Cheers to 2010

Here’s to the people who packed up their lives and handed it over in boxes and bundles to brothers or movers or your new hospitals HR department (as was the case for a few friends). To people who said goodbye to places they loved and good friendships they had fostered and went where everyone was a stranger. Here’s to the ones who gave up hospitals with CT scans and department calls and seniors!

Here’s to those of us who found themselves the most qualified on more than one occasion. The ones who taught themselves how to do forceps deliveries and then taught themselves how to suture a 3rd degree tear.
To the unsuspecting anaesthetist who landed up resuscitating a newborn or 3 at the same time as the mom was dropping her blood pressure dangerously.
Here’s to surviving 24 hour calls, end of the month calls, calls when the anaesthetist was 45minutes away or the surgeon’s phone went to voicemail.
Here’s to surviving the theatre sisters and their diet week; 90 patient wellness clinics, Ventersdorp, HR, management.

Special mention goes to Valium and Ketamine, to the genius that figured out intraosseus access and staple guns! How did people survive Saturday night without staple guns!
That being said, thank goodness for smart phones and Google, for Woolworths Food and 24 hour Wimpy Coffee.

Here’s to the glue that keeps all of this from falling apart… The friendships that come from staying in casualty until the last folder is discharged, the bonds forged on long clinic days. The memories made around dinner tables or drinks tables or theatre tables.
I loved working with you. I wouldn’t have anyone else second rounded in your place. I hope this is not the end of our stories although realistically I know a lot of us collided only for this season.
I wish you well – a lifetime of good calls, minimal J88’s and successful resuscitations.
Mostly though I hope wherever you land up, I hope you land up with a great bunch of people, like us.

There's something wrong with this stomach

I had a breakthrough moment today.
I know you all think it involved some important medical concept like, understanding the concept of a direct and indirect inguinal hernia, or recognising type II respiratory failure on a blood gas.

No, this is nothing you will ever find in a text book and it probably won't be relevant to a lot of people out there, but for a select few who pay appropriate attention, and who work in this hospital and or department in the future, this little gem is going to make your life so much easier.
(Also, the only reason I'm not selling it and making millions so I can retire early and sleep in my own bed every night, is because it's not marketable...else I would have.)

For 6 months I have been working in surgery, and because I am NO surgeon and occasionally; ok, make that daily; need a bit of advice on 'what now?' it's nice that in this little almost-middle-of-nowhere dorpie, we have a really-real surgeon (with and FCS and everything).
Like most 'Cnsultants' though, he's virtually impossible to actualy track down and keep in one spot for an opinion, unless you can use the words 'stab heart' or 'toxic megacolon' somewhere in your sentence.
Since my sentences usually have the words, "Come to clinic" or "There's a guy in the ward",I get ignored a lot.
He ignores pages(please refer to previous blog on pagers), he ignores sms's, he occasionally answers his phone, but if he's in theatre and operating, even if the anaesthetist takes a message and you impress upon them the need for a referral decision before 15h30 in the afternoon, he's probably only going to get back to you at 15h55.( Not 16h05 when it's technically the on-call persons problem either)

It's been 6 months and I've just accepted it.
The way I've accepted that pharmacists only give 1 week supply of antibiotics even if the protocol/Essential Drug book and your prescription say 2.
The way I've accepted that even an urgent CT report will take 48 hours to make it's way in cyberspace from Klerksdorp to Rand Clinic, back to Klerksdorp and then faxed to Potch even if you call every hour for those 48 hours to impress upon them the urgency of URGENT CT Report.
I've accepted that unless you harass him, he won't get back to you and your patient's gangrenous toes will eventually just auto-amputate themselves.
Today I get to a patient in my ward who was admitted during the night with what looks like a bowel obstruction. I see the patient, ask a few questions, feel his stomach and pick up the X-ray. Something is wrong....I mean I've seen a fair amount of air fluid levels in my life, but this is one impressive air fluid level, this needs a 'What now?' decision.
I know if I page him, he won't answer. I know if I sms, he won't respond. and it's not even 9am. It's too early to start whining.
So I put the X-ray on the light box, take a photo and then thanks to my very cute little Blackberry, BBM him the pic with the caption
'Something is wrong with this stomach'.

