It's just flu.

I knew this would happen....

I knew when I heard it on the radio on Monday afternoon.

I knew it when I saw it on the street poles on Tuesday...

It was confirmed on Wednesday when the queue started outside Med Reg*

Pandemonium has erupted in the Cape as a result of that one unfortunate Stellenboshie. Suddenly Flu is not just flu...suddenly it is akin to having Ebola, or meningitis. Consequently, not only did we not get our raise, but now we are working twice as hard because some chop (who has a 9-5 journalist job) put it on the front page of the newspaper that if you have a common cold you are going to die.

And the people started coming...because lets face it; it's winter in Cape Town.

I know we all get it, some of us twice a year, so it's perfectly normal that one would want to panic. It does feel a bit unavoidable doesn't it?

Come now...it's just flu! I know you pretend like this never happens ever, but believe it not, last year before Swine flu arrived people died of flu...and the year before that and the year before that.

Whether you get the H1N1 variant or the H1N2, or A2E3 varient, it still feels the same.

Your body hurts, your nose is runny, your throat is sore, you get a temperature, you get a headache, you cough and splutter and just feel crap.

Lets just fastforward through a lot of explaining and take you from first year medical school to final exam in two sentences.

Influenza's aetiology is a VIRUS...there is no cure. The treatment is supportive....

That means if you feel so sick that you come and see a doctor, a fairly decent one will listen to your symptoms, take your temperature, listen to your lungs and make sure that you are not turning blue, stick an ice-cream stick with no ice-cream on it down your throat and poke around in your ears. Then he will tell you you probably have flu and that you should be at home, in bed, with orange juice and hot chocolate. To make you feel like you didn't waste your time he will give you some fancy panado/myprodol and a sweety for your throat and a sick note probably.

If you happen to be turning blue, or your heart is running a marathon he will put you in a hospital and do a few more tests, just to confirm that you are not fighting off a really dangerous bug that he can actually do something about with antibiotics, and maybe give you some expensive oxygen and a pretty little drip.

Because you belong do Discovery, he will send away some of your 'mucous' and do an influenza/H1N1 PCR. This costs about R750 (about the same amount as 2 months of ARV's) and because it's quite a complicated biochemical process will take at the very least 3 days to get a result back (by which stage you'll be feeling semi-human or you'll be dead).

Ag...I suppose the people that I really want to be telling this to are the 15 people still sitting on the benches at med reg. The one's whose kiddies are running around and tearing the place down but who happen to have a bit of a runny nose.

Number 1. Someone will probably only see you at 3am tomorrow morning.

Number 2. If your kid really has swine flu...he's not going to die from it.

It's just flu.

*Med Reg is basically the 24 hour medical 'emergency' service that operates at Red Cross Childrens Hospital...yes, because a runny nose is a 'medical emergency'.

Sparkle Pager Ruse

We call it a bleep.
I don’t know why…well actually…it bleeps…therefore it is a bleep. But it is a bit of an arbitrary name.
On Greys they call it a pager… (Which if you think about it is an even more arbitrary name). A pager is an upgrade however.
Pagers are standard issue with each pair of designer scrubs (in the real world scrubs are the least attractive item of clothing you will ever wear). They never sound annoying, if anything they sound ‘cool’, much like the letters D and R in front of your surname. And pagers can convey large volumes of information with a single ‘bleep’… exactly where you need to be, which patient you need to be seeing, their temperature, pulse rate and oxygen saturation!

Bleeps are a little bit less attractive.
Health care on a budget means that bleeps are communal. Certainly registrar bleeps are eventually individually issued albeit not with a smashing pair of baby blues. Intern bleeps are shared. They are the baton passed between post call and on call victims.
They have usually passed their sell by date and hence are invariably held together by Elastoplast. They come with 2 settings…off and infernal irritation. They are loud at 2 in the afternoon. They get exponentially louder with each hour after midnight. They do one of two basic things…they bleep (because they are bleeps) and they flash numbers of wards, extensions at the lab, extensions in theatre etc.
Pretty much after one or two calls you develop a little bit of bleep ESP and can anticipate what information the bleep would convey if it were a pager.
For example; if it’s a number starting with a 5 it means it’s a phone in theatre and it’s either your registrar telling you to get your butt over here and scrub in, or get your butt over to casualty and sort out the patients because I am in theatre, or it’s the anaesthetist shouting for more blood.

