Amanzimtoti

Tables turned

2010-11-25T08:54:00.000-08:00

I saw this patient who complained of heartburn. I gave her standard treatment and told her that if she did not respond, we would refer her for gastroscopy.

Months later I saw her again. This time she complained that the medication she was on was making her feel sick. She was very aggressive and accusative, as some patients get when they feel you are not giving them the right treatment. I checked and saw that it was metronidazole. Now, drinking alcohol while taking this particular antibiotic makes you feel dreadful, so I asked about alcohol consumption. She immediately denied it and became very defensive. I then asked about her heartburn. She said it wasn't getting any better. I asked about Grand-pa (a headache powder containing aspirin and caffeine) or aspirin use, as abuse of these can cause peptic ulcers. She had previously denied it. This time she paused for a while and then admitted to occasionally using Grand-pa. I starting explaining the link between Grand-pa use and ulcers. She then immediately backtracked and claimed it was actually paracetomol she was using.

I told her that we should refer her for gastroscopy and started explaining what it was. At this point she interrupted me and said that she had already had this procedure done. Oh, ok, I thought. I asked what they had found. "They found that I have ulcers" she said. Great, I thought, a diagnosis! "I'm taking tablets", she continued. I sighed on the inside. Usually at about this point my heart sinks because people who start with the statement "I'm taking tablets" often don't know what these tablets are. We usually become entangled in a complicated web of descriptions of size, colour, frequency, shape and formulation. For example: I take half of a small white diamond shaped tablet in the morning, two large round yellow tablets in the morning and at night; and a large blue and white capsule at night. This usually doesn't help me at all because, firstly, I'm not a pharmacist and, secondly, you get alot of small white tablets and alot of large yellow tablets.

"Do you know the name of the medicine?" I asked. "No" she said, as expected. "Actually, it is the same colour as your pen" she exclaimed. I looked at it. Coincidentally, it was a Nexium pen given to me by a drug rep. I turned it around to expose the label. "Is this the tablet you're taking?" I asked, showing her the label. "Yes" she declared happily. "But this is a treatment for ulcers" I said surprised. "Are you sure you aren't drinking Grand-pa?" I asked, knowing that this is probably why the Nexium wasn't working. She went quiet and I knew.

"You should stop drinking the Grand-pa and you'll get better I said". She smiled a sheepish smile and said "ok".

What's in a name?

2010-05-26T01:50:00.000-07:00

I collect odd names. I realise now that sounds a bit weird, but having a odd name myself, I think it's fine. Anyway, here are a few odd names I've picked up over a couple of years. They're a mix of patient and non patient names, including waiters, shop attendants, etc. - generally people who wear name tags. No surnames are included.

Nappy - this is the non American word for diaper.
Surprise - his mom was obviously not expecting him!
Simian - maybe mom anticipated he would do alot of monkeying around?
Trinity - a cool name if you're a female superhero in an alternative future where machines rule the world.
Father - he was named after a Catholic priest. I asked. I don't think his parents realised though that "Father" was his title and not his first name.
Girly - must have been the only girl.
Pietstraus - Was named after a guy called Piet Straus. I asked.
Sakkie - Afrikaans for packet.
Icy - either it was very cold when he was born, or he gave his mom the cold shoulder. I think so anyway.
Goodboy - self evident. Or maybe wishful thinking.
Treazer - should be a character in Harry Potter.
Class - was born in a classroom maybe? Maybe his parents thought he had alot of class? Maybe his parents wanted him to become a teacher? Maybe he was named after a guy called Klaas.
Million - one in a million maybe?
Mongo - it just sounds funny.
Ribon - why would you name your child ribbon? Maybe she felt she deserved a blue ribbon for her efforts. I know I did after I gave birth.
Staffnes - he was named after the staff nurse who delivered him. hehehe.
Saloon - as far as I know we don't even have saloons in South Africa!
Wonderful - quite sweet actually.
Lickim - hahahahahahaha! Maybe it's supposed to be Likehim.
Sycho - maybe he is.

Priorities

2010-05-24T03:46:00.000-07:00

So I see this patient and she's at death's door. She has multiple pathology and needs admission to hospital. I'm pretty sure I can pull her through, given the chance. But will I be given the chance?

Her husband has escorted her in and whilst I'm filling in the admission forms, the nursing sister comes to me and says that the husband wants to leave and take his wife with him. I'm flabbergasted. "What's the problem?" I ask. "He needs to go back to work and there's no one but his wife to watch the children" I'm told. I feel relieved. Easily solvable. I'll give him a medical certificate I say: family responsibility. He can't stay even if given a medical certificate, I'm told, because he has already been off of work for three weeks and if he doesn't go back today he'll lose his job. I stop dead in my tracks. "So what has he been doing for the past three weeks?" I want to know. "Why didn't he bring his wife in then?" (I should have known something was up when she claimed that she'd only been sick for 3 days even though she had clearly been sick for quite some time.) "She has been getting treatment from the traditional doctor."

At this point I am more than just a little annoyed. The husband comes in. "Why didn't you bring her in when she didn't respond to the sangoma's treatment 2 weeks ago? Or even 1 week ago?" No reply. I struggle to understand what the hell is going on. I know they're not being forthcoming. Why would he refuse help for his wife when she's clearly in a very bad way? But what can I do? The sister calls the social worker to counsel them.

I finish the forms and go back to seeing other patients. I go back a short while later to find out what progress we've made. They're gone. "What happended?" I ask the nurse. "They left" she says bluntly. "But why? I ask."

The story emerges: The wife was being treated by a sangoma and they were paying good money for this treatment. That morning, before I saw her, they went for another treatment. This time however, they informed the good sangoma that their money had dried up. He then promptly informed them that, on second thought, he could no longer help them, but that she probably needed an HIV test and that there was a good clinic (ours) she could go to where they would "save her life". That's how they ended up with me. Because he had stayed out of work for so long and given the sangoma all his money, however, the husband had gone into a panic about losing his job. At the last minute. So he took his sick wife home to watch the kids, while he went back to work.
I could not understand his logic. Who is going to watch the children when she's dead, I wondered.

But the more pertinent thing here is the fact that this sangoma preyed on these desparate people. He took their money when he knew he was giving her the wrong treatment.

Collateral damage

2009-11-27T08:08:00.000-08:00

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

2009-11-24T22:20:00.000-08:00

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

2009-09-03T14:32:00.000-07:00

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

2009-08-30T06:29:00.000-07:00

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

2009-08-05T09:36:00.000-07:00

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

2009-08-03T05:30:00.000-07:00

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

2009-06-22T06:40:00.000-07:00

"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.

In mourning

2009-05-31T04:44:00.000-07:00

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.

