did as he said, and sure enough, when I lifted my hand after silently whispering 'three hundred' in my head, the bleeding had stopped. The patient's nightie and sheets and blankets were soaked in blood, but she just looked at me and pouted. 'Can I go home now?'

FIFO

2007-09-03T14:45:00.000+02:00

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

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

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

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

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

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

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

Confusion query cause

2007-09-02T21:41:00.000+02:00

Apart from 'haemopneumoTx' and 'HIV/TB', the acronym that appears most frequently in the casualty officers' book of patients-to-see is 'Confusion ?cause'

The inexplicably confused patient, most often brought in by a distressed and exhausted relative, usually falls into one of two groups: really old, or fairly young. In the really old confused patient, it's usually petty easy to clarify the cause: a quick squiz at their urine under the microscope in the lab will often reveal the white blood cells that confirm a urinary tract infection (an annoying burn to those of us still young and fit, but enough to briefly turn your brain into chocolate mousse if you're on the unforgiving side of eighty), or a quick neurological exam will demonstrate a unilateral weakness in keeping with a recent cerebrovascular accident.

In the fairly young patient, however, it's not so easy to turn '?cause' into an official diagnosis. In most cases, we can make a good case for the diagnosis based on a general exam: oral candida, temporal wasting and generalised lymphadenopathy are the holy trinity of signs that convert into the words 'HIV suspicious' on paper, and the vast majority of young patients who arrive at the hospital in a state of confusion have those three signs on presentation. It is then up to us to try to figure out what superadded insult to their already hopeless immune system caused their sudden deterioration, an investigation that involves scanning their brains, X-raying their chests and harvesting every type of fluid we can from their bodies - blood, cerebrospinal fluid, urine, sputum, and sometimes even stool - in the hope of finding an organism or a bacillus or one of the little clues they leave in their wake, so that we can know which antibiotic, antifungal or antiviral agent to fight back with. In many cases a microbiological diagnosis evades us completely, and it is only when we get the patient to ultrasound a week after admission which shows us what we knew would be there already: splenic microabscesses, generalised intra-abdominal lymphadenopathy and pericardial effusions - all features in keeping with disseminated tuberculosis - that we can finally make an official diagnosis and move on.

But it is not only through TB that HIV can addle the human brain. The retrovirus seems to have endless tricks up it sleeve, all designed to render grown men helpless, crying wrecks, and adult women paranoid, hysterical banshees. From central nervous infections caused by fungi, mycobacteria, bacteria, virusses or parasites, to strokes caused by vasculitis, to plain old hypoxia caused by monster chest infections, to the eternally frustrating and hopeless diagnosis of 'HIV encephalopathy', there seems to be an endless number of diagnoses to hunt down and insert in place of that old question mark.

Fortunately, the confused patients often get better. They generally cause much grief and/or amusement before doing so: just last week I started laughing inappropriately at the sight of a colleague sprinting down a corridor after a patient, waving a handful of TB tablets and vitamins and screaming 'But it's just medicine! It will make you better!' For what felt like several weeks the back row of the ward housed a patient who sang hallelujah in an operatic voice all day, pausing only to eat (she was encouraged in this endeavor by a group of well-meaning Jehovah's Witnesses who were handing out free Bibles: 'That's beatiful my dear, just lovely,' they crooned, as her hymn amplified in volume to drown out the loudspeakers overhead). Usually, a few days of TB meds with a bit of antibiotic cover is enough to get these people cooperative and oriented again.

But many of the 'confused' patients don't get better, and in those cases, I don't think confusion is quite the right word to describe their state. Sure, they can't remember their own name, let alone what day of the week it is, but their delirium is far too sinister to share the name of the feeling we get when we turn down an unfamiliar street in a new city. Those patients have brains that seem to have shut down completely, and whose bodies have simply not yet caught up. No amount of face-mask oxygen, IV fluid and antibiotics or anti-tuberculous medication is going to allow these people to re-orientate, and despite the fact that we really do our best, we're often called to the ward a day or two after their arrival to confirm their absence of pulse or respiratory efforts, and to then quietly pull a sheet up over their heads before calling their familes.

