Little man G.

Little man G.

What a pleasure to have you in our lives for this little while.

Your home has been Red Cross for the past 6 months. You’ve moved around in the wards and left stories all the way.

A couple of memories you have imprinted in my heart.

When I just started in ICU your were living in bed 9 and coping on a bit of high flow oxygen. And I remember one day you sitting up in bed and being entertained by a mountain of colourful toys…. And how you’d cry for your mom when she went home in the evenings.

What I most remember about your second stay with us is your big round eyes watching us work around you, the little clicking noises you made to get our attention, your big sister sitting on your mom’s lap having long conversations with you.

Your mom, sitting tirelessly at your side.

And your tube – coming out your nose similar to a  little elephant ‘slurpie’ – and how it became like another limb and you just accepted it. Wide awake, playing with your toys, hooked up to the ventilator.

I’m sorry the last 6 months were so yucky beautiful baby boy – time to sleep now.

The Scenic Route

It feels like I take the long way around a lot...and I spend a lot of time waiting. 

Waiting for a plane. Waiting for the luggage to come. 

Waiting for the nice boy to notice you’re amazing. 

Waiting to get into med school. Waiting for second round applications. Waiting for a registrar job. 

Waiting for the sats to come up...waiting for the Scoline to work. 

Waiting for the spinal. Waiting for the surgeon. Waiting for ICU to get a bed ready.

Waiting for the call to end.

Because I belong to the microwave popcorn, smartphone, PVR generation I generally don’t love it and I very seldom admire the scenery along the way. 

But why?

I always learn just as much in the waiting, if not more, as I do in the action. 

I’m not sorry I had to do a BSc first - I got to be a normal university student for a while. I got to ‘blommetjies vou’ and Serrie and Teddy Cheer and lie on the ‘Aula gras’ and sleep 3 hours a night for a week in Orientation week, twice, voluntarily... and I wouldn’t swop that for being 32 and a consultant. 

I’m not sorry I had to go work in the North West for 18 months while I reluctantly watched some of my peers walk into nicer  jobs...those were probably the 18 months I have enjoyed medicine the most. Those are the patients who taught me the most, the mistakes I will never forget, the saves that made me feel like I was swimming and not just treading water, the friends I still chat too even though we all live in different corners of the country now.

And now, at the end of another season of waiting I find myself acknowledging that I’m not sorry about waiting for this registrar job really. 

I’m grateful that I got to sink into the system slowly. Grateful for a few months of quiet supervised responsibility. For a few months when I could spend weekends off not working on research proposals and academic presentations. Grateful that I could read fiction novels and not journal articles at bed time. Grateful that there was time for drinks, and dinner parties and weekends away with lovely people. 

Everyone loves instant gratification - getting their way without much of a struggle - no red robots, clear highways - but nobody enjoys a person who is impatient. 

No one has time for the weaver on the N1 or the person who jumps the queue. 

So mostly what I have learned in all of this is how to wait graciously despite the frantic pace that everyone else seems to, or wants to be living at. 

And I’m still waiting for some things, so I hope I get better at waiting quietly and optimisticallly and  if they do ever eventually come around...I hope I’ll be greatful for scenic route. 

It doesn't always go well

Death is a shadow that wonders the halls of work. He moves with unassuming quiet like some of the porters, or cleaners or security guards. He is neither grumpy nor terrifying but doesn’t really smile much either. He will pass you in a corridor or a ward and acknowledge you with a simple nod and continue around the corner - off somewhere. 

Mostly I meet him at work, but on the odd occasion I see him out and about and he mingles in my world of sometimes friends and other times family. 

It’s the familiarity that forces us to process death differently. 

We are trained to spot him coming a mile away. We are trained to deal with him when he shows up unexpectedly and escourts his patient with all the finesse of 5 burly bodyguards.

Sometimes he sits in the corner and quietly waits for days. Sometimes it seems he’s been stalking a patient for years. Sometimes it’s a little person and it seems he came too soon. 

Yet despite the frequent encounters Death is never routine. 

There is always a sinking feeling when he nods at you from across the room. 

Sometimes I am grateful that suffering comes to an end. Those are the easy certifications to do. There is relief in silent chests and fixed, dilated pupils. Those are the easy phonecalls to make and you sleep a little easier that night. 

Sometimes I am so deeply disappointed I cannot look him in the eye. Those are the lives that we fight for...the newborns who don’t breath that we do CPR on for too long. The dehydrated babies that we push needles into bones for, to get fluid into their veins. The 17 year old who had the unfortunate luck of being the unseatbelted victim of a head on collision. 

Sometimes I feel responsible, feel like Death isn’t even there; only me. 

What there isn’t usually, is time to process. There are relatives that need explanations. There are 40 other folders in the casualty box or  sick babies who need you focused. So you shelve it somewhere in your heart...and like that journal article that someone gives you to read, you never actually come back to it. And one day you notice you are quite good at switching off emotion when Death walks into a room. And you accept that like taxes it is inevitable, and you remind yourself that God and not your capability or inability decides who lives and who dies. 

And you focus on the ones who live. 

On the Tweety’s who nearly died of TB and malnutrition but then who came back to visit us  3 months later flourishing and healthy. 

Or the Thato’s, who’s mom we counselled thinking her 8 year old at worst would die  of TB Meningitis and at best would be severly brain damaged, yet went back-to-his-old-self-Thato and came back a few months later bragging about how well he’d done in his school athletics.

Or the Owami’s who we thought would never come off CPAP. 

