Christmas cracker instructions

From the Comserv Files

So there we were... trapped somewhere between Saturday and Sunday.
I imagine because it was about 2-o-clock in the morning and because both of us were still in casualty, it means that it was a standard Saturday night comserv call - attempted murder and mayhem, unidentified drunken injuries and the old faithful GBP's (generalised body pains which is code for end stage HIV and MDR TB because I stopped taking my ARV's again, 7 months ago).
If things had been semi manageable we would have split up for a bit of rest or supper.
But no - we were both there.

So this guy comes in with acute urinary retention and by the scar just above his pubic bone - this is not the first time his pipes have gotten blocked. I reckon after having a baby and allegedly a kidney stone - this has got to be the 3rd most unpleasantly painful condition - to have a litre of urine in your bladder and not be able to get rid of it.
He was not happy.
So we tried the conventional catheters - we tried the small ones, and the big ones, I tried and Dr S tried. No luck.
It was very obvious that the only way to get this beer byproduct out was to access it from the slightly less conventional route - trans abdominally.
Basically this involves shoving a trochar (medical jargon for a needle the size of a thin pinky finger) through your abdomen in the vicinity of your bladder to create a hole big enough to feed a catheter in.
We use a bit of local anesthetic - emphasis on 'a bit'.
Having done a few subsequent to this story I can now say that putting one in is a lot more benign than it sounds, but when you haven't been exposed to the machinery before, you are terrified. You see - abdomens do not only house bladders - they house a few other organs which do not take kindly to being pierced with big ass needles.
(In reality - if you're at the point of putting in a suprapubic the bladder should be the size of a small baby and in the way of most of these organs - but you never consider that when you're confronted with your first few.)

"Have you ever done a suprapubic?" I ask Dr S - confident that at some point in her 2 years of Baragwanath internship she must have done at least 1.
"No." was her slightly less confident answer.
Nervous laughter.
"Me either!"
So I'm thinking - 'Don't panic! I'm sure these suprapubic packs always come with instructions so...'

Dr S and I get our little trolley together - trying to think of pretty much everything we could need bearing in mind our poor patient is rocking and rolling on the bed in the casualty cubicle.
What was slightly disconcerting was that our instruction manual looked like it came out of a Christmas cracker...seriously it was about 3 x 5cm piece of paper with font 6 writing and no punctuation

"Ok, one of us must instruct and one of us must do...what do you want to do" I asked Dr S
She looked at me like I was asking the stupidest question in the world...
"Instruct."
Sometimes my calmness surprises me, and maybe at this stage of the year I had enough confidence to not care or my adrenal glands had burnt out. There may have been just a teeny tiny shadow freaking out inside of me though.
"Ok." Here goes nothing I think.
"Step 1: Clean the area..." fairly straightforward.
"Step 2: Inject local anesthetic over the area..." again - fairly straightforward. Patient not to happy about the 10mls of lignocaine that gets distributed between bladder and skin - but it's a lose lose situation for him.
"Step 3: With the scalpel make a 1cm incision approximately 1cm above pubic symphysis." Straight forward again.
"Step 4: Insert trochar..." Ok so this is where it stops being straightforward. There's this plastic sheath around the trochar that stays behind when you pull the trochar out to leave the hole that you just created open. Problem is, as you push the trochar deeper into the abdomen the plastic sheath slips down over the front of the trochar and well - it becomes a case of cutting flesh with plastic - in a word; ineffective.
Also - what you don't realize when you put a suprapubic catheter in for the first time is that there is actually quite a bit of tissue to get through before you hit a bladder. Of course you start freaking out half way thinking how can I not be in the bladder yet...surely I've missed it and I'm about to hit the aorta!
"Are you sure that's what it says Dr S?" I ask, seemingly making no headway while the patient writhes in agony - a combination of a full bladder and having minor awake surgery performed by 2 would be pediatricians. "Are you sure we didn't miss a step?" and that little freak-out voice is getting louder.
I take the trochar out, I make the incision deeper with the scalpel, I try again...not quite working...
"No I don't  think we're doing anything wrong" Dr S encourages me meekly from the side..."Just keep going..."
So we continue to slowly push through the tissues - sometimes smoothly with sharp trochar, sometimes less smoothly with blunt plastic. Eventually there's a give and a veritable fountain of urine. Patient and Doctors are both covered in urine but very much relieved (no pun intended).

There's something awesome about getting these things right on your own... a little bit of a confidence boost for the next time you find an imminent breech delivery or a patient's heart stops beating in front of you.
Then there's the post-panic laughter that descends after the catheter's in and secured with a stitch, and the realization that this is not Greys Anatomy medicine which is supervised and sterile. This is South African medicine which is powered by camaraderie and Christmas cracker instruction leaflets.