The Zoo

2007-07-08T14:06:00.000+02:00

Once upon a time, not so very long ago, a bunch of bureaucrats who preferred to call themselves 'humanitarians' created something called 'The Mental Health Care Act'. Designed to protect the human rights of potential 'Mental Health Care Users' (more commonly known as psychiatric patients), the MHCA consists of a series of laws and regulations concerning the admission, treatment and discharge of such patients. One of the regulations was that of the so-called '72 hour observation period', which declared that should someone require involuntary admission to a psychiatric hospital, they must first undergo a three day period of observation and evaluation at a health establishment other than the psychiatric hospital they would ultimately be admitted to.

Where I work, a 72 hour observation service is provided. Now, I imagine that when the Humanitarians, sitting in their air-conditioned boardroom with a giant window overlooking some beautiful city thought of the 72 hour observation period, they imagined a nice big ward with lots of soft comfortable beds for the acutely psychotic to snooze in, staffed with scores of dedicated nurses and doctors diligently interviewing and observing patients all day. What I'm sure they didn't picture in their rose-tinted minds' eyes was what really happens.

In my hospital, we only have four wards, and these are filled to capacity with surgical and medical patients. Casualties holds another hundred patients at any given time, creating a situation where the hospital is virtually always running at approximately a hundred and fifty percent of capacity. In this casualties is a small room know as 'The Green Room' – once used for minor procedures, the green room now holds two beds, dedicated to psychiatric patients. This is a problem, because there are usually between seven and twelve patients under observation, so what generally happens is that the recently sedated get the beds whilst the rest of the patients roam around casualties begging for cigarettes, flashing their genitals at little old ladies with hernias, and trying to use the phones. Sometimes particularly violent patients are locked into the green room by themselves, and I've seen one break a hole through the door with his fists in an attempt to get out.

Some of the patients are common-or-garden schizophrenics or bipolars, but most of them suffer from a disease I like to call TMT – Too Much Tik* - and are (if you'll forgive my completely un-PC term here) completely bonkers. They tend to be strong males in their late teens or early twenties, they're acutely psychotic and aggressive, and they're dangerous.

Doing my post-intake ward round yesterday morning in casualties was like trying to do a ward round in a zoo. While I was trying to demonstrate the neurological fallout of one of my patients to my consultant, a young man wearing nothing but a brown hoodie jumped onto the doctors' desk and started screaming hysterically. The casualty staff tried to wrestle him down but what ensued was a mad struggle involving nurses, security guards and doctors, and one bare-butted patient crawling under trolleys and over scared gomers. At the same time, one of the 'recently sedated' managed to break the supposedly indestructible window separating the green room from the rest of casualties, and started smacking other patients in the area whilst demanding cigarettes. The man already had more than triple the normal dose of Valium in him but was still kicking, prompting the head nurse to turn to my consultant and say 'Listen here, the drugs isn't right' – we'd apparently been sent a batch of dud sedatives.

On my way out of casualties, I looked into the green room through the gaping hole that used to contain the window. Lying on the beds were two men, their hands tied to the bars of the cots. Around the door, sitting on chairs in their blue hospital gowns, were a few more psych patients, some of them rocking themselves and crying. Our hospital isn't equipped to deal with people suffering from acute mental illness, but because of some government legislation, must. It's not fair to us, it's not fair to non-psych patients, and it really isn't fair to psych patients. In creating their special human-rights protecting law, the Humanitarians have created a situation where human rights are abused more frequently and more severely than in any psychiatric hospital in this country. But they probably don't know that, because they stay in their air-conditioned boardrooms, and go home in their air-conditioned cars, and when they get sick they go to air-conditioned private hospitals that don't offer 72 hour observation services. Like with so many other things in our health care system, I wish I could pull the policy-makers by the hand and show them what's really happening, and ask them what they're going to do about it. But that will probably never happen.