Misinformation

2009-05-24T12:03:00.000-07:00

I read this article in a parenting newsletter recently and was actually impressed with its useful advice. However, there were two things that bothered me about it: firstly it states that probiotics strengthen your immune system, which isn't actually true, although it does boost the immunity of your intestinal mucosa, so it is somewhat true. But then it also had a blatantly false statement saying that anti-oxidants scavenge viruses and bacteria.

I decided to write to the editor. I didn't mention the probiotics statement because I thought there was an element of truth in it, but I pointed out that the antioxidants statement was completely false and that although antioxidants do infact help your body fight viruses and bacteria by scavenging free radicals and thereby strengthening the immune system, they do not directy fight viruses and bacteria. I thought this was important because perhaps the next time Jane public's kid has a bacterial infection she might think it's ok to only give the kid some anti-oxidants. Which may not be the brightest thing to do, but it illustrates how misinformation can be dangerous, especially in today's media hungry, self diagnostic world.

The editor forwarded my letter to the dietician who sent me a direct response:

Thank you for your comments. Indeed, this is a good example of what can so easily happen and the dilemma with which we are often faced when having to try to translate complex and often detailed explanations into simple language whilst having a limited number of characters at our disposal. For example, consumer research has shown that even a concept such as 'FREE RADICAL ' is poorly understood - let alone oxidate damage, reactive oxygen species etc.

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.

Foot-in-mouth disease

2009-05-22T07:41:00.001-07:00

I was assisting in threatre today and we were doing laparascopic work. We were using a new system from a guy whose equipment we've used before - and this guy is really panicky on a good day. So today he actually had to be somewhere else, so he had someone else come to theatre (I think she's his rep or something) to see that there weren't any glitches. So at a stage, the surgeon tells this rep to phone the guy and tell him the screen is not working, the surgeon is screaming and that all hell has broken loose, basically.

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 ;)

...pants on fire

2009-05-16T00:58:00.001-07:00

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.

Road works

2009-05-12T09:48:00.000-07:00

My commute to and from work has been quite difficult lately: there are road works on the one and only road between the town where I live and the town where I work. It's quite annoying to have to sit in such slow moving traffic every morning and every afternoon considering we moved here to get away from the big city and its evils such as traffic.

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!

That's Doctor Evil, I didn't go to six years of evil medical school to be called miss, thank-you very much...

2009-04-03T09:58:00.000-07:00

I've had my share of difficult patients but one in particular stands out...

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.

Shocked

2009-04-01T08:10:00.000-07:00

I heard on the news today that a doctor at a Johannesburg hospital allegedly raped a patient at the hospital's rape centre! So this woman was raped, and then the doctor who was supposed to help her and care for her, violated her. It's too shocking for me to accept that this sort of thing can happen. Even in South Africa.

Sexism

2009-03-20T23:21:00.000-07:00

I recently attended some lectures where the speaker told us about an exam question she'd set about adherence to HIV drugs. Some guy had answered: 1. Rural people cannot be trusted to be adherent 2. Especially women.

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.

Leave of absence

2009-03-20T23:10:00.000-07:00

I haven't posted for a long time. Having two small children and then going back to work as well has kept me busier than I could ever have imagined, so I haven't had much time to do anything else, let alone blog. This has also been aggravated by the fact that my phone's been giving me problems so I couldn't blog with it, and I can't usually use the computer at home because a certain surgeon tends to hog it :) Hopefully I can get back into things now.

Red tape

2008-11-05T08:53:00.001-08:00

I find dealing with medical aid's extremely frustrating.

Before I could be admitted for confinement I had to obtain a pre-authorization number from my medical aid scheme. The first time I called (which was about a month before my due date) I was told to call back in two weeks because the authorization was only valid for two weeks. I was also told that because it was for confinement, I could call at any time if I went into labour because obviously I could theoretically go into labour at any time and they would then immediately give me authorization. When I called back two weeks later I was told to rather call back on the day I went into labour because that would ensure the number wouldn't expire. Fair enough I thought.

So on the morning that I started having contractions I called the medical aid for my authorization number. The call centre lady asked if my due date was still the same. "Yes" I answered, "but I'm having contractions now so that's why I'm calling for the number now". "Have you seen your doctor yet?" she asked. "No" I replied. There was a short silence, then she gave me the number. At the time I had so many other things on my mind that I didn't really have time to get annoyed.

So I went to the labour ward that evening (21 October) as I've mentioned and gave birth the next morning.

This morning I received an account from the anaesthetist and a note asking me to submit the account to my medical aid scheme. I thought this was strange as accounts are usually submitted by a doctor's secretary so I phoned the medical aid to find out if they had in fact received the account. I was told that the claim had been rejected as their records show I was admitted on the 22nd and how could the doctor operate on me on the 21st if I wasn't even there? I was completely taken aback by the pedantry. Obviously there had been a mix up with the dates somewhere, but they were using this as an excuse not to pay out. I felt my spirits sink because I knew this meant I was in for a fight and I hate fighting.

"I was admitted to the labour ward on the evening of the 21st" I said "and delivered the baby on the morning of the 22nd. And he didn't operate me, he gave me an epidural". "What time were you admitted to labour ward?" she asked. "In the evening around 5" I replied. I didn't see the relevence of the time, but anyway. "Well that's not what our records show" she said, "we'll need a motivation from the doctor". Damn, I thought. I know how much doctor's hate writing motivations. I could tell I wasn't going to get anywhere with this woman so I said goodbye and decided to call the hospital.

Dealing with the hospital was pain free. I stated my problem and was immediately put through to the right person who told me that their records showed I was admitted on the 21st but that the medical aid had probably not received their account yet. She gave me her name and number and said I was welcome to ask the medical aid to phone her directly.

I then decided to phone the anaesthetist's rooms and speak to his accounts lady to cover my bases. This was a mistake. When I told her what was going on she started moaning like a banshee. As I was listening to her tirade, I considered cutting her off and being short with her. After all, it wasn't my fault, why did I have to listen to her whining like I was her boyfriend? You don't shoot the messenger! But I decided to just let her go on because I was too tired to fight - I regretted this afterwards though. When she came up for breath after about 2 minutes of ranting, I told her I'd try to sort it out and get back to her. She then started ranting about the medical aid again before she finally said goodbye.

I phoned the aid scheme again and told them that the hospital's claim did show I was admitted on the 21st. I was told that the authorization was for the 22nd. You have got to be kidding me, I thought. After all the run around I got from them about the authorization? This just pissed off. I was put through to another department.

Once again I stated my case to the next person I spoke to. She put me on hold to check something and when she came back she told me that the project manager wasn't in so she took my number and told me... she'd call me back.

NVD

2008-11-01T10:07:00.001-07:00

So I narrowly escaped having my baby cut out by a gynae.

Due to unforseen circumstances, I ended up having my baby in Cape Town. This meant I had to find a new gynaecologist/obstetrician. My cousin suggested her gynae and I went with him.

