Collateral damage

One of the most difficult things to deal with in the HIV/AIDS epidemic (for me anyway) is its effect on the children. But the disease is not only affecting children through infection and death. It's also leaving behind a staggering amount of orphans.

I met a woman who was quite young and had two beautiful, well dressed, well cared for little children. They were well groomed, healthy and happy. "These aren't her own children" I was told (for we did not speak the same language). "They're her sisters' kids". There was a boy who looked to be about 2 or 3 years old and a little girl who looked about one. "Both of their mothers died of AIDS when they were very young and she's been caring for them ever since". They looked very healthy and very well adjusted. Both of them had escaped infection and to them, she was the only mother they knew. They had no memory of their real mothers.

Their fathers were still alive, but were not contributing in any way. She had apparently sued both of them for maintenance, but nothing had come of it. She had also applied for help from social services as she was very poor and could barely keep head above water. She had heard nothing from them. There is a social grant available for people taking care of orphans, but this woman did not qualify for it as these children were not technically orphans - their fathers still being alive. Although for all intents and purposes they were. I was astounded. They looked amazingly well. It was clear that this woman was not just taking care of them, but was absolutely devoted to them.

But there was more, for years ago another one of her sisters had died, also of an HIV related disease, and this woman had taken in her children as well. They were teenagers now and in high school and were basically able to take care of themselves, so to speak. One of them even had a part time job and was helping out a bit.

I did not have words. Here was a woman who was fighting a deadly disease, who had lost all her siblings, who was living on the bread line and who still had enough strength to take the best possible care of these little kids. And these children were clearly very happy. Carefree in fact. I commended her. She was doing an amazing job with them. She gave a sheepish smile.

I referred her to a social worker who managed to get her an appointment with legal aid and with another social worker who worked in her area. All I could do was try to help her fight this disease that had already decimated her family.

I wondered what treatment her sisters had sought, if any. I wondered if their efforts to get treatment had been thwarted by the South African government.

But she was getting treatment now and hopefully it wasn't too late.

She was such an impressive person. She was one of those heroes walking around in plain clothing.

Sleep, glorious sleep

Last night my daughter slept through the night. She has been depriving me of sleep for 1 year and 1 month now. She still wakes up in the middle of the night, every night. Except last night. Now, I am not under the delusion that she will sleep through the night every night or even most nights from now on, because my three year old son still wakes up at night at least twice a week. But at least he goes back to sleep almost immediately. Anyway, the point is, this morning I woke up feeling refreshed and that doesn't happen very often.

It got me thinking about calls: and lack of sleep and how exhausted I used to be as an intern. And how it's nothing compared to how exhausted I am as a mother!

I hate calls. Fortunately I don't do calls anymore, but having to get up 2 to 3 times a night to feed a baby or put a toddler back to bed is like doing calls in itself, except you're on call every night and every night you're guaranteed to be called out and it's certain that you will be called out more than once. And even though you don't actually have to get dressed and go to the hospital, it is constant and by far more exhausting. As soon as you fall asleep again, the "beeper" goes off yet again. Normally, on a call like that it would be better not to sleep at all, but you don't really have that option as a mother. And sleeping when the baby sleeps... well, that's a laugh! And there's no such thing as sleeping in or taking a nap either. the kids will have none of that!

But I think the problem is more interrupted than litttle sleep. I think interrupted sleep is much worse than getting even a solid 4 hours. When we went to Las Vegas recently, my mom babysat for us and so, although I was jetlagged, when I slept, it was uninterrupted and so when I woke up, I wasn't exhausted. I felt rejuvenated even. It was strange because I'd kind of become used to the sleep deprivation.

But I'm back to being a walking zombie now. Hopefully not for much longer though.

SurgeXperiences 305: This Is Africa

Welcome to Africa for this 305th edition of SurgeXperiences:
we have some great articles for this edition of the fortnightly surgical blog carnival...