*Tik is a form of methamphetamine

New Rotation, New Post

2007-07-05T18:39:00.000+02:00

I'll admit it: I've become a bad blogger. Worse even than the type who just never posts, I am the type who goes as far as promising to post, and then still doesn't. I'm sorry. Anyway, in honour of the fact that I started a new rotation this week, I thought I'd attempt to restart my blog (again). This time, however, there will be no promises of scores of posts - just a warning that although there's a post today, there might not be another for the next month. I'll do my best though.

So, the new rotation: Internal Medicine. I realised a long time ago that I'm not on the medical side of the blood-brain barrier: I never feel compelled to listen to a heart for half an hour to discover whether the 'pssssht' falls after the 'lub' or the 'dub', I don't really think the full-blood count is the best thing since sliced bread, I loathe sputum above all other bodily secretions, and I really do believe that an operation is the solution to many problems. Over and above that, the medicine practiced in district and secondary level institutions in this country is utterly depressing. The vast majority of the patient load consists of patients so loaded with HIV that almost every organ system is infested with opportunistic viruses, bacteria, fungi and other organisms. The patient population of the medical wards is so dismal, in fact, that it makes me long for the gomers of surgery: little old ladies with gangrenous toes and sweaty middle-aged men with chronic pancreatitis. Whilst these patients may lurk in the ward for weeks on end, and may come back over and over again, there's something infinitely sadder about the wasted figure of a twenty-five year old being fed through a nasogastric tube, who is most certainly young enough to die*.

But the thing that really got me down about medicine this week was not the patients, but the way I felt exactly like I did at the beginning of the year. Back then though, I took solace in the fact that I was just taking a bit of strain in my very first week as a doctor. Now, I just feel dumb and disorganised. After six months in surgery I knew what to do with most of the problems I was faced with on a daily basis, whereas now I found myself floundering in a pool of uncertainty. Last week I could organise a referral for an ERCP without thinking, now I'm trying to figure out the complex etiquett involved in organising a cardiac echo. Instead of draining abcesses whilst chatting to my anaesthetic friends about what I did over the weekend, I'm sweating over a lumbar puncture and desperately praying that somebody walks past so that I can ask for help. Instead of opening bandages and finally being able to tell whether or not a wound is clean, I'm slapping patients on the back all day in a desperate effort to get them to cough up decent sputum.

I know in a few weeks it'll all be second nature to me - today is already better than Monday was. This week was just a bit stressful and more than a little demoralising. Tomorrow's the first call, and i'm praying for a quiet one. Keep your fingers crossed.

*I see that Wikipedia has twisted the true definition of a gomer somewhat: what is important to remember is that the first Law of The House of God is that GOMERS DON'T DIE

The Great Unknown

2007-06-06T16:46:00.000+02:00

In his book, The Dressing Station, Jonathan Kaplan says,

'All doctors have their ghosts...

For all of us - even the most dedicated and skilled - the dead pile up, the results of clinical decisions swayed by fatigue or hubris or blind bad luck.'

I remember I had this book in my hand at a paediatrics tutorial once, and the doctor taking the tutorial took it from me and read the back. She wrinkled her nose and said, 'I don't have any ghosts. That's because I know that for every child who died under my care I did the best I could, and when I think about their cases afterwards I know I wouldn't have done anything differently.' It's nice for her that she had such confidence in herself, but I suspect that the vast majority of doctors don't share this same self assuredness: I certainly don't. At this point in time, almost six months into my internship, a number of patients have died whilst being partially under my care, and whilst there were some I knew we could do nothing for, and others for whom it was much better to just give analgesia to while they quietly left us, there are a few where I have to wonder: could we have done something more, if we'd just known we should have?

On Monday night I had a bad call. It was the kind of call that is beset from the outset by a plague of annoyances: restless patients, complicated inter-hospital transfers, piles of lost drips and misplaced X-rays,and striking hospital staff. But the thing that made the call really lousy was that I was involved in three resusses, and all three of those patients died.