I started having contractions last Tuesday morning. As I've mentioned before, my first labour went very quickly, so I was anxious about waiting too long before going to the hospital. When my contractions started getting reasonably strong I decided that maybe it was time to go in. My partner suggested I rather call the gynae first. So I did and he suggested I go to his rooms and he'll check me out. When I got there, I was having fairly strong contractions. However, my cervix was still closed, but because my first labour had progressed so quickly and I was already having strong contractions, the gynae wanted me to go in to hospital. Both my partner and I were uncertain about this but we decided to go through.

We went home first (my parents' home) to pick up our son and my mother to go along to the hospital. When we got to the labour ward, the nurses remarked on how the gynae had been phoning constantly to see where I was. Not a good sign.

The midwife set me up in the labour ward and gave me an enema as per the doctor's instructions. Unpleasant. Anyway, she then told me she would call the anaesthetist to get me an epidural. I said I felt it could wait (I wanted to know how far I had progressed first because I didn't want to have the epidural too early) but she told me the gynae had said that the anaesthetist was very busy and that if I didn't get it then I might end up not getting it at all. My contractions were starting to get quite painful and I didn't want to end up not getting an epidural. Also, I knew they could top it up if started to wear off, so I agreed to go ahead with it. The anaesthetist who was first on call was indeed too busy so the second on call came in. He also apparently had alot lined up that night so in the end I was happy I'd gone for it then.

The epidural was much more painful than my first one had been and I reacted quite badly to it. At a stage the anaesthetist even dropped my bed and drew up some adrenaline. I recovered with only fluid resus though. I felt terrible though and at a stage I even wondered what was worse: the pain or the effects of the epidural? (The epidural started to wear off later though and I came to the conclusion that the pain is definately worse!)

Then my gynae came to see me. He remarked to the anaesthetist that he was exhausted. I knew this didn't bode well. He did a PV. I was only 1cm dilated. He seemed unhappy. It was already about 8 in the evening by now. He decided to rupture membranes to speed things along. He came back to check on me about an hour later. 1 and a half centimetres. I knew he would soon try to sell me a caesar. He started talking about how I should have progressed much further by now and started throwing around phrases like "big baby" and "malposition of the head". Then it came: he said that we could either wait and see or we could just call it quits and go for the caesar then. We told him we'd wait.

He decided to go home and asked the midwife to check my progress in about another hour. My partner and I discussed the situation. I felt he should only check on me in another 4 hrs seeing how I was still in passive labour. We both knew there wouldn't be much change in an hour. We knew he would try to coerce us into taking the caesar.

After about an hour, the midwife came to check on me. No change. She called the gynae. She came back with the message. He had given it a chance but I was not progressing so he would book theatre for a caesar. I said no. I told the midwife that as far as I was concerned there was no rush. I was still in passive labour and doing fine and the baby was being monitored and she was fine. If anything went wrong, we would know immediately and then we'd agree to a caesar, no question, but right now, there was no need for it and we were happy to wait.

She seemed to agree with me but said she'd give us time to discuss it.

We agreed that there was no reason to have a caesar. My partner decided to call my original gynae (a colleague of his) to cover our bases. He confirmed what we suspected. We turned down the caesar. The midwife relayed this to the gynae and he asked us for a time frame for how long we were willing to wait. It was nearly 11 at night by then. We said we'd wait until 6 in the morning. She came back and said that he'd told her that if nothing had happened by 06h00 he would book theatre. I was still not happy with that and told her that if nothing had happened by then we could discuss it again. She said that would be easy enough to do.

We decided to try and get some sleep. I was unable to rest easy though. At about 02h30 the midwife came to check on me again. She said she thought something was happening. She was right: I was 5cm dilated. Relief washed over me (and my partner when he woke up an hour later. He slept slightly better than I did ;) ).

By about 05h30 I was fully dilated and the midwife called the gynae. At 05h47 I delivered a perfectly healthy little girl. (He made some remark about how the head must have turned at some stage. Yeah right.)

I ended up having an episiotomy and a vacuum extraction as the baby's head remained high, so it wasn't actually an NVD, but at least I escaped having unnecessary major abdominal surgery.

It's a girl!

2008-10-23T15:18:00.000-07:00

So I've finally given birth, yay! It's a beautiful little girl and she was born yesterday morning :) Quite a story about how it happened but I'll tell it next time. Right now I'm just going to recover and spend time with my family.

Family make the worst patients

2008-10-13T15:03:00.000-07:00

I'm not sure if this is universal, but in my personal experience and those of my close friends and colleagues, your own family members and close family friends are always the worst patients.

Maybe it's because the transition from 'lay person' to doctor happens in front of them so they don't view you as a real doctor, but invariably, when they ask you for advice, they don't take you seriously and they don't bother to take it. It's quite frustrating because you think "why did they bother to ask?" but after a while you just get used to it, shrug your shoulders, shake your head and brush it off.

And they tend to be non-compliant. My dad has essential hypertension. He's had it for years. Still, he tends not to take his meds on time and sometimes even skips a few days. Two of my uncles have type II diabetes mellitus yet still continue to eat poor diets, but not only that, all their kids are obese! If I were faced with such a terrible affliction, I'd make damn sure my kids don't get it, but it's like they're making sure their kids do! All advice falls on deaf ears.

Then there are the phone calls saying they have x, y and z signs and symptoms. You ask a few questions to guage the severity, but whenever you think it might be something serious and suggest they go see a doctor in person to be examined, they say they don't think it's necessary. So why did they ask you wonder once again? But it's pointless trying to get them to listen to you.

And whenever you suggest a certain treatment or specialist, you're invariably faced with "but can't I just do this or use that?". "No" you say. They never listen.

A close family friend told me she had a personal problem. "Yes?" I asked and listened. "I have a painful swelling on my vagina", she told me. Knowing her personally, I wasn't keen to examine her, but she gave me enough information for me to make the tentative diagnosis of a Bartholin's abscess. I told her what I suspected the problem was, advised her to see a doctor asap and told her it would have to be cut open. "But can't I just put antiseptic ointment on it?" she asked. "No" I replied. She didn't listen. About 4 days later, in the middle of the night of course, the pain apparently became completely unbearable and her husband had to rush her to casualties. I laughed when I heard this. She was probably seen by some poor casualties officer who wondered why she had waited so long and until the middle of the night. I'd often wondered that myself whilst draining an abscess in the wee hours of the morning, now I seemingly had the answer.

But what can you do? They're family, so when they ask, you have to listen and advise, even if you're smiling to yourself knowing they won't listen anyway and wondering once again why they even ask and why you even bother.

Birth day

2008-10-03T16:43:00.001-07:00

The time is drawing nigh and I'm actually getting a bit nervous.

With my first pregnancy I decided that I didn't want to be one of those annoying women (like many a patient I've seen) who comes in claiming to be in labour, turns out to have a cervix that's 1cm dilated, gets told the true signs of labour and to come back when she's got those but shows up again the next day and is then only 2cm dilated.

