Take home Teddy

Thursday morning after Wednesday OPD chaos - the folders in the box are remnants of the previous afternoon, told to rather come back in the morning than sit on the uncomfortable passage bench, to be seen somewhere in the vicinity of midnight.
None of my follow-ups have arrived yet so I pulled the first folder - green triage sticker, complaint - 'sores in the mouth'.
So typical of MOPD, the real reason for coming is not always well captured by the triage nurses, and in this case it was a complete red herring.

A very cute little 3 year old girl comes into the room with her mom. A pleasant little pair.
Her mom speaks a slightly broken, Eastern Cape version of English; her grammar giving it away more than her pronunciation. Her daughter is a sweet little poppet who barely says a word the whole consultation, just sits quietly next to her mom and wanders around the room with her eyes.

Sores in her mouth - not so much. Sores on her hands and feet - yes. More alarming is the blood in her urine and then very nonchalantly she tucks in this statement...
"The other thing doctor, I almost forgot... she was raped last year."
No, not how I like to start my Thursdays.

So we stumble through the story which is a good year old and sadly, probably the story of a thousand other little people.
Mom can't actually tell me what happened, at the time her daughter was too small to talk for herself. The only real clue may have been that she was suddenly reluctant to go play next door with the neighbors kids. The clinic had done a courtesy examination and said nothing was wrong and left it at that. The police had said a case wasn't necessary as there was already one opened by the first victim.
And so the system let her down.

For most of the examination she is a honey. She sits quietly, not a peep. Only right at the end when the consultant joins the examination do the tears come, and our promise that nothing is going to hurt fall on deaf ears. Surprisingly, we get through it with very little kicking and screaming and as a bit of a lackluster consolation prize the kids get to pick a take-home-teddy
What happens next is a moment I want to burn into my memory forever.
A little face, with big, sad, uncertain eyes slowly melts into a smile when the teddies are presented and she is allowed to choose one. She spots one in a pink dress, plucks it out of the bag without a moments hesitation and hugs it close to her little heart. By the time my notes are finished and social workers have been called, the teddy has been inspected from every angle, wrapped up in a blanket and rocked to sleep.
It is in those moments that she melts back into the shape of a normal three year old girl, and the reality of the morning is a deep contrast to this innocence.

In Her Shoes

Edit: I would just like to say that having worked with the person in this post for more then a year now I have to say there is nothing wrong with her work ethic. She is one of my favourite people around and has never shot me down or not been obliging when I've had to phone for help or advise. Perhaps the first conclusion is more appropriate. 

You could spot them from a mile away - so out of place at seven-forty-five-ish on the cardiac morning round. Surrounded by Trainers and Crocs and the occasional cheeky sandal, they looked as at home as a slinky catwalk model in the middle of a 'Vroue Federasie' AGM.

The female obsession with footwear is not poorly documented. Most of us dream of a shoe-closest like Carrie in 'Sex In The City'. I love having a reason to slip on a pair of heels (not just because they add a few centimeters to my shortness) but because they make you feel more ... I don't know...stylish and grown-up. It's the way they finish an outfit, the way they sound when you walk in them, the way they show off a pretty pedicure and most importantly, make legs look skinnier. No one pulls off a power suit in pumps.
But they are made for women who do a fair amount of sitting. After a few hours they start pinching, and feet start burning and muscles start aching. That's why they come off when the party gets going, why they are work shoes and occasion shoes, not holiday shoes, or weekend shoes.
They certainly aren't intern shoes, or ICU shoes, or call shoes. In fact, they aren't hospital shoes.
This is not a job where you get to sit a lot. This is a job where you do a lot of standing, and walking, and every now and then when people stop breathing, occasional running. These are not 8 hour days, they are sometimes 12, sometimes 18, sometimes 28 hour days.
It just concerns me when someone has been around in the profession long enough to have an MBChB and a Fellowship Qualification, and then doesn't choose their shoes with the same wisdom they apply in choosing antibiotics and inotropes.

I know they say you shouldn't judge a book by it's cover, and probably in the same vein a doctor by her shoes - but I cannot help but wonder about the person who willingly chooses heals over flats in this profession.
I have to assume that

1. They have no idea what is about to hit them, in which case shame for them, or  

2. Their work ethic is going to be a problem, in which case shame for the rest of us. 

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!