The first death was not one we could have prevented: a young man, stabbed into the right ventricle, pulseless and cold and dead on arrival. Resus was initiated but called off quickly: for some, there is absolutely no chance.

The second death was that of a fifty-four year old woman who was perhaps let down by the system more than the doctors who attempted to save her: when she was rolled into casualties she was awake and talking, but arrested minutes after arrival. After a twenty minute resus she was declared dead, and although it was a good resus, I think it was far too little too late - perhaps if the ambulance had responded to her call quicker, or a doctor had been around earlier to see her before she arrested, she would have made it. But we can't really know.

The final patient to pass away was a forty year old male who came in late in the night with an upper gastro-intestinal bleed. He came in shocked and unresponsive, but responded well to fluids. When we put in a nasogastric tube, he immediately drained a litre of blood. He was horribly acidotic and hypoxic. We ordered blood for him and called the surgical unit at the tertiary hospital down the road: the registrar on call told us she couldn't accept the patient in such an unstable state. She told my registrar that if the patient had an acute abdomen he should call the consultant and take him to theatre, but the patient's tummy was soft, so my registrar didn't do this, and decided to reasses the patient in two hours. Early in the morning, I got out of my warm bed to do the said reassessment. Although the patient had drained another half a litre of blood, he was no longer acidotic and had a decent blood pressure. Blood products had just been started. While I was doing cardiac compressions on patient number two he informed the nurse that he was hungry and wanted some food. I left him in the resus area, my plan being to come back in two hours to reasses him. An hour later the casualty officer called me to tell me he'd vomited up the equivalent of all the blood we'd given him, and that they were going to intubate. I got to casualties a short while later and he was dead.

In this case I have to wonder, did we do our best? When my reg called the reg over at the tertiary hospital, she told him he should've taken the patient to theatre. Our consultants said the tertiary hospital should have accepted the patient earlier. My reg asked me with doubt in his voice whether the patient really was as stable as I'd said he was earlier. We all looked at each other and all tried to find a way to tell ourselves we'd tried our hardest and were let down by something other than ourselves, and we all felt the heavy weight of the things we just didn't know: the reg at the tertiary hospital didn't know that she had to accept that patient, my reg didn't know that the patient was so sick that he should've been opened up, and I didn't know that a small increase in pH and blood pressure and a patient asking for food didn't compensate for an actively bleeding gastric lesion.

When I was in orthopaedics a few months ago, one final-year reg said to me, 'The worst thing about being an intern is that you just never know. That feeling doesn't get better. I know more now, but I also know that there's more I don't know about. I still look at all sorts of things every day and think "I just don't know".'

For me, that's the hardest thing about being a doctor: the great unknown, and the knowledge that I'm standing right in the middle of it, and that even as I'm trying to see through the fog and the black holes in my brain, people are dying all around me. I hope, in spite of what that orthopaedic reg said, that it does get better, and that the ghosts accumulate at less of a pace as I move along.

This Blogger is Back

2007-06-05T10:45:00.000+02:00

Yes, I know. It's been an inexcusably long time. But I am back now. I finally have internet in my home, and will hopefully be posting with a vengeance from now on.

Watch this space.

Ew

2007-04-05T10:04:00.000+02:00

(This post is not for the faint-hearted or easily-offended)

People are often telling me that they could never do medicine. They cite many reasons, but the one that comes up most commonly is that it's 'just too gross'. It amazes me just how truly squeamish people can be: I have a father and an uncle who need to breathe into a brown paper bag at the mention of something so mild as a skin incision, a boyfriend who shudders in disgust if I so much as breathe the word 'pus' near him, and a brother who becomes indignantly repulsed if if he has to witness any scenes from Extreme Makeover, no matter how brief. I always tell people that they would be able to deal with these things if they were introduced to them gradually, as is done over the course of a medical degree. We make acquaintance with the various nasties of the human body at a pace that is gentle and unjarring - we're not just tossed into a vat of diarrhoea and amniotic fluid at the beginning of first year and then told to deal deal with it.