Ward bleeps are the bane of one’s existence.
“Dr…I have 3 drips for you”, is code for I actually have 5 and I’ll definitely find another one to pull out before you arrive.
“Dr…Mr X has got nothing written up for pain”…Code for he’s making me get up from my comfortable chair and ruining my tea break, won’t you come write up some morphine/strong sedation.
“Dr…We need some Augmentin from the drug cupboard”…a protracted excursion which involves coming to the ward to get the patients details…missioning to E floor security for the key…missioning to D floor to the Emergency Drug Cupboard…back to E floor to take back the key…back to the ward to drop of the Augmentin.
“Dr…Mr X doesn’t look so good”…Code for imminent resuscitation required.
“Dr…the patient is gasping”…Code for inevitable death certification approaching.
What is great about ward bleeps is the speed at which the person who ‘bleeped’ you can get away from the phone from which they ‘bleeped’ which results in a speedy reply on your part and a less than speedy pick-up on the other side. But my personal favourite is when they won’t answer the phone but somehow manage to bleep you twice in the time it takes you to answer the first bleep.

Strangely bleeps are probably the most annoying when they don’t bleep.
They create an uneasy disquiet that there are drips that need resiting, drugs that need fetching, blood that needs hanging, patients that are not breathing and that at some ridiculous hour the bleep will start bleeping.
Because when they are quiet it means that you can sit down, which invariably leads to slumping, which invariably leads to sleeping, and the possibility that your exhaustion may be so ‘human’ that you will sleep right through the infernal ‘bleeping’ and have to explain to some angry senior person in the morning, why someone who should have been resuscitated is now being certified.
Consequently even if you strike it lucky and are not required for these mundane tasks at 2 in the morning, you cat nap and wake up every hour or so to make sure that you haven’t missed a bleep, or that the stupid thing is still working. And so even when they are not bleeping…in a way they are.

I have a friend, a new graduate to non-Greys Anatomy medicine, who a few days before her first bleep call commented on that very fact and may have used the words “I can’t wait to have a bleep!” I held my tongue and smiled quietly and came to fetch it from her the next morning. With dark circles under her eyes and that distinctive hour-24 ponytail she practically threw it at me and may have said something like “Take it! Take it! I hate this stupid thing!!!!!”
Yes, at first glance bleeps look cool…they have sparkle pager deception. Turns out, it’s just another Greys Anatomy ruse.

The Cute Factory

I have recently finished up a 2 month stint in the Neonatal Unit; a place where miracles happen everyday and is the one ward in the hospital where life usually trumps death.

I have stories but for now just a glimpse at a happy moment.

As part of the job I had to go up and facilitate the arrival of all the caesar babies, just make sure they come out crying and not too small. This photo was taken about 15 minutes after this little Poppit was born and she was mostly fine although a little bit small and a little bit early and we were giving her a bit of oxygen because her lungs were working just a little bit hard and it's mostly reflex to grab whatever you put in her hand but it was such a precious moment when she held onto the mask and kept it in place almost as if to say..."9 months underwater! Give me the good stuff!"

Youth

I want to revisit a patient…a lovely face that was only a part of my training for a week. She came back from the dead, literally, in the last week to haunt me. An unexpected ghost.

I must have clerked her on Friday the 26th of December. I remember this particularly because the Registrar that I presented her to was not our usual Friday firm reg. Jo was away for Christmas and Noor, being Muslim, had agreed to do her call in exchange for his New Year call. I remember it was him because next to him she was so weak and small and he wasn’t being very empathetic.

She was 13 years old. Let it sink in.Physically she could have passed for a 15 or 16 year old. She certainly didn’t look terribly out of place in the adult Internal Medicine ward.