Maybe it's because I did all my obstetrics in the state, where days are long and beds are few, that I always got annoyed by those women. In private, you probably get admitted if you want to, but in the state, your admission ticket is active labour and nothing less.

So I decided, armed with my knowledge, I was going to do everything right. And I did. But things actually went too well. When I showed up at the labour ward, my cervix was 4cm dilated. I got my epidural and then, even though I was a primigravida, within 1 hour I was fully dilated and ready to deliver.

So this time around, knowing that the second time everything goes much faster, I'm nervous because I know I have to get to hospital asap!

I have great respect for midwives. Most babies can actually be delivered at home by a midwife. A trained midwife though, because although most pregnancies are actually uneventful, when things go wrong, they go very wrong and you want someone who knows what to do and when to get you to a doctor. Having said that, there is no way I'd deliver at home. I know too much and I'm way too paranoid. I want to be in a fully equipped hospital with lots of drugs readily available and a fully trained obstetrician. But I have to get there on time to have that.

I always find it amusing in movies and TV when the expectant couple rushes to hospital at the first sign of labour, tearing up the streets, only just making it there in time before the baby pops out, because real labour is nothing like that, but I've really been worried this pregnancy that that might really happen to me.

Today I had a few mild contractions. I was pretty sure they were Braxton-Hicks, but when they started coming approximately every hour, I started thinking it might be early labour. Then I started wondering if I should go to the hospital. Like I said, I've already decided to make haste this time, but then I started thinking: how early is too early, even with a history of a previous short labour? Also, I wasn't convinced they were real contractions. So I decided to wait and see. I thought I might be taking a gamble, but it turned out ok because after a few hours they stopped.

So in the end it was good I didn't rush off to the hospital because I would have looked like a fool.

But now I'm really left with the predicament of how soon I should act.

Corruption

2008-09-28T14:31:00.001-07:00

Corruption in Africa is widespread. So widespread in fact that most us aren't even suprised by it anymore. Occasionally, however, someone comes along and takes corruption to a whole new shocking level.

Just as common as corruption around these parts is the desire for a DG or disability grant. It is highly sought after. Scoring a disability grant is almost like scoring a jackpot to alot of patients around here. It's a strange phenomenon. Even better than getting a DG for a serious illness though, is getting one for no good reason at all.

What I am about to say is absolutely true.

A group of staff members at a community clinic were caught trying to abuse the social welfare system. In South Africa, the government grants DG's to HIV patients with CD4 counts less than 200. So what these people did was intercept the blood specimens of HIV positive patients who looked very ill and send the blood away for a CD4 count under their own names. In this way, they had a legitimate record of a very low CD4 count which qualified them for a DG.

Fortunately though, the actual application for a DG has to be filled in by a doctor (usually one who does nothing else but that) and when one of these people approached one, he was suspicious of a very healthy looking person supposedly having such a low CD4 count. In this way, this person and eventually all of them were caught out. They even received disciplinary action. Now that's something that's rare in Africa.

Too late

2008-09-12T10:09:00.001-07:00

One of the most difficult things in medicine is accepting that there was nothing more that could have been done.

One case that affected me quite badly was that of a young pregnant woman with TB .

When she came in she was already 7 months pregnant and had been on TB treatment for a few months. She was in a bad way. She was wasted and malnourished, had oral candidiasis and was short of breath. She tested HIV negative on rapid test. I didn't believe the results so I sent stat blood to the lab for an Elisa. It also came back negative.

In the meanwhile, she'd had a chest x-ray which should extensive infiltrates and lung damage - she barely had any normal lung left.

I made a tentative diagnosis of multi-drug resistant TB.

The baby was also not doing so well. There was very little amniotic fluid and although there was a heartbeat on ultrasound, there were no foetal movements.

The patient also complained of abdominal cramps and on abdominal exam she did seem to be having some mild contractions. On vaginal exam her cervix was very posterior and very difficult to assess.

I sent her to the state hospital with a diagnosis of probable multi-drug resistant TB, oligohydramnious and possible early labour.

She was reluctant to be admitted but her mother seemed to understand the gravity of the situation and talked her into it.

Next day, on enquiring after her at the state hospital, it seemed there was no record of her being in either the gynae or obstetric wards (the baby was viable, but the state hospital did not have adequate staff or resources so whether the baby was considered viable by them probably depended on whether they had a neonatal ICU bed. Nevertheless, she was apparently in neither ward.)

I remember thinking that she might have absconded, considering how reluctant she had been to be admitted. More likely though was that she was in fact in the ward but the hospital staff were just too lazy to look and claimed they had no patient by that name (very, very common in South Africa. In fact, if you enquire after a patient, it's the exception rather than the rule that anybody bothers to make any effort to help you).

About two months later, I saw her mother again on an unrelated issue. She told me that her daughter had been admitted to the hospital. She said that the baby had died in utero and that her daughter had then died a few days later.

I was devastated.

She had essentially died from a curable disease.

What had happened up to the point that she'd presented to me was uncertain. Whether the system had failed her, or she had been non-compliant, I don't know, but from the time that I saw her, it was already too late it seems.

Love and devotion

2008-09-05T00:04:00.001-07:00

With HIV positive patients you get two types of families. Either the family abandons the patient altogether, or they are highly involved and do everything they can to ensure the patient gets help.

(Unfortunately, even with the latter type, patients who have been away from their families often only return to their families when it is too late and sometimes even refuse treatment even when the family members -usually their mothers - do everything they can - even forcing them to go to hospital etc.)

One day I saw a very elderly woman who tested HIV positive. She was about 75 years old and demented. She also had a previous stroke (found on examination, not history), was blind from cataracts, and was in
adult nappies (diapers) with a severe nappy (diaper) rash.

I couldn't help wondering why, with all these co-morbidities, she had been brought in to test for HIV. I was even more surprised that she had tested positive.

The only thing that could really be attributed to the HIV was that she also had a severe peripheral neuropathy. The dementia may also have been attributed to the HIV but AIDS Dementia is really a diagnosis of exclusion and I thought it was probably due to something else in her case considering her condition. According to her family member though, she had been quite functional before and had rapidly deteriorated in the last month or so. I felt that she was in a dismal condition, but in view of this, decided to do a work up.

The family member who accompanied this woman was her 20-something year old grandson. He had been taking care of her for a while. This was an exceptional case so I didn't expect him to fall into either family category frankly. In fact, I felt quite sorry for him: I thought his sick grandmother was probably quite a burden for this young man but that he had been caring for her out of duty and now needed some reprive.

I got the social worker involved. My plan was to admit her to hospice, treat her other problems symptomatically and do a work up for the dementia. Thereafter I planned to place her in a long term palliative care facility. I decided that if the dementia was due to AIDS Dementia Complex, I would start her on ARV's, otherwise I didn't think it would be practical or beneficial.

