It's not like Greys Anatomy

Worth his weight in Gold

2012-02-11T13:21:00.000-08:00

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

2012-02-01T07:59:00.000-08:00

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.

Sammy

2011-12-24T08:46:00.000-08:00

There’s such a stark difference between her and the other 5 year olds in the ward you can’t help wonder how someone left her like this for so long? Did they think it was normal for a 5 year old to stop running, stop playing, stop laughing?

Sammy is 5 but she looks about 80. A real life Benjamin Button. She weighs 10 kilograms - skin and bone and Disseminated TB. Her hair has that coppery malnutrition tint. Her big eyes are sad and tired.

The first few days she really just lay there...drifting in and out of sleep. To weak to fight drips and bloods and NG tubes with more than a little crying.

She’s so far gone I don’t know if we got to her in time. Even though she seems to be turning the corner slowly she still has a long way to go around the bend. All of us in the ward are being quietly optimistic but cautiously realistic that despite all our best measures she may slip away quietly and suddenly.

Too beautiful though was yesterday morning.

About a week ago, just after she got to us - Father Christmas came to visit. With minstrels and carolers he wandered around the wards and handed out Christmas presents.

Looking at her you’ve got to wonder if she even really knows what Christmas is. Regardless - Sammy was far too sick to realise he was there. Too weak to open a present, it lay next to her bed for days.

Yesterday - I don’t know if she spotted it or if one of the nurses pointed it out to her but the wrapping paper came off.

Inside was one of those R20 Barbie dolls...I wish you could have seen her little face.

Propped up, but still too weak to change the outfits one of the nurses helped her put the Barbie’s shoes on.

We watched through the glass that looks into the isolation room. She managed a wave, and one whole Niknak.

Her smile - probably the first one any of us have seen - was bigger than her little body.

It would have melted my heart if it was the middle of June.

If I get nothing else for Christmas other than that little smile, to see that little flicker of a real 5 year old - there is nothing more that I need.

Cheers to 2010

2010-12-31T05:35:00.000-08:00

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

2010-12-21T10:34:00.000-08:00

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

2010-12-07T10:53:00.001-08:00

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

2010-05-22T14:14:00.000-07:00

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.

2010-02-26T12:16:00.000-08:00

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

2010-02-25T12:57:00.000-08:00

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

2010-01-31T02:37:00.001-08:00

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!

Remember me

2009-09-11T23:29:00.000-07:00

Of course I remember her...

It must have been a little bit more than a year ago when I was doing obstetrics. A call day when the queue of patients outside triage in labour ward was halfway to the exit.

She climbed onto the bed and told me her story...

I remember she was young; maybe 22, and pregnant with twins. She was a pretty girl and one of those lovely, chatty girls who despite the fact that she had been sitting and waiting for about 3 hours was not at all unpleasant about it.

She was about half way with the pregnancy, maybe 23 or 24 weeks. She was complaining not so much about pain actually, as about a little bit of bleeding.

So I examined her and wasn't expecting to find much (a little bit of blood is not uncommon in pregnancy) What I distinctly remember are those bulging membranes and a heavy feeling in my stomach with the realisation that the situation was far worse than it appeared. It's true, a little bit of blood is not uncommon, but every now and then it heralds something ominous.

It was what we would call an inevitable miscarriage...past the point of no return.

I remember watching her world and her family's world crumble in a few seconds. I remember having to explain over and over again that the babies would be too small to survive and there was nothing we could do to stop them from coming. I remember the first one being delivered, a tiny, perfect little person, probably weighing about 4oograms, with a heart beat and 10 fingers and toes and jelly-skin. I remember wrapping him up and showing him too his granny and him quietly just slipping away.

I remember the sadness of the whole situation and the reminder of how quickly a world can be turned upside down.

You can imagine my surprise when the case that I took over from the on call anaethetist yesterday morning is this same woman. When we were finishing up she looks up and says

"I remember your face! You and the midwife delivered my twins last year..."

Of course I had to think a bit...delivering twins with a midwife is definately something that I should remember. And then the whole day and all it's pictures came rushing back.

"Of course, the little boys who were too small" and she nodded her head.

You'll be happy to know (aside from the fact that she was in the obstetrics theatre having a third degree tear repair done) that she was back because she had had another baby. A little girl weighing 3kg's and healthy.

It's no secret that this is a profession where happy stories are heard of but not common.

So you collect them up and store them away for the days when you need a bit of gentle encouragement to go back for another 24 hour shift.

It's just flu.

2009-08-06T12:43:00.000-07:00

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

2009-08-02T04:44:00.000-07:00

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

2009-08-02T01:56:00.000-07:00

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

2009-08-02T01:47:00.000-07:00

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

2009-08-02T01:33:00.000-07:00

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

2009-08-02T01:27:00.000-07:00

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

2009-08-02T00:57:00.000-07:00

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.