She couldn’t have been less out of place though. She had the wide eyed eyes of a child scared in hospital. She cried if I came near her with a needle and pleaded like a 7 year old for another way of doing the transfusion.

She was coming to the end of a summer holiday. She was starting high school in January. She didn’t have a boyfriend. She just kept asking me if she could go home…”I promise I feel better today.”

Actually, in the week that I had left over in Internal Medicine we didn’t have a clue what was wrong with her. She had started feeling weak and tired a few months before…apart from that nothing specific to complain about. She had a positive TB contact and so her lethargy was immediately put down to being TB related and despite any clear symptoms or evidence she was started on TB treatment.(The golden rule in the Western Cape: It's ALWAYS TB until proven otherwise). A few weeks later she presented with pain in her hip and a limp and for some reason the casualty officer did a lumbar puncture, excluded meningitis, did a hip X-ray and excluded anything concerning and sent her home. A week later she arrived back in casualty vomiting blood…not huge, dramatic Greys Anatomy volumes…maybe a cup she said. The only signs of anything being wrong were this profound proximal weakness (basically she couldn’t lift her arms or walk without support and a strange, broad based gait. She also had an unusual tachycardia, which did not improve after 3 units of blood. There was no evidence of infection. She was 13 and a girl…we were still feeding her TB treatment and trying to prove something autoimmune.

I’m pretty sure her Gastroscope came back normal. For some reason she was booked for a bone marrow biopsy…at that stage I changed rotations.

In 4 months of family medicine I often wondered what ever happened to her. I assumed that it was autoimmune and eventually she was sent home, sent back to school, sent back to being a 13 year old in a 13 year olds world.

On my first day of Paediatrics I was in the caeser theatre and the obstetric intern had just finished up in medicine and in the Friday firm.We got to chatting, in-between an elective Caesar for macrosomia/’big baby and another for previous C/S x2 and he mentioned that he had taken over some of my patients. She was one of them.

It turns out she did not have TB. It turns out she did not have an autoimmune disease either. Her bone marrow biopsy had an unusual amount of atypical cells which the cytologists eventually narrowed down to malignant adenocells.

Adenocells don’t belong in bone marrow. Adenocells belong in lungs, ovaries and intestines…mostly. She had a massive colo-rectal tumour and basically it had spread everywhere!!!!

Now for those of you reading for human interest and not medical, 13 year olds don’t get colo-rectal tumours. 30 year olds don’t get colo-rectal tumours. Old people, and by that I mean people over the age of 60 at least, get colo-rectal tumours. There is a very rare group of unlucky individuals who inherit a particularly nasty genetic mutation which predisposes this abnormal growth of cells in their colons and before they turn sweet 16 they succumb to a malignant tumour. On top of that, by the time you figure out that they’ve got cancer almost the last place you look for a tumour is in their colon…because they’re not supposed to have a tumour there.

You could have knocked me over with a feather.

She was 13.

She was discharged from hospital to hospice and died sometime late in March, early in April. Her mom came back to say thank-you.

She never went to high school.

She never kissed a boy.

She never went home.

Little Old Lady

I suppose it is a bit Greys Anatomy to want to put some of those memorable patients into paragraphs. I want to be able to remember them though; in the years that will follow I want to be able to tell my story of being a doctor with their stories, however brief the encounter was.