OrThe 700grammie who now weighs double and has proved me wrong! 

I suppose you appreciate life more when you become familiar with Death.

My little superheroes

It’s easy to forget that this is actually a hospital up on the E-floor. 

These super specialist paediatric wards become second homes for so many of these kids. They come with their broken livers and kidneys and carve out a place for themselves in this little family. 

In this ward there is no such thing as a short stay - an admission here is typically never less than a week, and sometimes stretches out for four or five months. 

It is well described that kids eventually adapt to any environment - although it may trigger a few abnormal and sometimes worrying coping mechanisms. 

It doesn’t happen overnight, as is certainly evident in the more general wards where the kids are being exposed to the hospital environment for the first time. There they regard every approach with cautious apprehension - never sure if something unpleasant and painful is about to happen.

But upstairs they slip into the routine of the ward. They call the nurses by their first names. They know the names of all their medications and when they have to take it.

If you spend more than 2 days in the ward with them they greet you with running hugs in the morning and blow you kisses from their beds on ward rounds. 

They get beyond excited when they are well enough to join the other kids at the hospital school. They all know Bubbles the clown comes on Thursday morning. 

Downstairs in the B-wards it’s easy to remember you’re in a hospital for sick kids. 

Up here I have to actually remind myself that these kids are sicker. These are the babies who have had more general anaesthesia than I will probably ever have in my life. These are the kids who have survived transplants, life threatening infections and cancer after the immunosuppresants we gave them stopped them from keeping the abnormal cells in their body in check. This is where most of the blood that you donate lands up - not in a trauma ward, but in a ward with chronically ill patients. 

Yet they have so much life in them I struggle to imagine them not living a full one.

I forget when in the afternoons after the dialysis machines and gancyclovir infusions have been disconnected, and the kids are racing around in the corridor wearing their ‘duck-bill’ masks, that this is not a playground.

I forget when Tracy comes around with her arts and crafts that this is not a classroom.

I forget that they have chubby cheeks not because they are fat and flourishing, but because of the steroids that keep them from rejecting their organs. 

I forget when it’s time to drip one of them and she points out which veins are better - that kids are supposed to be afraid of needles. 

I forget that these  kids  are living on borrowed time and that big school and dreams of being ballerinas or pirates may never come true. 

Working with them has been an eye-opening and humbling experience. 

My little superheroes. 

The Universal Pen Theory

Some people may think that the essential tool of any doctor is maybe their stethoscope? Maybe needles and syringes? Perhaps a defibrillator (picture a flatline on a monitor, someone shouts Vfib and then they pull out these paddles and call "Charge to 300")? Perhaps an ENT set or those nasty ice-cream sticks that no one loves?
No not true.
You see surgeons' stethoscopes gather dust and I don't think a radiologist would know what a defibrillator was if you showed it to him and said the word r-ea-l-ly sl-oooooow-l-y.

No. The essential tool of any doctor, the one thing that unites us all and leaves us lost and useless at work in its absence is a pen. Specifically, a black pen.
Blue is apparently tantamount to giving an A+ patient, B+ blood, it would seem. I once dared to use a blue pen because I could find no other pen to make notes with, and the sister in charge of the clinic sent the whole folder back and informed me with a very straight face, that I had to rewrite everything from the consultation; notes, prescription, admission forms and consent documents, because no where in the hospital would they accept blue pen notes!
Allegedly, blue does not photocopy well - and makes keeping records of the records problematic, which becomes problematic when you need your notes to defend you in a lawsuit somewhere down the line. Hey - you hear the word lawsuit you do what people say...but I think the bureaucrat that came up with that fallacy had a standard issue government photocopier that probably hadn't been serviced since the stone age.

I digress...the point I actually wanted to make is a secret of the universe that I have discovered which is guaranteed to cut down on pen frustration everywhere.
You see, pens - like socks and teaspoons, have this annoying tendency to disapparate. One minute they're in your pocket and the next minute they're gone.
Any doctor worth his MBChB salt avoids pen frustration by firstly never buying anything more expensive than a standard Bic Click pen, and never having less than at least 2 in your bag. Drug reps also usually provide handy emergency stashes, but emergency is all that they qualify for. They are designed to get you to the end of the day only - their life force is simply not strong enough to survive more than a few hours of government doctor writing.
The loss of a trusty Bic Pen produces profound pen anxiety. There simply is very little you can do in your day without one. It is somewhat alleviated by borrowing a pen from a colleagues emergency stash.  Some anxiety still remains however, as the possibility of returning the pen is slim to none. No one intentionally steals a pen. Everyone does it purely by accident...but the stigma remains in our minds none the less.
Failure to locate a good samaritan results in you taking on a desperate search of the local environment looking for a lonely pen that has been neglected by it's owner. The charge on your head is so much greater for the day though...kidnapper!

It's all been for no good reason.
You see, pens are not property of individuals (the one exception being fancy Parker pen sets with names engraved on them).
Pens are property of the universe.
Bic pens especially are so standardised they gave themselves away immediately. I myself on many occasions have unintentionally neglected to return a pen to it's rightful owner and on one occasion I can remember being desperate enough to kidnap one. At the same time, I lose a pen a week, at least, and as such I am constantly adding to the universal pen fund. If I manage to get a Bic pen to the point where its ink runs out before I lose it, I basically throw it a funeral. I also keep more than 2 in my bag so that I can give them out freely to the universe without needing them to return.
I haven't had pen anxiety for ages...and neither should you!

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.