Life and Death

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.

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

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

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

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.

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

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.