Currently I am based at a Community Health Centre in Bontheuwel, Cape Town. A primary health care facility which swarms with patients that queue for hours to access even the simplest of its services. One day I'll walk you through the process, but for now lets move to the heart of the facility - "the floor" as we call it. This is the central purpose of the clinic, the point where patients sit and sit and sit and sit some more, waiting to see a doctor. Mostly they are there for some kind of follow up; they have high blood pressure and/or diabetes and/or asthma/Chronic Obstructive Airway Disease (which is what happens when you smoke a packet of cigarettes a day for most of your adult life) and just for fun we usually throw in a bit of Gastro-oesophageal Reflux (aka heart burn) or osteoarthritis.
This week I've spent most days on "the floor". The patients tend to blur into one big bunch of similarity. They shuffle in and out, they complain about sore backs and knees and ankles, they promise they are taking their tablets and that they are not smoking as much as they used to. It has the potential to be mind numbing stuff... if it weren't for a few colourful characters along the way.
One particular dear old lady stands out in my mind from this week. When I picked her folder up off the top of the pile in big capitals across the front was scribbled 'DEAF'. I anticipated a protracted and painful consultation, as some of these patients are hard enough to talk to when they hear just fine. Surely, I think though, someone must have accompanied her and will be able to facilitate a speedier process... alas no.
After calling out her name about four times a little hand goes up and she seems to gesture, unsure if I am calling her or not. "Well", I think," if she could hear her name she can't be that deaf!" She shuffles after me into my little room and has a seat. Obviously used to the long wait she has come armed with a knitting project and I wait for her while she neatly folds away the grey chunky wool and the needles into her little shopping bag. What you must understand is that for some patients, a trip to the clinic really is a whole day affair and probably one of the few excursions they venture out on, and while it cannot be said for everyone, some of them make a special effort. Though I never thought about it until one of my patients mentioned the other day that she had specially had a bath the day before because she was coming to clinic, I now noticed that she is wearing what is probably one of her 'going out' dresses, because by primary health care standards it is designer. Made out of that soft, cheap chinese satin; a deep purple with little blue, white and grey flower prints, and matching buttons that go up to her neck, it is not faded or frayed which is what makes me think she probably wears this when she goes somewhere special... and it humbles me.Assuming now that 'DEAF' simply implies speak louder than normal, I do just that but she shakes her head and waves her arms and the only sound she makes is a little squeak! It's too gorgeous, but I have no idea how to communicate with her.
Perhaps if it had been a straight forward consultation I would have been a bad doctor and examined her, rewritten her prescription and despatched her to the next queue without having to say boo, but what complicates the process is that on her last visit the Doctor who saw her had diagnosed her with fast atrial fibrillation (google it) and refered her to Somerset Hospital for review. The whole point of her coming back to see the doctor today was obviously to follow up on what the Somerset doctors have decided would be the best management for her. Now you can see why communication was necessary. I'll admit I was stumped and was about to admit defeat and despatch her on her way to be some other doctors problem in a month... but my conscience got the better of me and I gave it another shot. Her squeaking and gesticulating seemed to indicate that she would be able to read, but since I can't speak Xhosa, reading and writing it certainly wasn't an option.
"What are the chances," I thought, "of this little deaf-mute 72 year old african lady being able to read and write English!!!!" Being out of options though... I took a piece of scrap paper and wrote in big, neat letters "ENGLISH?"
Amazement is too tiny a word. There were several small excited squeaks, vigourous head nodding and gesticulating for the pen and paper upon which she wrote in perfectly legible print "YES I CAN READ AND WRITE ENGLISH"
A silent and protracted consultation followed; she had been to Somerset, and had an appointment for the 9th of April, she was still getting palpitations although her pulse was reasonably slow and regular today. She wanted to show me a sore on her leg that was not getting better...I asked her how long it had been there for to which she replied since 2007! I was amazed...how did she have so much faith in the system that she comes back for her medicine every month, if no where in her folder it was evident that she could read and write English, or if she hadn't been able to tell someone about this ulcer on her leg since 2007!

I saw no other interesting, colourful patients this week and I spent 4 days on "the floor", but this little gem made up for all of that boredom. She was so beautiful...because she didn't look 72, because of her little purple satin dress, because of her chunky grey scarf/sleeve that she folded so carefully away, because her blood pressure was perfect, because she never seemed upset or frustrated with me because I didn't know how to be her doctor at first. I left our written consultation in her folder, I wrote a little note about communicating with her in my notes and put in big capital letters next to 'DEAF' on the outside of her folder 'BUT ABLE TO READ AND WRITE ENGLISH!'