I asked the social worker to explain the situation to the grandson and then arrange placement. The grandson however was not happy with this plan. He did not want his grandmother to be placed in a palliative care home, he wanted to take care of her himself!

I was amazed. Here was a young, single male telling me he wanted to care for his sick elderly moribund grandmother.

As it turns out, this woman had only one child - a daughter. Her daughter in turn had 3 children. The youngest of these was the young man now accompanying his grandmother. His mother (the patient's daughter) and 2 siblings (the patient's other 2 grandchildren) had all passed away (I didn't ask what of but in our setting it's likely it was also due to HIV). This sick elderly woman was therefore the only family he had left.

I was so touched I nearly cried.

I had such sympathy for this young man, but more than that I was deeply impressed by his devotion to his grandmother.

It seems there really are selfless people out there willing to do whatever they can for the people they love.

ONE HUNDRED BILLION DOLLARS!

2008-07-29T07:41:00.000-07:00

Usually African news is deeply depressing but I read a few things over the past week that really made me laugh.

Firstly, our mayor's house got burgled, but that's not the funny part, what's funny is that when he went to the police station to report it, he had to wait an hour and a half before he was seen to. He hadn't declared that he was the mayor (but shouldn't the police know who their mayor is anyway???) and I respect him for not wanting special treatment, but in true African style, no-one could be bothered to help him. Eventually he could take it no more, so he told them who was and he was seen to immediately. We're always complaining about how pathetic our police service is but at least now we know they treat everyone equally badly.

The next thing I found amusing was a report on an abandoned house somewhere in Nelspruit. The residents were complaining that it was attracting criminal elements etc. and wanted the municipality to do something about it (which they rightfully should but most probably won't). One resident in particular was complaining that the house still had running water so homeless people were coming there to cook and even bathe! (those damn dirty homeless people taking baths!)

But the most hilarious news by far is that the Zimbabwean reserve bank has now issued a $100 billion note! Ohmigosh, I can't breathe! ONE HUNDRED BILLION DOLLARS! Can you imagine having a one hundred billion dollar note? Manohman, I have got to get my hands on one of those! And I think $100 billion (Zim) is equal to about R5. How can mad Bob seriously still say there's no crisis in Zim when their reserve bank has got to issue $100 billion notes because of their ridiculously high inflation rate?

Dilemma

2008-06-25T07:00:00.000-07:00

Before I tell this story, let me just express my intense hatred of all Microsoft programmes. I hate my Microsoft. It is unpredictable and unreliable. I hate it hate it hate it hate it hate it. That off my chest, lets begin...

I recently saw a patient with a serious medical condition and another, even more serious, underlying medical condition.

The patient was started on treatment for the one condition but treatment of the other condition was delayed.

The patient then returned. He had applied for temporary disability leave form his employers and had brought ~~a ton of~~ some forms for me to fill in. Included with these ~~millions of~~ one or two forms was a consent form. The consent form stated that the patient grants permission to his doctor/medical practitioner/health care professional/nurse/any other person who has ever had any medical contact whatsoever with the patient ever to disclose any and all medical conditions/blood results/lab reports/x-rays/correspondence about/any medical information whatsoever pertaining to the patient. Basically.

I asked him if he understood what this form meant and he seemed to have no idea, so I told him that it meant that I could tell his employers about all his medical problems, including the very serious medical condition that he had, and give them copies of all his blood results, etc. He said that he only wanted me to tell his employers about the less serious illness. Again I explained to him that he had signed this form and that it was a legal document giving me permission to disclose all his medical information. He said that he did not want his employers to know about the underlying condition.

This obviously left me in a bit of a predicament. I now had to decide whether I should fill in the forms in their entirety as the employers requested on their forms, in view of the signed consent, or whether to only disclose information about the one condition.

I wasn't sure what the legal implications were - whether I was legally obligated to disclose, all things (including a signed consent form) considered. I reasoned though that consent is fluid and that a patient is allowed to withdraw their consent at any time. I also felt that my ethical obligation to the patient outweighed any other present obligations.

So I filled in the forms, only disclosing information about the one condition and indicated that the patient had asked me not to disclose any other information. There was also a "declaration" section which I had to sign which stated that all information I supplied was true and correct. I had no problem with that, but it also stated that I had not withheld any information. I drew a line through that section and signed it.

Afterwards I felt uneasy about the whole situation and sought legal advice from the medico-legal society of which I am a member. I was advised that I had done the right thing and that I was legally in the clear. I was relieved but felt that I had always been morally in the clear.

Germs are NOT for sharing

2008-06-17T06:10:00.000-07:00

Anyway, so I’ve been impregnated again by the said caboodle-hole.

Pregnancy really changes your perspective on things. For one, paranoia.

Now I’m paranoid on a good day - I’ve always had mild OCD which I manage to keep reasonably under control in my every day life and doesn’t affect my work too much - but being pregnant elevates my paranoia to a whole new level.

Working with HIV patients on a daily basis, there’s always that fear in the back of your mind that you’ve picked it up somehow. It didn’t help that at a recent conference I attended we were given statistics of doctors
who have seroconverted after exposure to HIV infected blood – some supposedly through blood splashes on the skin. Freakin blood splashes on the skin! Now, I’ve had blood splashes on my skin – who amongst us hasn’t – so that made me worry to no end. Then I thought to myself that I should have myself tested again (my last HIV test having been as an intern after a blood splash. The patient turned out to be negative though, thank God! And so did I) but like most doctors I am terrified of having HIV and even of having an HIV test. It’s ridiculous I know. I’ve discussed it with other doctors before and even though we keep telling patients to “know your status”, the truth is, we're terrified of being tested ourselves in case it’s positive. Anyway, so I reasoned to myself that if I was positive, I’d better find out now since I’m pregnant and it would be irresponsible if I did have it and passed it on to my baby. So I got tested ... and it was negative! WHAT - A - RELIEF!!! Even caboodle-hole was relieved because it basically meant he didn't have it either (and his risk is even bigger than mine. He even went and pricked himself recently.)

Then my assistant got diagnosed with TB (by me FYI) and I started worrying that I had that. I worry about TB everyday anyway but now I felt like it was really possible that I had it. Nevermind the small fact that I was asymptomatic.

I’ve since seen to two people with suspected MDR TB and every day at least one undiagnosed TB patient comes into my room coughing their freakin lungs out. Great. So I’m spending the majority of each day breathing in TB bacilli infested air.

Then, to add to my paranoia, I’ve been having sacro-iliac pain. Now, I know that it’s because of the pregnancy, but at a recent talk, this HIV medicine guru presented a case study about a guy who had chronic sacro-iliac pain which turned out to be caused by a retro-peritoneal TB abscess. I know that I don’t have a retro-peritoneal TB abscess, but I just can’t stop thinking about it.