That being said, we're not immune to unpleasant things, and although we certainly don't enjoy being up very close and personal with something that smells, looks and feels hideous, we love talking about it afterwards. There are protracted discussions in the tea room on a daily to weekly basis that revolve around the most revolting things we've ever seen.

Currently doing the rounds is a story about something that was seen a few weeks ago. Patients at the hospital I work at are first seen by a casualty officer, who then decides if they're going to medicine, surgery, or home. Once the decision has been made to send them to surgery, the casualty officer writes the patient's name in a big book on our desk, and alongside that the presenting complaint. Now, I could blab on for hours about how truly unglamorous medicine is (contrary to popular TV-series belief), but I knew we'd hit a new low in the anti-glamour stakes the day a casualty officer wrote in our book: 'Mrs X; Maggots in Anus'. What awaited the surgeon-on-call was an elderly lady with advanced rectal carcinoma. The tumour had grown so large that it was protruding from her anus, and sure enough, there were several small, shiny maggots crawling about in its necrotic centre. (This particular case begs our favourite question here in this country: 'Why did you wait so long?')

Another nasty that we're exposed to on a daily basis at the hospital that I work at is diabetic foot. Now, dear readers, I know that many of you hail from civilised places like America and Europe, where the term 'diabetic foot' refers to a bit of a fungal infection between the toes, or a small ulcer or two. But, as Leonardo DiCaprio recently said, 'TIA, baby', and in Africa we mostly don't have to choose between antibiotics and minor debridement, but between below- and above-knee amputation. My first exposure to diabetic foot on the African scale was as a fourth year student, when I was required to hold the leg up while the scrub sister cleaned it in preparation for surgery. I'm short. The foot came very close to my face. Everything went fuzzy for a moment, and I had flashbacks to the time I went on holiday with my family for two weeks, and the electricity cut out back home, and we came back to a freezer full of rotten meat. The distinctive smell of a diabetic foot fills up any room quite quickly, and if you know it, you know that if you follow your nose you'll happen upon some dejected looking individual hunched up in a wheelchair, with one foot wrapped messily in a long bandage which is soggy and black with necrotic ooze. (It's not uncommon to find maggots underneath these bandages, either.)

And for those of you still with me: one last paragraph of yuk. If I thought I'd hit rock-bottom when I saw anal maggots, my friend Iwan felt he was there a few weeks ago after he had to spend the day with a rectangular stain made up of blood, mucous and genital wart-juice on the front of his shirt - placed there by a patient who had slapped him on the belly with her sanitary pad (it was apparently an accident, but still...). 'Foul-smelling vaginal discharge' is the presenting complaint of thousands and thousands of South African women every day, and it is usually caused by either pelvic inflammatory disease, or by foreign bodies in the vagina - another favourite tea-time topic. People put weird things up there. As a student I once saw an old lady whose family brought her in when they just couldn't take the smell anymore. We found a bottle of paracetemol wedged up near her cervix. A gynae once told me about the finger of a latex glove he extracted from someone's posterior fornix: whether it was left there by a careless doctor or someone who was trying to use it as a condom-substitute is a mystery to this day. A friend of Iwan's recently saw a woman who had for several weeks been trying to manage her discharge on her own. The son of a cardiothoracic surgeon, I imagine this friend had been exposed to human innards at an early age, and is actually quite strong of stomach, but when he inserted his speculum and started pulling out wads of soggy, green, stinky tissue from the patient's vaginal canal, he just couldn't take it anymore: he turned and vomited into the basin behind him.

I could go on forever: the smelly abcesses, the fallen-off penises, the bum troubles, the tum troubles. But I think you get the idea. What's the most horrid thing you've ever seen?

More on the Mandible

2007-03-10T16:24:00.000+02:00

You may remember that in my post Violence Against Women, I mentioned one woman who had a fractured jaw after being kicked in the face two weeks previously.