The Crazies

It's not like Greys Anatomy...in fact at the moment it couldn’t be further from the truth.
I mean on any given day, my life is not half as glamorous or drama filled as those Seattle Grace Interns make it out to be (though sometimes in my little brain I like to imagine that it actually is). Currently it is so lacking in any kind of stimulation I was actually excited to have a Friday night call in Cape Town gangster central!!!

So now I’ve piqued your curiosity… I mean what could be so awful about work at the moment that I look forward to inevitably busy calls.One word… Psychiatry.
I retract any previous statements that I may have made on the cushiest speciality you can go into. If you want minimal patient contact without committing yourself to a lab for life or if the phrase pulseless electrical activity strikes fear in your heart; if you lack diagnosis confidence and want to be able to change it 5 or 10 years down the line, if frequent coffee breaks are necessary in your hours, if you want access to the strong stuff and if you’re in it for the money then look no further. Forget about Dermatology!* It’s actually quite hard trying to distinguish between a macular-papular rash of benign inconsequence and a similarly looking one that comes just before multi organ failure. At the same time I’ve spent a week doing jimmy* in their wards and a Stevens Johnsons syndrome can keep you busy for days before they die.
Also scratch off your list Ophthalmology*** where every now and then there will be a foreign body that will need extraction, you occasionally need to scrub up for theatre and sometimes topical antibiotics don’t work.
Now I can hear all of you muggles (that be the non medics) already…no. I don’t get to work with the psychopaths and those partial to human liver on toast. If my job was like Greys Anatomy then yes…it would be worth dedicating a string of episodes to the crazy. Sadly for my Dad and his hard earned money, 2 years of BSc, 6 years of MBChB and my days have been reduced to wandering the grounds of Valkenburg (very much like some of the chronic patients do) in search of an unsuspecting, but usually paranoid schizophrenics to do a mental status examination on. On a hectic day there may even be one or two fresh ones to clerk and on the rare occasion there may even be someone who needs blood drawn or (very difficult I know) a CT scan form!!!Sigh…I feel like I have been made an involuntary admission...

*Skin-ology for the muggles
**the mind numbing yet refreshingly hands on everyday ward work real interns do…namely dripping, bleeding, bagging and labelling, form filling, pharmacy fighting, fingerprinting etc…(please refer to previous notes)
***Eye-ology

THINGS THEY DON'T TEACH YOU IN MEDICAL SCHOOL

So here we are, 11 months down the line from graduating. Not so shiny and sparkly anymore. A little bit rougher around the edges, a few more worry lines, too tired to shave...living the dream... or not.Like any profession (although one would think in this career they would avoid this mistake!) what they covered in the textbooks, what you crammed into your grey matter is probably not what you end up using everyday. For the unenlightened, the desk job muggles and the newly crowned medics here follows a few secrets that I have picked up along the way...(feel free to contribute!)

Bad doctors do eventually kill patients but bureacracy kills more.

Failing to acknowledge that they with the epilettes on their shoulder control your life will result in much anguish and gnashing of teeth on your part.You will be called at 2am, 230am, 250am, 3am, 320am, 410am, 415am… for the stupidest reasons.

Apparently you need an MBChB to
Put up a drip
Put up a male catheter/ 3 way catheter/ fine bore nasogastric tube (because it has a guidewire in it.) Fingerprint a dead person
Fetch blood from the bloodbank and hang up the first unit…but only the first unit!

You can’t transfuse packed cells through a blue jelco unless you have an IVAC.

You can transfuse FFP’s through a blue jelco without an IVAC.

The secret to a quiet night in the wards is prn lorazepam…for the patients…and the occasional sister.

If a patient can ask for morpine they probably shouldn’t be getting it but if it’s 2am you will be shooting yourself in the foot if you don’t give it.

Not for max is relative to the registrar who made that decision

Surgeons and Physicians have only one thing in common…they despise Obstetricians.

Pharmacists are a law unto themselves.

It's a mystery how people did 24 hour calls before woolworths!

There are 2 kinds of people in this profession...the eternally miserable in spite of there surroundings and the surprisingly happy despite their surroundings.