Manohman.

Pause

2008-06-17T05:34:00.000-07:00

I've taken a very extended break from blogging, partly because I went
on a long holiday, but mostly because when I got back, someone very
close to me went on a blog radio talk show and failed to mention my
blog when asked a question that was directly relevant to it. This made
me question my writing ability and I lost confidence and motivation.

What his actual reasons were I will never know, but I've since decided
that he was just being a caboodle-hole. So now I'm back...

Infant persuasion

2008-03-19T08:58:00.000-07:00

Today my son tried to force Barney to eat smarties:

His paternal grandmother gave it to him. Barney that is. My mom gave him the smarties.

Don't call me baby

2008-03-09T23:49:00.000-07:00

One of my patients called me baby the other day. I've seen him before a few times and he's always been very quiet and subdued but he came in the other day smiling and very upbeat and proclaimed 'hi baby'. My assistant immediately snapped back 'who are you calling baby?' (she's very snappy on a good day) to which he replied 'both of you actually, but I'm going to marry her one day' *gestures towards me*. I didn't know what to do, so I said 'oh really?' and laughed, then we all laughed. Maybe it was an indication that he's on the healing path but I felt very uncomfortable. I really didn't want to examine him and I felt incredibly uncomfortable doing it (him grinning foolishly the whole while). Then I wrote his prescription and sent him on his way too merry way, secretely hoping I never have to see him again.

We had a big family gathering...

2008-02-25T02:27:00.000-08:00

at my boyfriend's parents' house this weekend. It was in honour of his dad's 'evil twin' visiting from Australia (but that's another story in itself). There was a huge hand-me-down trampoline passed down from a rich uncle for the kids and we decided to keep it at their grandparents' house. They spent most of the day on it.

It was fairly hot and since their pool has recently taken on the appearance of a small swamp (frogs and all), the kids asked grandpa to hose them down with the 'tuinslang'. Grandpa was only too happy to oblige! My 20 month old son saw this and thought it looked like great fun! He snatched the hose pipe from grandpa and proceeded to chase and spray anyone within range. My boyfriend happened to be in the firing line (watering line?) and got squirted. He later told me that as our son was squirting him, he was shouting " 'skies papa!" (sorry daddy!).

T.I.A.

2008-02-21T11:23:00.000-08:00

Yesterday I called for an ambulance to transport a patient with suspected meningitis to hospital. After about an hour the ambulance had not arrived yet so I asked a clerk to call and find out what the delay was. Meanwhile, I continued to attend to other patients. When I went back to the clerk, he told me that the ambulance service had simply told him they were on the way. I waited a while longer and still there was no ambulance so I called the dispatch myself. I was told that the reason for the delay was that there was only one ambulance that day servicing the entire draining area for our local hospital. I was shocked. I was also told that this ambulance first had to go to three other clinics before coming to collect my patient. I asked why there was only one ambulance. The dispatcher eagerly told me that they normally have TWO but that the other on had been involved in an accident the previous day.

I ended up having to ask my patient's family to take her to the hospital in the back of their bakkie (pick up truck).

What's in a name?

2008-02-18T07:13:00.000-08:00

I was recently given a sample of a new deodorant out on the market

It's quite a cool little bottle and has a very pleasant fragrance

but I can't figure out why it's called 'Bamboo Splash'

when it's made with aloe vera?

Sugar, we're going down

2008-01-31T08:00:00.000-08:00

I received an e-mail from the South African Medical Association yesterday. As some of you may know from reading Bongi's posts on the matter, Mpumalanga health is in crisis. I read a related article recently, but the real reasons are in this e-mail:

*Media Release:*	SAMA speaks out on Mpumalanga Hospital closure
*Date:*	29 January 2008
*Embargo:*	None, Immediate Release

The South African Medical Association expresses its grave concern about the closure of emergency services at hospitals in the Mpumalanga Province.

Reports have been received that Bethal, Standerton, Secunda and Ermelo Hospitals – all district hospitals, have shut down after-hour emergency services due to shortage of medical officers. In addition, the Rob–Ferreira Hospital in Nelspruit, which is classified as a provincial hospital and referral hospital for the above hospitals, has closed its maternity ward and is not admitting new patients after hours since 25 January 2008.

Of great concern is that patient care is compromised when interns who have to work under the supervision of a medical officer in a hospital, are now expected to work without such supervision. This problem has emerged as a result of the two-year internship programme which was introduced in 2006, as opposed to the previous one-year internship programme. It has therefore created a gap in the provision of Community Service doctors who normally fill posts of medical officers in peripheral hospitals when they complete their internship.

The Provincial Department states that they do not currently have the budget to finance additional overtime for doctors, and that funds will be made available when the new financial year starts on 1 April 2008.

In 2007 the South African Medical Association made suggestions to the Department on the envisaged shortage of medical officers for 2008. They were very receptive to the suggestions and advised different provinces to implement them to avert a crisis. However, some provinces such as Mpumalanga have not, and hence the problems that they are currently experiencing.

SAMA urges the Mpumalanga Department of Health to engage urgently with medical officers in the affected hospitals to ensure continuity of patient care, as well as considering the utilisation of additional capacity from doctors in the private sector who are prepared to assist in containing this crisis. We would like to urgently meet with the Mpumalanga Department of Health regarding these issues.

Issued by the SAMA Corporate Communications Department to the South African media on 29 January 2008
Corporate Communications Manager - SAMA

More funny presenting complaints

2008-01-16T04:15:00.000-08:00

As I've mentioned before, because most of my patients don't speak English, we have interpreters who take their complaints and then write them down in the patients' notes before they are seen by a doctor. I have seen some pretty funny complaints:

"Sore chick".

"The patient fell and the finger knows it's painful". Does he?!

"Virginal itching" (spelt eaching). If it's itching down there it's probably not virginal.

"Sport in the body". Isn't that a good thing?

"Sport under the feet". Dito

"Sore leg and week". I've also had a sore week dude.

"Lazy body". Yep, I have that too.

"Little beat eating". What?

"Headache side by side". With what?

"Anus liking pus". Bwahahahahahahaha!

"Buttocks rash". Okay, there isn't really anything wrong with that, it just sounds funny.

And here are some strange names I've seen (maybe South Africans will appreciate these more):

Rice
Eggy
Storom
Dankie
Jernniffer
Ingelinah
Dephne
Preciace
Exson
Renwel
Pleaseman (yes, it's a real name)

The Good the Bad and the Ugly

2007-12-12T05:35:00.000-08:00

As with everything in life, in medicine you get the good and the bad: good doctors and bad doctors; good patients and bad patients.

I recently had a very bad patient.

I work at an NGO and we operate on donations. Patients also have to make a contribution. If someone says they are unable to pay and they live within our catchment area, we send someone out to do a home visit and assess the situation and if indeed they cannot afford medical care, we treat them for free. If, however, they do not fall within our catchment area, we refer them to a facility close to where they live where they can receive free care. This makes sense right?