It wasn't even 30seconds...phone call.
Consultant: "What X-ray is this?"
Me: "It's a patient in the ward"
Consultant: "I'm coming"

And what do you know, without having to whine all day, without having to use the words "stab heart" or "bleeding varices" my patient was seen in 10 minutes and was in theatre before lunch.
I've been taking pictures of X-rays and patients all day.

27 patients

1 doctor, no intern, 27 patients; one of them being the guy in room 12, who stabbed himself in the abdomen, intentionally, deep enough to injure an organ...because of a girl. 90 percent of the time it's because of a girl; the other 10 percent they weren't doing anything. They had had one beer and they were going home and these guys just attacked them for no good reason...yes, it's all fun and games until someone lands up with a chest drain hey? worse of course, is the guy in 6 bed 1, learning how to walk again after he was stabbed in the spine.
Who else is in the ward...it was 'break-one-mandible-get-a-black-eye-for-free' weekend this weekend, so I've got a couple of those in the ward. Shame, the guy in room 1 bed 2 looks pretty bad. I mean his face literally is swollen the shape of a soccer ball and he can't talk his lips and face are so distorted.
Then there's conundrum in room 4 bed 5. He's my 'Dr House' patient. Seriously. I keep going through this list of differentials and getting nowhere and then today he went all 'acute flaccid paralysis' on me and I had to do an LP - in a surgery ward!Lucky I'm not really a surgeon otherwise I wouldn't have known what to do and then we would've been in trouble and by we, I mean the patient...not me really. Surgeons don't care.
Speaking of LP's, can you believe they admitted a 'bacterial meningitis' into my ward! I was tired and I didn't feel like seeing him properly so I turfed him to medicine (appropriately so) without a phone call. Didn't feel bad though, Dr Grumpy in ward 9 had turfed a sinusitis/intracranial abscess back from Baragwanath without a phone call. Ha, at least my patients fixed. Your's is still broken!
Ah, but my absolute favourite was the patient admitted by my Consultant with an appendix mass, who I suspect has a bit of a psych history (generally only patients who have required an admission at Witrand know about Witrand) because when I examined his super soft and non-tender abdomen this morning and asked him what was wrong he only had 1 thing to say..."I want Beer".
That my friend, is the get out of jail free card in ward 6...except if you're the 1 doctor.

Life and Death

There are a lot of things about being a doctor that I don’t like, but being caught in a moment like this one is something so surreal, I wouldn’t change it for the world.

Thursday was clustered chaos. It was mayhem in casualty which seemed to overflow into theatre. Red and orange patients, caesareans for fetal distress, ruptured ectopics and then first onset seizures which escalated into cardio-respiratory arrest.
45 minutes later, despite getting a pulse back, the damage to her heart and her brain was just too much and so she breathed her last.

Before I had really finished talking to the family I was called up to theatre for a fetal distress caesarean section.
There was nothing eventful about the delivery. The little boy came out kicking and screaming which is what we prefer them to do.
While I stood there examining him it struck me, that I had watched life end not even 10 minutes before and here I was now, watching it begin.

There are a lot of things about being a doctor that I don’t like, but there are moments that make up for it. They are fewer, I’ll admit but I don’t walk away because of the six bad days in a week, I keep going back because of that one good one.

The Transfer Tango…and other fun things to do on a Friday afternoon.