The case bugged me for a few reasons. The first was that I almost missed the fracture. In order for a patient to get seen by the surgical team at a regional hospital in this country, they need to go through quite a few levels: first they're seen by a GP, or at a clinic, from where they're referred to the casualties unit at a hospital the next level up. In our case, we are the next level up (there's no district hospital in our area). After being seen by the casualty officer, they are then referred to surgery. By the time I see the patient, they have two or three referral letters in their folder. I almost always only read the one written by the casualty officer. In this case, the casualty officer suggested that the patient had a jaw abscess due to poor oral hygiene. After questioning the patient (who could barely speak english) all I could establish was that her jaw was hurting, and had been doing so for two weeks. I reached the same conclusion as the casualty officer, and booked the patient for incision and drainage in theatre. It was only while I was writing up her prescription chart that I idly glanced at the original referral letter from the clinic she'd first been seen at, that I saw she'd been kicked in the face. I went back to the patient, and mimicked someone punching her, and she nodded, pointing at my feet. I immediately sent her for jaw x-rays, and felt an absolute chill run through my body as I saw the two large floating segments of jaw - a major fracture I'd almost missed completely because of the fact that I hadn't taken a proper history.

The second bothersome issue in this case is the issue of the actual crime itself: who kicks a woman so hard in the face that her jaw cracks in three places? A few men had robbed of her purse and cell phone, but she was a small woman: even a lone man could easily have taken these things from her without causing her much physical harm at all. Crime is bad by itself, but why must the crime in this country always be so excessively violent?

And finally, and perhaps the thing that bothers me the most, is what does it say about the public health service in this country that a patient would rather walk around with a broken jaw for two weeks than go to a doctor? The woman could barely talk, and chewing must have been nightmarish, but she still chose to stick with the pain until it became unbearable before coming to hospital. We often complain about the way patients delay their presentations to health care sites so extensively: all South African doctors have a story about the patient who left a tumour to grow so long that it was the size of a soccer ball by the time they came in, about the patients who walk on ankle fractures for weeks before asking for help, about the thousands of patients who allow themselves to waste away to nothing before looking for answers. These patients are endlessly frustrating and hopelessly demotivating, and most often the blame is placed on the patient for being apathetic and disinterested in his or her own health. But we have to ask: what does this apathy and disinterest say about us as doctors, and the system within which we work? In the olden days, people were scared to go to hospital because people believed they were houses of death. Is it possible that we haven't made any progress since those days, and that the general public is still terrified of us and the institutions we staff?

We thought it was funny

2007-03-03T14:02:00.000+02:00

A friend of mine at the hospital has had a formal complaint laid against him. He's a medical officer in surgery, and the whole thing went like this:

He was walking down the passage, and a nurse from one of the administrative departments stopped and asked 'Dr P, do you know in which bed patient so-and-so is lying?'
In response, Dr P said 'Sister, I don't like to name the animals because then it doesn't feel right when I eat them.'

In her complaint, the nurse said she found Dr P racist and insensitive.

What do you think? I know Dr P quite well, and although he can be quite insensitive, he's definitely not racist. He was trying to make a joke. Do you think it was funny? Not funny? Extremely unfunny? Let me know... (poll in the sidebar)

Have you ever...

2007-02-27T16:48:00.000+02:00

...gone out with a group of medical people, and as the only non-medical person there, spent the evening bored out of your mind?

I imagine that this is something that happens often to those 'civilians' blessed with a friend or partner or relative who is in the field of health care. They get invited out for drinks with their doctor boyfriend/girlfriend/friend and then spend the evening sidelined to a corner of the table, beer in hand, praying that the conversation about the grossest gangrenous foot ever seen is going to end soon. It's something I'm conscious of: I live with non-medical people, and my boyfriend is non-medical, and whenevr I take those people out with my 'doctor' friends, I'm acutely aware of the amount of time we spend having conversations that non-doctors can't take part in, or having conversations that put non-doctors completely off their nice fresh sushi.

