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.

Sammy

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

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.