Sid Schwab of Surgeonsblog writes about the current health care debate in the USA and points out how private healthcare insurers do not provide cover for what you really need it for. They are businesses after all and a "Guy's gotta make a buck, right?" We all know that insurance companies will try anything to get out of paying out, but some of these examples of exclusions are ridiculous. Dr Schwab states: "The question is, does the current system work and is it sustainable without significant change? In my view, the answer is clearly no."

In another post from Surgeonsblog, Dr Schwab talks about one of the most difficult decisions a surgeon has to face: the decision not to operate. A fitting piece of advice given to one of the commenters by a wise mentor: "not everyone has to have an operation before they die".




Dr Alice from Cut On The Dotted Line tells us what it's like to spend a day in the cardiac ICU. Part 1, only takes us through her morning, but it seems like a full day already! She concludes here.



rlbates does an article review on radiation therapy and breast reconstruction, a very important topic in women's health, the approach to which appears to remain contraversial.



The ever proliferative story teller Bongi tells a poignant story about memories and reflection and how one can never really go back; a stomach turning story (if a surgeon gags, you know it's gotta be bad!); a very typically South African story; and an absolute must read about a frightening, surreal experience he had as a student in a maximum security mental institution - or it may have been a scene from a bad zombie movie, I'm not sure ;)

Jeffrey Leow, looks back on his psychiatry rotation. It's a very interesting reflection and a worthwhile read.



KevinMD talks about operating on patients with situs inversus.




Shirley Wang of The Wall Street Journal Health blog interviews Elliot Haut, the first author of a recent study published in Archives of surgery, which found that a trauma surgeon's experience makes no difference on patients' likelihood of survival. The overall system of care appears to be the important factor. Interesting. Take a look.




Sheepish from The Paper Mask, talks about the growing discipline of Cosmetic Medicine and the lack of regulation and standards in the industry. I've always found it interesting that people are very careful to take their cars, appliances, electronics, etc to an accredited dealer only, yet will take major risks with their health and lives by going to somebody who may or may not be properly qualified or even somebody who has no qualifications or accreditation at all, when your health is the very thing you should never mess around with. Boggles my mind.

Dan J. Schmidt tells a story on Pulse about why he chose to go into Family Medicine despite the allure of surgery and trauma.

Elizabeth Gudrais brings us an article about Atul Gawande, a "slightly bewildered" surgeon who also writes for the New Yorker.

Ralph Silverman: The Colon Doctor talks about legal pitfalls in surgery.

A shocking story of a Swedish surgeon who removed an ovary instead of the appendix and only received a warning.

Howard Luks tells us in his Orthopaedic Posterous how social media has influenced his practice positively.

Adam Frucci from Gizmodo tells us about a Brain Surgery Simulator. Looks like a very useful tool for neurosurgeons to plan their surgery.




Wat Tyler talks about the shortcomings of the NHS, reform and a possible solution on Burning our money.





The next edition of SurgeXperiences will be over at Other Things Amanzi on 20 September 09. Be sure to submit your posts via this form.

Thanx for coming!

SurgeXperiences 305

Surgexperiences edition 305 will be hosted here on 6 September 2009!

This surgical blog carnival is open to anyone and everyone who has a surgical blog or article to submit.

Please submit your articles via this form by midnight on Friday 4 September.

Looking forward to reading your articles!

Don't judge a book by its cover

Few patients around these parts are clued up about their health care. They usually don't have any idea what medical conditions they have or what medication they are taking and why (patients on ARVs tend to be the exception, but even they can't usually tell you on their first visit what other medical conditions they have). Add to that that there is usually a language barrier, and taking a history can be difficult at best in South Afican hospitals. I have an interpreter at my disposal these days, but back in my student and intern days it took very long to figure out why a patient was presenting. I would often hit a snag at the second question "How old are you?"("What is your name?" would usually go off without a hitch). Back in medical school it took all of us a little while to figure out that when we asked a patient their age, they were giving us the year in which they were born instead. None of them actually knew how old that made them. They would say "64" meaning 1964, but we didn't know that at first and we'd say to each other " but he doesn't look that old". It was a waste of precious time in short cases in clinical exams when you'd have to waste 2 of your 15 minutes trying to figure out how old someone was when you could have been asking them important stuff (like what their dog ate ;))

