Friday, November 27, 2009
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.
Tuesday, November 24, 2009
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.
Thursday, September 3, 2009
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.
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.
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!
Sunday, August 30, 2009
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!
Wednesday, August 5, 2009
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."
Monday, August 3, 2009
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.
Monday, June 22, 2009
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.
Sunday, May 31, 2009
The ones left behind. In my line of work and especially in the setting in which I work, I see alot of widows. There is still a very strong belief in the local community where I work that a widow should be completely dressed in black for at least 6 months and even for up to a year. I've already been told by my significant other that if he were to die, I have to wear black from head to toe for a year!
But seriously, I always feel a deep sense of loss when I see one of these women in the waiting room and especially when one of them consults me. In true doctor stereotype, I never really know what to say to them. I mean, what can you really say to someone who has lost their life partner? Yes, some people take it harder than others, but I just imagine how devastated I would be if it were to happen to me. I usually just give my condolences, which they acknowledge, and then feel very inadequate. I always send them for grief counselling - I have such respect for those counsellors for knowing what to say and do.
As doctors, I think we tend to try and stay clinical because the work we do and the things we see would destroy us in no time if we reacted to it as people normally do under normal circumstances. But we do not work under normal circumstances. The circumstances are extraordinary, unnatural. So we keep a certain distance. We get philosophical. We switch off when it gets too emotional or when we can feel it permeating too deeply. But neither can we allow ourselves not to be affected or we would be in danger of losing our humanity. So I feel their loss. Then I move on.
I think it is probably a sexist society that dictates that a widow must outwardly show her grief by wearing black whereas a widower is not under any obligation to show any outer sign of mourning, but then again, most cultural norms and beliefs are passed from generation to generation by the women of that culture. Still, I think it is a very beautiful thing for a woman to show that she is mourning her husband's loss. However, I don't think that she should be forced to do it. In any case, whenever I see one of these women in black, I find it very poignant.
Sunday, May 24, 2009
The editor forwarded my letter to the dietician who sent me a direct response:
I am certainly very aware that anti-oxidants in fact are involved in the complex processes relating to free radical damage associated with oxidative processes, that some do not necessarily posess anti-oxidant status (e.g. zinc) but are important in inherent defence mechanisms and that the link is not necessarily directly between the anti-oxidant and the bacteria/virus. However, in the spirit of the article and trying to make the point that food remains vital to enhance health - rather than supplements, I have tried to simplify the complexities associated with anti-oxidant functioning, colds and flue and the potential and role nutrients have and play in preventing disease. In addition, our editorial team had to cut text again and in the process of this, another bit of vital info got lost.
You are therefore 100 % correct in your assessment that this statement is not 100 % correct - thank you for bringing this to our attention.
I feel she was trying to justify telling an untruth for the greater good - although in this case it was actually a lie - and I'm not sure if that is justifiable. I think that as medical professionals we are obligated to hold ourselves to higher standards.
Friday, May 22, 2009
She says she's a bit nervous do that because she's still rather new. So the anesthetist (who is just as bad as the surgeon, if not worse) volunteers to do it. He dials and the surgeon says "tell me when you're speaking to him and I'll start shouting". He chuckles menacingly. The guy answers and he puts the call on speaker phone.
He tells him that nothing is working and that nobody knows how to fix it. The surgeon timeously shouts "I can't work under these conditions!". The anesthetist goes on to say that his rep has been reduced to tears.
"I knew I should have come myself" he says, "I knew she couldn't handle it!"
The theatre explodes with laughter and he realises he's been had. He says something about the surgeon always trying to unnerve him. We all laugh.
Everyone except his rep that is ;)
Saturday, May 16, 2009
I've often wondered why patients bother to lie to their doctors. We have seen just about everything in the book as well as most things not in the book.
There's not much that phases me anymore and when someone has done something really stupid or embarrassing, I tend not to judge them, but when they lie (and trust me, a doctor tends to know when a patient is blowing smoke) that just down right annoys me...
If you get shot or stabbed in the middle of the night and come into casualties in a drunken stupor, we are not going to buy your story that you were selling bibles door to door and some heathen attacked you unprovoked and unexpectedly because you have nothing but goodness in your heart.
If come in with a foreign body stuck in your rectum, we are not going to believe that you were naked because you were on your way to the shower and en route accidentally slipped and fell onto it!
If you have half a steak stuck in your oesophagus, we are not going to believe that you only took a small bite and that it must have somehow expanded because of all the water you drank to try and wash it down.
Medicine is evidence based, so if the evidence is there, we'll believe what the evidence shows us.
I had this patient who complained of severe earache. I had a look and saw mostly wax, but peaking out from behind the wax I saw something which didn't look entirely normal. I actually thought it kind of looked like the leg of on insect - those things can get anywhere. I told myself it may just be a hair coated in wax, but I was not convinced, so I had no choice but to syringe the ear. Now, I absolutely hate syringing ears. When I was a 4th year medical student, we went on an "ENT camp" which basically entailed us syringing the ears of underprivileged patients for three days straight. It was horrible. I saw (and smelt) things there that I never want to see (or smell) again. But obviously I had to do it.
So I syringe and a whole lot of wax comes out. Then I look in her ear again and see what looks like tissue paper or cotton wool. So I ask if she had put an ear bud or something into her ear and she says no, she didn't put anything in her ear. Yeah right, I think. I syringe again and more wax comes out. Then, I syringe and out comes a blob of cotton wool coated in wax. I pick it up and show it to her.
She says she doesn't know how that got in there.
Tuesday, May 12, 2009
I must say though that if the company doing the construction cannot even label its construction vehicles properly, I have very little faith in them building our roads and bridges!
