R.I.P.

(This is not a post for sensitive readers. )


We had a lovely Pup that lived with us once. She was a real ‘pavement special’ - the markings (and the mind) of a Jack Russel but with the coat of a maltese mongrel. I have loved all my dogs equally, but Pixie lives in a special memory box.

She could beg before she was house trained. If she didn’t want to sleep outside she would jump up and down outside the bedroom window until you let her in. She followed you around all day if you were at home...from room to room just keeping you company while you got on with your day. 

She loved cheese. Loved it. 

But Pixie developed a heart condition, which presented with the most awful epileptic-type seizures. She had a dilated cardiomyopathy and spent her last 2 years on blood pressure medication and a diuretic. She aged but never lost her character. And when her heart failure got so bad that she swelled up like a balloon and was struggling to breathe we asked the Vet to put her down and he obliged.

In my year of being a medical officer in Potch a baby was delivered in labour ward who had the misfortune of being knitted together wrong.

He was born with an oesophageal atresia and so basically his oesophagus dead-ends before it gets to his stomach. While it is surgically correctable, in the interim feeding such a tiny poppet is tricky. 

It took about 3 days to get him transferred across to Baragwanath, the only paediatric surgery unit for about 3 provinces, by which time he had developed a bit of a cardiac murmer suggesting that more than one system had developed abnormally.

I can’t be sure, but I vaguely remember that the Baragwanath doctors confirmed him to have a Trisomy 18 - and largely because of this and his cardiac issues he was denied any surgical intervention - based on the fact that we are in a resource stressed environment, are dealing with a child who is unlikely to survive anaesthesia or post-operative care based on his abnormal heart and has a lethal genetic condition. Even if they could put him vaguely together again - he probably wouldn’t see his first birthday.

So Bara sent him back...

And here we sat with a not-even-2kg-baby and no way to feed him. Sent back to die...slowly. 

We had a drip up because it just seemed cruel to let the kid die of dehydration. Instead we waited for him to die of starvation instead. Waited for 3 weeks.

He lived in a little incubator in room 4. He spent most of his days alone because I literally saw the mom once about 2 days before he passed away. The only time he was touched was when his nappy was changed or when he was examined or when he was dripped. 

After 3 weeks he became undripable...the few veins left hidden under swollen soft tissues because he must have had no albumin left to keep the fluid in his veins. 

I probably spent 6 hours of that day trying to get a drip up on him because I couldn’t bear the thought of him lying there and getting thirstier and thirstier and unable to drink anything. And I left completely defeated and prayed all night that God would take him before morning.

He didn’t. 

He was still there. 

And the next morning too....

We seriously considered euthanasia - despite the fact that it’s illegal we put it on the table. None of us could bear to watch this baby suffer any longer. We picked a drug and called the parents in to explain what our intentions were. 

As if all he had been holding on for was a chance to say goodbye, when his mom arrived and cradled him in her arms he finally breathed his last. 

So in the end we never needed to, but it’s always going to bug me...

We treat our animals better than our people.

Debrief

You be my psychologist, because I basically work in a war zone 60 hours a week and I don't sound these things out enough. Some things have hung around in my head for the last little while.





I saw a 7 week baby on Friday morning, who was referred in because of respiratory distress. According to the mom she started breathing fast the previous afternoon... no coughing, no fevers, no issues feeding. The baby was beautiful... and blue. Her oxygen saturation in room air was low 70%...(this is baaaaaad.) A bronchodilator didn't do much, a 100% oxygen got her sats into the high 80's. An x-ray a big fat heart! Blood gas shows a pC02 of 7.3 and a lactate of 10! Prognosis is worsening.
Within 3 hours she was reviewed by an ICU doctor and a cardiologist who with a 10 minute echocardiogram diagnosed this little nunu with TAPVD - total anomalous pulmonary venous drainage...basically, the pulmonary veins don't connect with the heart, so the heart pumps blood to her lungs but then it dead ends...the only thing that's kept her alive for 7 weeks is an ASD (atrial septal defect) which allows some mixing of the pulmonary and systemic circulation.
And I watched a mom watch us make a diagnosis on her child. And I watched her get told that her 7 week old baby girl, who seemed perfectly well on Wednesday, needs emergency open heart surgery if she wants a shot at life.

On my rounds this morning I had to see a 3 year old little boy who weighs 8kg. He managed to escape getting his mom's HIV but unfortunately not her TB last year or her poverty. He's had an admission for severe malnutrition once before in his 3 short years. Now he's back...with a round puffy kwashi face and a stick thin marasmic body, the skin on his tummy is loose like and old man's. His electrolytes are in the floor, he's temperature is through the roof, his chest X-ray is a disaster and he won't eat - dying of starvation in the shadow of Table Mountain.
His mother sits next to him with a sad, bewildered look on her face. She doesn't speak a word of english. She doesn't look super healthy herself. I know she doesn't realise that he's so sick he probably won't pull through and I wonder how did they get to this point - twice. It's easy to blame.
But when I take him through to the procedure room to do more bloods I watch her put her face close up to his and comfort him with words I don't understand and soothing smiles... and a little voice whispers in me..."she's doing the best she can."

Upstairs in B1 high care is the loveliest little kid. Mich lived in B1 from February to May getting TPN (total parenteral nutrition) - which is food in a drip - but hectic R1000 a bag, too corrosive for small little arm veins, has to be run through a central line (sited directly into one of the big vessels in your chest or abdomen) stuff.
It also meant she could have absolutely zero food orally because a combination of her HIV and a couple of nasty stomach bugs have wrecked her intestines so badly that not only does she absorb nothing but eating something actually just damages her gut even more. Imagine being 5 years old and not being allowed to eat a thing!

She made it home for a few weeks, getting by with a lactose free diet...picked up a stomach bug and is back at square 1. Weighing in at 12kg's she is a scrap of the little sunshine kid she really is. She is lying propped up by a few pillows, shuffling through songs on one of the nurses cell phones. Realistically I'm not sure she's got more than a year of life in her body, though her little soul has fight for a few more. She starts listening to a Celine Dion song "Goodbye's the Saddest word"... and that was the end of me. I had to leave.

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.