I saw this patient a while back. He didn't speak English to me so I used an interpreter to take his history. He had a miriad of complaints, none of which I can remember now because none of them were very serious. When I examined him, I noticed he had a rash which looked suspiciously like a drug induced rash. I asked the interpreter to ask how long he'd had it and whether he'd been taking any medication before it started. He answered her in Swazi. I said out loud "This looks like a drug rash". He looked at me and said "It was a Stevens-Johnson syndrome that was caused by TB treatment. I was in hospital for about a week and then it got better."

Disclosure

Disclosure has always been a major controversial issue amongst HIV clinicians and the public at large. Unfortunately discrimination is still a fact of life around here. Many HIV positive people are the victims of unfair dismissal by their employees. Many are shunned by their communities and even their families. But when it comes to sexual partners, I don't think there should even be any question about disclosure. Yes, everybody should have safe sexual practices, but if you know you have HIV, I think you have a responsibility to your partner to tell them what they are getting themselves into before you get involved with them.

I saw this patient: an older man who had quite advanced HIV disease. He was in a profession that implied that he was well educated. It was about his third visit and he was due to start ARVs. His wife and daughter were with him. He complained of urinary symptoms, so I asked my assistant to take him to have his urine tested. As soon as they had left, his wife turned to me and asked "doctor, has he been tested for HIV?" I was a bit puzzled for a moment. I tried to gauge what her understanding was of why her husband was seeking medical attention and that from an HIV clinic, but she did not understand what I was saying. She spoke a broken English whereas her husband was fluent in English. So fluent in fact that I did not use a translator to speak to him. The situation became clear to me: he had not disclosed his HIV status to his wife and because she was clearly not nearly as educated as he was and not able to speak English well, she had not been able to follow what was going on at his medical visits. He was not being forthcoming with her.

Her husband and my assistant then returned, I pulled my assistant aside and said to her "this patient's wife just asked me if we have tested him for HIV. I think he has been keeping her in the dark about his diagnosis. Can you please speak to them and figure out what's going on." My assistant asked the wife to leave the room and spoke to the husband in his first language. In the meanwhile, I finished my clinical notes and filled in his prescription. After a while she called his wife back in and spoke to her for quite some time. She then led them away and told me she would fill me in on what had happened when she got back.

This she did. The patient had been sick for quite some time. He had been married before and this was his second wife and he had in fact been sick when he had met her. I wondered who gets involved with a man who is so sick. But I digress. The wife was very young - she had just turned 21 - whereas her husband was in his fifties. He had not disclosed his HIV status to her, as I had suspected. But worse than that, he had known his HIV status when he first met her and did not tell her. My assistant had explained everything to her after speaking to her husband and had taken her HIV counselling and testing. She was positive. This woman was clearly not very intelligent and was very poorly informed about HIV, but her husband was clued up and had not only known he was HIV positive when he met her, but in all likelihood had transmitted it to her. My suspicion was reinforced by the fact that she was clinically very healthy, but not only that, she had a very healthy toddler with her. This implied that she had early stage HIV and probably did not have it when she was pregnant. Her husband, however, had very late stage HIV. I asked if the patient was the father of the child, who looked to be about 1 and a half years old, and my assistant said he was not. The woman had had the child before she met him. I breathed a sigh of relief. The child was most likely not HIV positive. I mentioned that the child should be tested anyway and my assistant said that the woman had decided to have the child tested at their next visit. The whole thing upset me so much, but at least the child would probably be ok I thought. But then it occurred to me that I had seen the woman breastfeeding the child - one of the ways HIV is transmitted from a mother to a child.