13:30 Busy in Gynae OPD which looks nightmarish…too much work and not enough doctors has left a bit of a backlog. I got a call to say that an eclamptic patient has arrived from Carletonville
I find a rather robust but completely confused and uncooperative patient with blood pressures of 212/130 (that’s like aneurysm popping high). 22 years old, previous caesarean section, now best case scenario 31 weeks by sure dates, possible twins. Thrashing about, walking a fine line between the hyperirritable phase that precedes coma and death. It’s like rescuing a beached whale.
First tried to get hold of my consultant to find out what to give for the Blood Pressure since clearly the standard Adalat was probably not going to fly….No reply.
Phone slightly more senior MO…Labetolol, ICU, deliver.
Easier said than done.
14h00ish: Attempt to get labetolol from theatre: I’m not surprised, they said no: “we only have 3 vials left” (because you use it everyday?).
Plan B; phone pharmacy. First response, no we don’t have that. I’m not worried yet…theatre will just have to give. 4 minutes later...Pharmacy responds, sorry doctor, we do actually have it we just never use it.
Shot...get Labetolol. Read up in SAMF how to give it. Calculate…tell sister. What do you know…it doesn’t happen. Blood Pressure still 210/130.
14h30ish. Try to get old of senior anaesthetist. Voicemail.
Slightly senior anaesthetist available. “Ok, we’ll come and see.”
Phone ICU consultant….what do you know, ICU is full. “We can maybe move the paediatric organophosphate out but you have to phone Dr K.”
*sigh* Phone calls to him are laborious and non-productive. Dr K, makes a valiant effort to not move the child.
Phone Klerksdorp ICU…no beds.
Phone Tshepong ICU…no beds.
Phone my consultant on private number. “Stabilise, deliver, ICU….make it happen”. This said from the comfort of another city.
15h15ish. (I think at some point here, the VBAC (Vaginal birth after Caesar) at the back of the ward goes into foetal distress and doesn’t want a Caesar. I roll my eyes and get someone to translate…”you have two options. 1 – You have a Caesar now. 2 – you have dead baby or even worse a CP baby”….I make it seem like she actually has a say in the matter.)
15h30ish. when I phone the surgeon about the VBAC I mention the eclamptic.
“Linda, I think you must try and transfer her.”
S*@t…why didn’t someone senior just say this 3 hours ago!
Phone Klerksdorp…phone me back in 2 minutes…(2 minutes)…we have a high care bed but you need to discuss it with the medical manager. Phone not answered…thereafter voice mail…twice. Decision to abandon Klerksdorp.
16h00ish At least my 2 fellow obstetricians have managed to clear out GOPD and are now in the ward…I manage to explain that she hasn’t had any BP meds because she doesn’t have a second IV line up and apparently that is not a sister’s job. But is also not a sister’s job to phone around and find an appropriate centre to refer this patient too. I am good at multi-tasking, but since we don’t have cordless phones in labour ward, I am dial-up bound.
They are dispatched. The drip is up and then they dope her up to 1 level short of high heaven with Valium.
16h10ish. Ok…phone Bara…route to labour ward…route back to switch board…route to Gynae admissions…route to high care…route to registrar…” You need to discuss with ICU”…route to ICU…awesome reg on call. How do I know this…I’ll call you back Dr Riemer. Fanflippentastic.
17h00: (yes that’s right…50 minutes on the phone) "We have a bed, so we can potentially take her but she needs to come through obstetrics."
Phone back obs reg…Ok we’ll take her but you need to try get an obstetric ultrasound and some kind of foetal monitoring….are you kidding lady, I had to dope her with 10mg of valium just to do the ultrasound and it knocked her out for about 10 minutes…now you want me to do at least 20 minutes of CTG’s on 2 babies weighing about 800g’s each with an uncooperative 90kg (at least) mother.
Mmmm…maybe not hey.
17h30ish.Phone anaesthetist…Bara says we can send her (Imagine if Carletonville had just done this in the first place.) I can almost hear the happy dance on the other side.
No ambulances in Potch (there haven’t been since Tuesday…apparently they are all in for a service! What kind of chop sends all the hospital ambulances for a service at the same time; and what are they doing, reassembling them from scratch! It’s been a week since they went for a service.)
No problem…I’ll phone for a private ambulance. Get the medical manager’s permission.
Phone ER 24(lovely people, I have had to speak to them quite a bit this week).
Ambulance booked. Transfer booklet filled in.
Look in on foetal distress baby: 4.2kg …yup, you were never coming out ‘normally’.
18h00…Hayley shares her cupcakes (celebrating last day in TB ward!) Home. Couch. Drink. Back again tomorrow.

Musings on M&M's

Death is a humbling thing.
Because it levels us all I suppose.
Those who succumb quickly and those who fade slowly. Those who die with fluffy pillows and those who die on a casualty stretcher. The brand new baby. The tired old lady.
We all suffer the same fate.