I had a patient recently who said she could afford to attend our clinic (they are told our fees when they come to reception to open a file). After I'd seen her though, when she was to pay before her file could be sent to the pharmacy, she could suddenly no longer afford to pay. The medical superintendent was called, she assessed the situation and cancelled her medication (it was chronic medication). She made a note in the patient's file saying that if she was unable to pay next time, she must be referred somewhere else. Some people might think this is harsh, but you must bear in mind that we have to buy the medication - we don't get it for free - and pay for equipment etc. and if someone who can afford to pay doesn't, that may well be detrimental to someone who really can't afford to pay.

A month later she was back. I asked up front if she could pay and she said that she could, but then afterwards claimed she could only pay part of the fees. I let it slide because, this time, she had a serious condition and I admitted her to the inpatient unit. She was transferred to another hospital the next day because her test results showed she had a condition that we could not treat (the medication is too expensive so we can't afford to stock it - we only have stat doses). Two days later she was back. She said that they had refused to admit her at the other hospital and had sent her home with the medication. Now, as bongi from other things amanzi has already mentioned, you can't always believe what patients tell you. She may very well have refused to stay there. She probably did.

She told me that she still had symptoms and wanted medication - she said that she had paid at the previous visit (although she'd only paid part of the fees) and had been discharged without any meds and therefore wanted some now. I explained that she would have to take the medication that she already had for a while before she would start to feel better and gave her a follow up date to come get her chronic medication (she didn't have any money that day). Two days later she was back again. She wanted her chronic medication. This time she said that she did have money, although only enough to pay what she still owed, not enough for the consultation that day. I was fed up! I just wanted to get rid of her now, so I decided not to charge her for that day and only asked that she pay the money she already owed. I wrote the prescription, but I made a note next to it to the pharmacy instructing them not to dispense unless she paid. A little while later a staff member came to me to say that the patient had said that she doesn't have any money. I'd had enough. I cancelled her prescription and wrote a letter to a clinic where she was already attending on a regular basis to take over her management entirely.

I have no doubt that she'll be back.

Sad Update...

2007-12-02T07:57:00.000-08:00

...on that patient I spoke about in failure. She was admitted for 3 days, rehydrated and then discharged in an apparent stable condition. She died in the car on her way home. I was extremely upset about it, but as my boyfriend pointed out to me, she was going to die anyway. The disease had already gotten the best of her.

O&G

2007-11-22T10:33:00.000-08:00

A friend of mine sent me this sms (text) message when we were both interns and he was rotating through obstetrics and gynaecology:

"O&G. I love it. The sound of screaming women and angry nurses. The rich aroma of blood & liquor with a hint of feces. Mmm. Delightful."

Ah yes, O&G is, indeed, delightful ;)

The worst resus I ever saw...

2007-11-20T10:35:00.000-08:00

... was at a clinic ill equipped to handle a resus. Why you may ask? Because this particular clinic treated only HIV patients and if an HIV patient presents in a state requiring resus, it means it's already too late.

But on this particular day, a patient presented with huge glands in the neck (most likely due to tuberculosis - TB) which caused obstruction of his airway. He was basically dead already (FUBAR, BNDY). He still had a weak pulse and was only barely breathing but he was completely unresponsive and his pupils were dilated and very nearly fixed. His treating doctor decided that if he was intubated (a tube put into his airway so that his breathing can be assisted) and started on TB treatment, his chances of survival would be good. I was thought that it was probably already too late, but that she might as well go for it. So she sent for the resus bag (most hospitals and clinics have a resus trolley, which is a cart containing equipment and drugs needed to resuscitate a patient and is set up in the emergency room. In a hospital, one is also held at the nurses station in each ward. This clinic did not have one. This clinic had a bag containing some equipment necessary for a resus and it was kept in the back of the pharmacy somewhere). In the resus bag there were endo-tracheal tubes and even a laryngoscope but no ambu-bag (used to assist breathing when a patient can't breathe for themeselves - attached to a face mask or breathing tube). The room did have an oxygen cylinder though. For the non-medical readers suffice it to say that all this was not ideal to resuscitate a patient.

The intubation failed, so the doctor decided to go for a nasal intubation (we usually pass the tube through the mouth into the airway but it can be done through the nose). However, this also proved unsuccessful and when she pulled the tube out it was covered in thick mucus, blood and secretions. So she decided to suction. Only there was no suction. She then remarked that they had ordered suction a while ago and that it should be in the pharmacy. So someone was sent to the pharmacy. I meanwhile stood staring at all this in amazement. Then I was called for something else, so I left. I went back about ten minutes later to find the patient still lying there gargling loudly, barely breathing (I think) and the other doctor, medical student, a nurse and some auxillary staff trying to set up the suction! They couldn't get it to work. Then someone remarked that there was another suction machine. So they decided to pack the first one up and get the other one. At this point I left again. I couldn't believe all this madness.

A few minutes later someone came to say that the other doctor had called for me. When I got there, she had managed to get the suction to work and it looked as if she had suctioned most of the patient's lungs out! Seriously, there were chunks of tissue coming out and it looked like what was left of his lungs.

Then, not only did he start blinking, he also started flexing. I kid you not. He was breathing spontaneously and his Glascow scale went up a good few points. So she put him on face mask oxygen and called an ambulance to take him to the hospital. I am not even making this up.

Rights

2007-11-18T11:55:00.000-08:00

There's been alot of controversy here lately regarding freedom of speech and freedom of religion. It all started because of a newspaper article stating that satanism is a religion and that satanist should have the right to practice their religion under the constitution, which protects freedom of religion. There was a public outcry with people threatening, not only to no longer purchase the newspaper in question, but also to boycott any shops stocking this newspaper if the journalist who had written the article was not fired.

The newspaper then fired the journalist which resulted in an outcry from the media, touting freedom of speech. There was also alot of talk by the media about freedom of religion. There were even some reports saying that satanism was not actually evil and talk of satanists being misunderstood.

I had alot of thoughts about this, but I'll only touch on a few issues.

Firstly, since when is satanism not evil? Surely if a person believes that satan exists, they also believe that he is evil? And if they worship him, and follow his "teachings", are they not also evil? To say that satanism is just another religion and not actually evil seems absolutely ridiculous to me.

Secondly, to say that they are protected by the constitution because it is a religion just makes me think that we can twist anything and claim protection from the constitution. With any right comes a responsibility. I may be wrong, but I think that the constitution actually states this. Surely, even if you have a right, you cannot just act on it even if it means others will be harmed? Performing ritual sacrifices and the like is not okay as far as I'm concerned. I'm sorry, it just isn't.