Master and servant

"Many of my past relationships didn't work out because the other person didn't realise they belonged to me" - Jack MacFarland, Will & Grace.

There is a syndrome which I believe to be uniquely South African. It is called "Madame syndrome". Bongi coined the phrase. It involves middle class (usually white) women - the madames, for this is how they are addressed - and their household help: the domestic workers. The Madames tend to take ownership over their employees - for their own good of course - and therefore usually accompany them to the doctor/clinic/hospital because they feel they are incapable of doing it by themselves. Incapable of telling the doctor what the problem is, understanding what the doctor diagnoses them with and totally incapable of understanding what medication they must take and how and why. One madame actually told a friend of mine, when told that her gardener was not a child but a person in his own right, that he had the mind of a child. Seriously.

All of us have seen the Madame Syndrome and often, but it still irritates the crap out of me.

The most satisfying encounter I've had with a madame was when one brought her gardener to the casualty unit of a hospital where he was accepted, even though he did not fall into the catchment area. She came to complain to me about the "blond nurse" who had initially not accepted her gardener and who had given her "a hard time" before accepting him as a patient. That "blond nurse" was in fact, not a nurse, but a doctor, and not just a doctor, but an emergency medicine specialist and happened to be the head of the emergency unit. When I told her this, she demanded to speak to the superintendent of the hospital then. As the superintendent was away on leave, the "blond nurse" also happened to be the acting superintendent at the time. The madame was furious and vowed to take further action. I thought she was ungrateful and pathetic, as our unit had accepted her gardener as a patient, against our policy and had given him pretty damn good treatment! I couldn't help but laugh inwardly at her frustration.

Recently I was involved in two distinctly different cases of Madame Syndrome.

The one involved a friend of a friend. This friend called me up one day to say that her friend had a problem. She had convinced her domestic worker to have an HIV test as the domestic worker's husband had recently unexpectedly succumbed to an unknown illness. The problem was that the HIV test had turned out to be positive and she now did not know how to break it to her or what to do about it. That's right, she had taken her to have an HIV test, she had had no counselling or preparation, and then she was not even given her own results! The pathologist had given the results to the madame! I was disgusted, although I didn't make this evident. I told her that the best thing to do would be for her friend to bring in her domestic worker and we would do proper counselling, testing and further management. Afterwards I was fuming. I have always had a low tolerance for madames. I decided that I would speak to her if she came in with her domestic worker on the appointed day, which she inevitably would. Unfortunately, our paths did not cross.

The other case was a proper referral. I saw the madame in the waiting room with whom I assumed was her gardener (he turned out to be one of her farm hands). I was annoyed before the fact. As it turned out, when it came to be his turn, I happened to be the next available doctor. He needed to have his vital signs taken, so he was taken to the nurse's room first. I got ready for a confrontation when he was called and his madame started following him to the room. There wasn't enough space in the room so she waited at the door. I went into the room, closed the door and asked the nurse to ask him who the woman accompanying him was and if he wanted her to come in with him for the consultation. He said that she was his madame. He said that he did not want her to come in. He was the patient and he had decided so I prepared to enforce it.

When his vitals had been taken, I asked him to follow me to my room. His madame followed. When we got to the door of my room I stopped and asked her "Are you his employer?" and she said "Yes". "I'm going to have to ask you to wait outside" I said. Unexpectedly, she answered "Of course". I felt a bit confused actually. She went on to say "I'm a registered nurse and I respect his confidentiality, I just wanted to tell you what I know." She told me what doctors he had seen previously, what they had diagnosed, what they had prescribed and the progress he had made. I felt a bit sheepish. "Thank you" I said. She waited outside during the consultation. I asked the patient if he wanted me to tell his madame what I'd found and what I would do. He had absolutely no problem with it, so I called her in and brought her up to speed. She was very co-operative and very grateful and I had a chance to see them interact with each other. Their relationship was not the typical master-subordinate one I was so used to seeing. I was pleasantly surprised.