Sometimes it encroaches on life…in the last week it has hovered around the corners of mine.
It was there while I was getting the presentations ready for our obstetrics morbidity and mortality meeting. The series of unfortunate events which eventually led to the death of post-dates baby because we didn’t realise just how much he was struggling inside…but we should have.
There was the 21 year old whose mother gave her some herbal tonic to induce labour, which it did but overzealously so that the contractions were too strong and so the baby was hypoxic and we realised it too late. How terrible to tell a mother that her baby is dead, how much worse because she unknowingly caused it. How terrible to know that I should have picked up the problem sooner.
There was the mommy who’s uterus gave us the impression that her baby was about 2kg’s, her membranes ruptured and we took her for a Caesarean Section but this is government and not everyone gets a scan so in actual fact her baby was only 900g and well, we couldn’t really put him back.
In the next room was Nombulelo; pregnant for the fourth time. Her first 3 babies were all pre-term and they all died. The same thing happened again. 1.6kg…big enough to survive but the placenta pulled away before the baby was born and again salvation came too late. She cried for 2 days.
And Aletta, who was discharged from ICU too soon (aren’t they all) and spent 2 days in my ward getting too much fluid while her kidney’s were shutting down so that when I walked into her room on Tuesday she said ‘Dr, I feel like I’m dying’…and she was literally drowning in her own body.
And then there was Tshidi who I saw about 12 hours into a 32 hour shift. She was 38 and diabetic and she arrived complaining of being tired and weak. I thought she had a chest infection and that was what was making her sugar’s all crazy. I stabilised her in casualty and sent her to the ward for observation. She wasn’t even in the ward for 10 minutes when they called us to certify her…and she was dead just like that. She was so well in casualty, no one could believe it.

What I’ve realised through all of this, and my consultant said it today as well: there will always be adverse events. Sometimes even when you do everything right you still miss things and they turn out to be important things.
Morbidity and mortality meetings are no ones favourite. They are generally protracted and boring if you are not involved and they dissect your faults under theatre lights if you are. But they have their place in therapy. They force humility, which is an underrated quality of a good doctor I think. They are an opportunity to step back and recognise that you are human like your patients and capable of error. Once you acknowledge the error you can learn from it and hopefully avoid it in the future.

It’s a tough pill to swallow – a real penicillin injection.
That being said: I will never forget now to not just write off severe pain in labour as just a low pain threshold, I will be less trusting of the size of a uterus and more insistent on a sonar. I will be more attentive to my instincts because they turn out to be surprisingly accurate.
And I will acknowledge my imperfections and be willing to learn from my mistakes and hopefully cultivate humility.

Platteland Practice

So, I've been upgraded from intern to community sevice medical officer, but I use the word upgraded lightly because I've been downgraded from the lovely Cape Town to the less lovely platteland 'dorpie' of Potchefstroom; I went from working in a hospital with an MRI and CT scanner to one where the phones sometimes work and most importantly I seem to be getting paid a lot less?

Here follows an exerpt from my catch-up email that I sent out this month; a snapshot of 'Platteland Practice'.