I feel bad about it, but at the same time argue that any people who belong to a group will have conversations dominated by matters that are unique to the group: accountants will always talk about money, geneticists about chromosomes, farmers about cows, models about clothes, artists about who's doing whom, and so forth. Is it really any different when medical people want to talk exclusively about medicine? My boyfriend is of the opinion that it is slightly different: whilst money may be a bit snooze-worthy and clothes a bit dull, at least most 'ordinary' people can follow the conversation. And nobody ever vomits in the middle of it.

The thing about medicine is that it's hard not to talk about it when you're around other people who do it (or even people who don't). It fills up such a vast quantity of your life, in both the amount of time it takes up and in the amount of emotional, physical and intellectual resources it requires, that it's hard not to let it overflow into other parts of your life: your dreams, your reading material, your conversation. In the survey I did of all the doctors in the theatre tea-room at one time, most doctors marry other doctors - probably because they meet their spouses-to-be at university or work, where they're surrounded by other medics - but many of them say that they couldn't marry a non-medic, because people who aren't doctors 'just don't understand' or 'aren't interested'. And when you're doing something that you need to talk about all the time, you need someone around who's going to listen.

I'm lucky in that I've got someone who has always been very understanding of my hours and the time I need to study, and of my need to work in a place and environment that makes me happy. But sometimes I feel like maybe I can't talk about work quite as much as I'd like, and that sometimes he maybe sighs inwardly at the thought of having to spend a few hours with only my medical friends. But yesterday, while I was chatting to him on the phone, he told me that he often reads my blog, and that he finds it really, really interesting. I was so happy - he's said nicer things to me, but at the time it felt like he'd never said anything so sweet before. Thank you! :-*

Violence Against Women

2007-02-24T09:30:00.000+02:00

Yesterday and last night, over one twenty-four hour stretch I saw:

One

A twenty-four year old woman who had been kicked in the abdomen by her lover. She was taken to theatre for laparotomy due to an acute abdomen - a small duodenal tear was found.

Two

A fifty year old female who had been stabbed in the right flank by her husband. She was also taken to theatre due to her acute abdomen - two perforations of the ascending colon were found.

Three

A twenty-five year old female who had been robbed twelve days ago. The muggers had kicked her in the jaw and she presented with left sided facial swelling, an abcess over the left mandible and difficulty chewing. X-ray showed a mandible with a floating segment - it had been fractured in three places. She was referred to maxillo-facial surgery at a tertiary hospital.

Four

A fifty-four year old female who had been shot through the right breast by unknown assailants. The gunshot wound was through-and-through, leaving only a bullet tract and haematoma in the breast. She was discharged on analgesia.

Five

A thirty-two year old female who had been stabbed in the back by the father of her child (not her current partner). She developed a right-sided haemopneumothorax and an intercostal drain was inserted.

(Victims of sexual assault are seen at a separate, dedicated crisis centre)

The Frozen Finger

2007-02-22T17:35:00.000+02:00

About once a week I see a patient with grade four haemarrhoids. It's easy to spot them: they're the ones trying hard to perch themselves on only one buttock while they wait to get seen by the doctor. Grade four haemorrhoids are the ones that have prolapsed (come out of the anus) and can't for love or money be pushed back. Apparently they hurt like hell.

This is not a post about how they're supposed to be treated, or how they can be avoided. This is a post about how I was taught to deal with them at our very busy and over-full hospital, where only the most urgent cases can be attended to properly. I was taught this by a medical officer I work with and in whom I have great faith.

The lesson came while I was dealing with a classical grade four haemarrhoid: the patient curled himself into the fetal position on my examination table and presented me with a little pink cushion sticking out of his bum. I touched it and he winced, I tried to push it back in and he screamed. I called the medical officer in the hopes that for once and for all he could give me the answer to the problem of piles. What he did was this:

He took a latex gove and filled it with water. He compressed four of the glove fingers and then tied a knot, leaving one water-filled finger sticking out. 'This,' he said to the patient, 'is going to become your new best friend. You make a few of these, and then you stick them in the freezer. When they're nice and frozen, you cover one in KY Jelley. Then you take it, and shove it up your arsehole.'*

In the corner of the examining room, I giggled hysterically. The patient himself giggled hysterically, and then asked for more gloves and a few sachets of KY. I added some stool softeners to his goody-bag and wished him luck.