Worth his weight in Gold

He's a big little boy. Bright eyed, well spoken, full of smiles.
"How are you today?" I asked.
"I'm fine thank-you" (Can I just this point out that very seldom does a child respond to any kind of questioning - let alone with such beautiful english and manners. They usually bury their faces in their parents arms or take one look at the stethoscope and identify you as an enemy.)
"You can't be that fine if you're here" - referring to the short stay ward where I'm working this weekend.
And there it is - a big goofy smile.
"So what's the matter?" I ask.
"I've been struggling to breath and my chest hurts"
"Since when?"
"Since about Thursday."
"And have you been coughing?"
"Yes - yellow phlegms"
"And fever?"
"I think so."
"How old are you now?"
"I'm 15" - goofy smile.
"And are you in school?"
"Yes."
"What grade?"
"Grade 8."
"And what's your favourite subject?"
"Maths"
"Oh - you're one of the clever boys!"
A bashful version of the goofy smile appears.
"Ok lets have a look."

He doesn't look 15... maybe 10. And at first glances in the ward you might mistake his crumpled frame for a CP child. There's absolutely nothing wrong with his brain though.
He's got SMA (spinal muscular atrophy) type 2 - a slightly less lethal type than type 1 which is fatal before 2 years of life in the best settings. Type 2 causes progressive muscle weakness and paralysis of the body due to a defect in anterior horn motor neuron cells of the spinal cord. (Basically the cells that control the nerves that control your muscles.) It's a genetic condition for which there is no cure. Most of these kids live not much further than their teens - mostly battling pneumonias there whole life long until eventually one cannot be beaten.

This little guy can no longer sit unsupported and he has very little use of his arms. He has a scoliosis which is compromising his already diminished lung function even more. His chest is badly deformed - I can hardly think there is much lung tissue on the right hand side.
He's got a raging pneumonia - but he's perky and chatty and polite.

While I draw blood and put up a drip he asks "please don't put it in my right arm because I can't write with it then." He moans that I'm not using the smallest needle and when I don't hit blood the first time he calmly suggests "maybe you should take it out and try again."

He is an absolute treasure. Worth his weight in gold and equally resilient in the face of the heavy hand that life has dealt him.  It breaks my heart and warms it all in one beat.
These are my favourite kind of patients.

On call phenomena

No call is the same. Sometimes they're crazy crazy busy. Sometimes they are unexplainably quiet. 

Certain things about calls are universal though...

Here follows a brief guide.

Pre-call blues.

Calls always start about 24 hours before the actual call - you have to go through the mental paces of preparing yourself for 24 hours (plus) of work. Naturally, a certain amount of depression accompanies the mental anguish of the task. The necessity of mental prep is most obvious when a call is sprung on you (i.e finding out on the day that you're on call that you're on call) when it suddenly your day goes from being an ordinary work day with the usual 'me time' at the end to suddenly being the day that never ends, with very little 'me time' at all. 

On call food bags

Food bags are always excessively full when you come on call. This is simple - if you're gonna be miserable at work, no reason why you should be hungry miserable too.

On call karma

There are some people who, whether by stupidity (people who look for work) or dumb unluck, have horrendously terrible calls. Their penchant for attracting nearly dead P1 patients is freaky. They're usually amazing doctors, and if the proverbial pawpaw is going to hit the fan you'd want them nearby - but still. If you're on call with them your pre-call blues are always a little more intense because there is always hope at the start of a call that it won't be too bad...sometimes though, you just know - unlikely!

The Q-word

Much like saying 'Macbeth' in a theatre, no one refers to a call being 'Quiet' until the call is over. Legend dictates that invoking the Q-word calls down the mischief of Murphy and somewhere nearby a passenger train derails, 30 cars pile on top of each other at high speed, labour ward fills up with twin pregnancies and breeches and someone starts bleeding - a lot. My rule is if you say the Q-word, you do the work that follows.

Post call EUPHORIA

The unexplainably, yet very real endorphin rush, when you walk out of the hospital post call. No matter how little you slept, how hard you worked, how dirty or smelly you are, whether people lived or died, whether you pulled any rockstar moves or not - you always leave with the same elation.

Post-post call

This is probably the most famous phenomenon. It is widely described by medics of all ages, disciplines and universities. 

Mostly, post call days are spent supine...on a bed or a couch of death...with junk food...watching mindless TV (E entertainment never fails). But these are great days actually. It's the next day - the one when you have to go back to work that you feel the weight of too much work.

It's a mystery. You would think 18 hours of sleeping would leave you refreshed. 

Best explanation I've had to explain it is "you're still actually tired from the call. Problem is you now lack the post call euphoria." 

Haven't found an explanation that comes closer.