• Post call is a rumour here...2pm, that’s the earliest I can leave. I might be tempted to let a few people suffer and then they might be forced to review that decision.
• Lunch is a rumour here too. I think I might have had it once since I arrived.
• My threshold for irritation is decidedly lower after 1pm (funny how that correlates to the time of day when lunch is usually consumed) ...if you’re going to ask a stupid question, or make me sign a stupid form, or be a stupid patient after that I apologise in advance.
• For such a small hospital there are a phenomenal amount of forms that need to be filled...I maintain if I had wanted a career in admin, I would not have spent 8 years at varsity and I will be grumpy about if I want to.
• Last week I couldn’t refer a patient up because you couldn’t phone out...every time the power goes out the phones stop working and the power goes out at least once a day.
• The female theatre staff here makes Sr Frankish and Carol and Paddy in MK (Groote Schuur Labour Ward) look like Sunday school teachers. The 2 males however are great. Once again my theory is proved...too much oestrogen in one room is toxic.
• I am getting so much better at my sonar’s...I can do gestational age, RI’s, AFI’s, find the placenta, and tell if it’s a boy or a girl. I am getting better at calling it an incomplete or a complete miscarriage. I have started to practice looking at cervical length and shapes but I still suck at finding the ovaries.
• I scan a lot of women for gestational age for the purpose of Termination...I always ask them why they want the termination and the answer always makes me sad...either because they have no real reason or because they have a perfectly valid reason. I wrestle so much with this issue because of my religious convictions. Different people draw the line on this issue in different places. It’s so easy to say don’t get involved if you’re not on the front line.
• The top 5 things I hate about gynae OPD...
o Making a diagnosis of cervical cancer by smell.
o Amenorrhoea...(the absence of periods)...you would think most women wouldn’t mind this, but for some reason they all freak out.
o Finding the cervix for a pap smear in a beach ball (overly nourished person)
o The paperwork (lab forms, histology forms, x-ray forms, TTO’s, motivation forms, sick notes and occasionally admission books.)
o Chronic Pelvic pain.
• We actually have an awesome bunch of comserv’s and interns (about 30 in total). Which should prove another theory of mine...you can work in an awful hospital, if you have nice bunch of people with you it can still be the greatest experience ever.
• I question being a doctor at least once a day.
• My new favourite post call food is a magnum and ginger ale.
• It’s unlikely to be Pelvic Inflammatory Disease in a 45 year old plus woman, but because she’s got a funny smelling discharge they land up as our patients. The only reason the surgeons get away with this is because the treatment's basically the same.
• It’s been raining a lot here...almost every day for 3 weeks. The Vaal Dam is 110% full. I’m not complaining...I love the thunderstorms. I’m just saying ‘cos it feels like its winter in Cape Town.
• My most memorable patients....
o That old man in casualty yesterday who is dying from emphysema. I saw his ID book picture and how much weight he has lost and it broke my heart.
o The man in casualty who had some industrial size door fall on top of him. He broke every rib on the left side of his chest, some in 2 places, had a pneumothorax and was paralysed from the waist down...but he was one of the most co-operative patients I have had for a long time. It was also the first time I have diagnosed a flail chest.
o The lady who I admitted with a Community Acquired Pneumonia, who told me she had tested HIV negative 3 months ago and then I got her old folder and she’s been admitted before with TB which she defaulted treatment on, Bacterial meningitis, defaulted ARV’s and was restarted and then defaulted again. When I asked her why she didn’t tell me she had HIV she started crying and said she didn’t know she was positive! I was trying to figure out if she was intellectually challenged or encephalopathic (stupid but with a good medical reason for it)!
o The lady who arrived at 4:30am on Monday morning, fully dilated and a breech presentation that subsequently turned out to have undiagnosed twins. It was my first breech delivery (x2) and my first twin delivery. Fortunately not my first neonatal resuscitation...and both babies survived with no hypoxic brain damage.
o The abruptio (when the placenta detaches before the baby is born) that I diagnosed, took to theatre, got the baby out just in time, closed up and saw in clinic 2 weeks later looking just beautiful.
o The old lady who came into casualty, discharged from the medical wards two days earlier where she’d been worked up for first onset seizures and treated for meningitis. She just smelt like a Cervix cancer patient, I couldn’t believe no one had bothered to look for it. It would certainly account for new onset seizures if there were cannon balls of it in her brain. What do you know...all you needed to do was a pelvic exam.
o This 8 year old little girl who was operated on in November for and appendix by an American surgeon who has subsequently quit and is rumoured to not even actually be a surgeon, who I admitted last week. She developed an obstruction post-op which was never opened up again, settled on her own and went home but has been coming back almost weekly over the last 2 months with abdominal pain and bile stained vomiting and sent home. I admitted her as a partial obstruction. They took her to theatre the next day where she nearly died on the table (these are medical officers giving the anaesthetic and medical officers doing the laparotomy so you’ve got to give them points for trying), the peritoneum was sutured into the wound and they had to take out a large amount of small intestine because it was dead. I don’t know how she is doing now.

1 month down, 11 to go... you could call this an adventure if other people's lives didn't depend on it!