Friday, April 3, 2009
That's Doctor Evil, I didn't go to six years of evil medical school to be called miss, thank-you very much...
This patient was an older man who was referred from the occupational health clinic at his place of employment. He was in the public transport industry. He was HIV positive with a CD4 count of 186 and had recently completed a full 6 month course of TB treatment. The referring sister had sent him for ARV treatment.
This was his second visit and one of my colleagues had seen him previously, repeated the CD4 and taken some other baseline blood tests. He had also prescribed some vitamins and sent him for an adherence class to prepare him for starting ARV's. I now had his blood results before me. His CD4 count had gone up to 258 - not really surprising since the CD4 count fluctuates anyway, but more because it tends to go down when a patient has an opportunistic infection such as TB an goes up again once it's been treated. I conveyed this information to him. He understood English but didn't speak it very well so he spoke to my assistant in Swazi and she translated for me. He said that he did not want to start ARV's as he didn't need them now since his CD4 had gone up. That's reasonable I thought. The cutoff for ARV's in our country is 200, even though the WHO recommends 350 in countries such as ours where TB is rife. We tend to start at higher CD4's than the state clinic's so he could still have started ARV's then if he wanted to but it was also ok to wait a while.
But I had also noticed that his blood pressure was very high. I checked my colleague's notes and saw that it had been high at the previous visit as well. It was so high that lifestyle changes alone would not good be enough. I explained to him what it meant, about end organ damage and that we needed to start him on anti-hypertensives.
His response was simply that his blood pressure was not high.
I explained that it was in fact high. Again he told me that it was not. Just like that.
I was a bit stunned and didn't quite know how to respond to this. I've seen patients who were in denial about TB or HIV before but never one who was in denial about Hypertension! I was also quite insulted that this uneducated man simply disregarded my medical education and clinical skills and simply told me that I was wrong.
I took a deep breath. I had visions of him transporting a load of people and having a stroke or heart attack behind the wheel, crashing and leaving a bunch of dead people scattered all over the tarmac.
I remained calm. I told him that I was not doing guess work, that this was a physical parameter and that I had measured it and it was, despite his expert input, high and needed treatment. I tried to convey to him that he was responsible for the people he transported and that with a blood pressure that high, a stroke was a high likelihood.
At this point he got aggressive. He told the interpreter that there was in fact nothing wrong with him, he did not have high blood pressure, he did not even have HIV, he did have TB but that had been treated, so there was actually nothing wrong with him now. He said that we were wasting his time and that the last time he'd been there, he'd flushed the tablets we'd given him down the toilet. I must admit I found that a bit amusing. Why did he even bother to take the tablets then? I pictured him standing over the toilet cursing and angrily flushing the tablets away, mumbling about how he was in perfect health and we were all deluded. He said that the only reason he was attending was because he had been referred to us by his occupational health nurse and because his employer was paying for it and had money to throw away.
I developed an acute case of compassion fatigue.
I sent him on his not so merry way, didn't bother to give him a follow up date and sent a letter to his occupational health nurse by email asking for him to be boarded him until his blood pressure was under control. I then called her to make sure she had received my letter and discuss the case with her. She shed some light on the matter saying that very high blood pressure was considered an occupational hazard and that he knew this, which was probably why he had behaved the way he had.
I had little sympathy for him. It was a problem that was easily solved, but he was not interested. If he didn't want treatment, that was his problem, but I was not about to let him put innocent people at risk.
Wednesday, April 1, 2009
Friday, March 20, 2009
Needless to say, he failed.
It got me thinking about sexism in medicine. It's is one of the disciplines where sexism is not really an issue anymore. Females doctors are equally respected and are paid the same for doing the same job. But sexism definately still rears its ugly head on occasion. Especially in surgery. I recently experienced it myself. At least I think it was. Maybe I'm wrong.
There's this surgeon who I assisted every Friday. I then went on maternity leave but there was an understanding that when I came back, I would once again be his regular Friday assistant. However, when my maternity leave was over, he told me that he had gotten a new regular assistant, an older man, and that he couldn't just let this guy down. He suggested I could assist him every alternate Friday. I pointed out that he had essentially given my job away. I told him that the clinic where I work the rest of the time had also gotten a replacement while I was away, but had told that locum that when I came back, they would have to leave. Let me just mention here that I was on unpaid leave, so my employers didn't even lose any money while I was away. Anyway, the surgeon eventually agreed that I should be his regular Friday assistant again.
This past Friday, I assisted, but the first case was a Nissen so the new guy was also there. He took of aside and said I could decide what I wanted to do. Of I course I said that I would prefer to do the camera work if he didn't mind. He said it's fine, but when we told the surgeon our decision, he said he wanted the new guy to do the camera work since his eye was now in (and I had just come back) and that I could do it next time. Fair enough, I thought.
Okay, here comes the incident in question. I noticed that the surgeon allowed the new guy to do all the prep work for the op. He had never allowed me to do this. He was always a control freak when I assisted him. He always did all the prep work because he said he was the only one who could do it properly. I thought he was just being a typical surgeon. Yet, now, he was letting the new guy do everything. After the op, I spoke to him in private and asked why he never allowed me to do the prep work but allowed the new guy to do it. He said that he trusted new guy because he had corrected him on all his flaws and had perfected his technique. He tried to make light of it and told me I might find it funny to know that the first time the new guy did it, he didn't dry the lenses properly and it was a complete mess up. He laughed. I didn't find it funny. What I got out of this little exchange was that the first time new guy took the equipment and started to prepare it, the surgeon did not stop him as he had always done me. And even though he messed up, the surgeon allowed him to do it again a few times, because that's what it takes to "perfect your technique" in my mind. I didn't say anything more on the topic.
Maybe I just misinterpreted what happened, but I doubt it.