Apparently it works: a week later I saw the patient again and he couldn't stop telling me how much better he felt.

*For those of you who understand Afrikaans: The MO actually said 'Jy vat hierdie ding en jy slat dit in jou poephol in.' I wonder if I'll ever talk to a patient like that? Luckily it went down well.

A Culture of Violence

2007-02-21T17:21:00.000+02:00

When I post so little, it's very difficult for me to decide what exactly to write about when I do actually get to the internet. There are things that happen every day that I feel like talking about, but as time accumulates and I don't get any of my stories onto my blog, I tend to forget about them and they seem to lose their importance.

Anyway, here's something that happened a few weeks ago that still sticks with me:

At about 15:45 on a Thursday afternoon, I was trundling away in casualties, just getting really excited about going home. Suddenly there was a bundle of action in resus, and one of the casualty officers yelled out to me to call my registrar: there was another stab heart. I ran to theatre in my sandals, past the nurses in the tea-room who scowled at my un-theatre-shoed feet, and pushed open the door of the operating room, where two registrars were busy with an amputation, and jumbled out a pile of words that included 'stab heart' and 'front-room thoracotomy'.

A front room thoracotomy is something I never saw as a student (I never saw any thoracotomies as a student, actually), but basically involves opening up a patient's chest in casualties to try and close a hole in the heart. It's an uber-emergency procedure, one meant only for those who are unlikely to survive the next few minutes unless something exceptionally dramatic is done. It has an extremely low survival rate: only one in a hundred make it. The last successful one that happened in the hospital I work at has become a story of mythical proportions, the registrar who performed it a cult hero in the minds of all the staff who spend their days and nights in the hospital's emergency unit.

On this particular Thursday, at 15:45, both of the hospital's theatres were occupied with procedures that could not be abandoned quickly, and in casualties there was a nineteen year old boy pumping litres of blood into his chest from a hole in his heart. A front-room thoracotomy was indicated, and done. What followed was a series of unfortunate events - from a thoracotomy set with no rib-retractors or cardiac staples, to a pile of medical officers who were wearing no goggles and were the unlucky recipients of heavy blood splashes in their eyes. After temporarily stopping the bleeding with a foley's catheter and his finger, the registrar wheeled the patient into the theatre complex, where a rather startled, brand-new amputee was speedily wheeled out. Inside theatre a series of staples were whacked across the two centimetre laceration in the boy's right ventricle. The bleeding stopped, but it didn't matter. He was dead. I gave a needle and syringe to the registrar so he could draw blood to test for HIV in case all the splashees needed post-exposure prophylaxis, and he pushed it straight into the slowly twitching heart.

Afterwards the registrar had the sad task of telling the boy's mother and sisters what had happened. I wasn't there, but the registrar relayed the story to me afterwards:

The boy's mom had been tearful, but not hysterical. She told the doctor she knew her son would die that day: two days previously, a number of gang members had presented themselves to all the residents on a little street in the area. They told the six or so families there that one of their members had been stabbed earlier in the week, and that they would have their vengeance. Although the children living in that street were not gang members, one of them would be stabbed to death that day or the next. That night, and the following morning, the mother prayed with her son. She spent the whole day with him, taking him grocery shopping and cooking lunch with him. At 15:15, she ran herself a bath, and climbed in to wash quickly. While there, a group of gang members entered her house, grabbed her son, took him out onto the street, and stabbed him in the heart. About fifteen minutes later he lay on one of our hospital stretchers, crystalloid-diluted emergency blood pouring from his chest onto the theatre floor.

The culture of violence in this country has gone beyond disturbing - it's become animalistic. What hope is there for a place where stabbings are as ritualistic as turkey at Christmas is in other places, and where murder is considered the most logical form of justice? How can we hope to progress when there are thousands out there who believe that bloodshed is a way of life?