Then there's the question of freedom of speech. Here, too, I believe there should be responsibility and usually there is. But was this a clear cut issue of freedom of speech? The editor felt that he had no choice: it was what his readers wanted and ultimately, if you're selling a product, you have to listen to what your clients want. He did have freedom of speech - he got to say what he wanted to and it was even published, but the readers didn't like it and decided they'd rather not hear any more from him. Is this not also their right? Do you have a right to say something if people find it offensive and don't want to be exposed to it? If not, why do we have a broadcasting complaints commission? Surely no right can be unlimited and go unchecked. From the editor's point of view it was probably more business than anything else.

Contamination

2007-11-15T01:46:00.001-08:00

Today an HIV+ patient who also has TB coughed in my face. It was horrible. No matter how many times I get body fluids spilled, spluttered, squirted or projected onto me by patients, I will never get used to it. I know doctors who are totally blasé about it. Not me - I'm extremely squeamish for a doctor. Blood is just about the only thing I can stand. I never flinch in front of a patient, but as soon as I can I scrub myself as clean as I can. I don't wear a white coat anymore because no-one does where I work now, but I always used to wear one before - not to look like a doctor, but as protection from body fluids!

I'm super squeamish.

Failure

2007-11-12T09:49:00.000-08:00

I usually don't blog too seriously about my patients because it's too personal for me. I try to keep it light, because it's sometimes too emotional for me to touch on the serious issues, but I saw a woman who I feel I need to talk about.

I was once told by one of the staff members of our organisation that most HIV+patients try traditional medicines for at least two years before seeking the help of "western doctors". Probably true considering the HIV/AIDS policy of the South African government, but it means that most patients present to us when they have a CD4 of less than 15 (antiretroviral therapy - or ARV's - is usually instituted when the CD4 is less than 200 in the state sector in South Africa and in the private sector and first world countries it is desirable to start ARV's at a CD4 below 350).

So alot of the patients we see have full blown AIDS by the time they first present to us. Usually, if we act quickly, they rapidly improve anyway - that's how effective ARV's are. But we still see alot who are too far gone.

A while ago, I saw a woman who was basically end-stage, but the organisation I work for has earned a reputation in the community for "bringing people back from the dead". She had a CD4 count of 1. She weighed 32 kg - the normal weight of a ten year old child. She also had Pulmonary Tuberculosis (TB) as many HIV+ patients do. She was started on TB treatment and as soon as I could, I also started ARV's (it's a bit complicated when the patient also has TB). She showed no improvement. Eventually she completed her TB treatment. Still no improvement. Her weight continued to fluctuate between 31 and 32kg. She just did not get any better and yet had no other concominate pathology or opportunistic infections. She denied the use of any traditional medicines.

After six months of ARV therapy, she still was no better, in fact, she started to deteriorate. When I last saw her, she was so weak that she could not stand (and therefore also not be weighed) had developed Dysentry with dehydration and had severe oral thrush. Maybe her family had stopped her "western medicine" and advocated traditional medicine. I don't know. But she was supposed to get better and she didn't. Everything pointed towards non-compliance, but she denied it. I decided to admit her to our in-patient unit, but I knew that she probably wouldn't make it.

I don't know what went wrong in her case, but it's hard to admit defeat when we did everything that we possibly could.

If at first...

2007-11-08T11:23:00.000-08:00

I went shopping the other day and one of the items I bought was a pack of chicken breasts. I love chicken breasts. My dad taught me how to make stuffed chicken breasts a while ago and it is divine. But I digress. So anyway, I got to the till and the barcode on the chicken breasts wouldn't scan (by the way, this just so happened to be the last pack they had, so I couldn't just swap it) so the cashier paged her supervisor. I hate it when this happens - they push some button that causes that loud beeping noise to sound in order to attract the supervisor's attention but it also attracts everyone elses attention! The supervisor has this key which she puts into the till which allows her to override the system. So she showed up eventually, used her key and then manually punched in the barcode. But the machine rejected it. So she tried again. Still it wouldn't work. So she just tried again. And again. And again. I tried to say something but she was repeatedly punching in the code at such super fast speed that I couldn't really get a word in. By about the tenth time, I started to think that maybe it wasn't going to work. By about the fifteenth time I thought that she too might realise this, but no. She was determined. Then, amazingly, on about her twentieth attempt, the code was accepted! I couldn't believe it. Her kung fu was strong. She walked away with this nonchalant look on her face.

I guess persistence does pay off.

Toddler

2007-11-06T06:35:00.001-08:00

There's never a dull moment when you have a 1 year old son.

My son is always exploring. He also likes to pretend clean :) (his dad says he gets that from me. hehehe). He especially likes the laundry basket. He'll pick up the clothes his dad leaves lying on the floor and throw them in the basket (my heart swells with pride). Sometimes he climbs into the basket. If it's too full, he'll throw some clothes out and then climb in (but he puts them back in when he gets out). One day he was playing with the laundry basket again. I went through to the lounge. He came in after a while and to my horror, was wearing a pair of my panties on his head!

I've learned that whenever he's quiet, he's up to no good, but I usually only detect the silence after some time. Today he went quiet for a while. When I realised it, I went to check what he was up to. Everything seemed to be in order. Later, however, I noticed that the lounge seemed to have been redecorated. I had my suspicions. He had been throwing things from our balcony lately, so I went out to check. Now, because we live in South Africa, we, like most South Africans, have barbed wire on our property to keep potential burglers out. The bottom story of our house is a store room and we have a wild garden, so there's no fence, so we have barbed wire between the top and bottom stories. My son however obviously decided the barbed wire was a bit drab because he decided to redocorate it with the scatter cushions from our couch.

STI?

2007-10-29T03:16:00.001-07:00

I saw a patient the other day who complained of penile pain. I asked
about a discharge (or 'drop' as it's known here. I have no idea why
it's called that but drop it is), but no. I tried urinary symptoms.
No. On further enquiry he admitted to only having this pain after
eating spicy foods. Of course my immediate response was WHAT? Ok, I
only thought that. I asked if he was sure about this. He was adamant.
I was baffled. I examined him - NAD. I checked his urine - nothing. I
decided to just go with paracetomol. His wife was with him and I did
consider asking if he had this problem when he ate spicy foods or when
she did. But I decided to let it go.

Any ideas?

My boyfriend, the food thief

2007-10-27T02:06:00.000-07:00

I doubt anyone else has a boyfriend/husband/partner who steals their food. I do. My boyfriend had to go to work this morning and I didn't, so I decided to make him some coffee and breakfast. There weren't many options so I decided to go for melted cheese on a roll. I made myself one too but I hid it because I thought he might try to steal it. After he'd finished eating, he went to the fridge to look for something else to eat. He settled on this liquid breakfast cereal stuff (that I usually drink in the car on my way to work in the mornings) and a red bull (ok, so the fridge isn't exactly stocked at the moment). I then decided it was safe to take my food out, but then our son needed some attention and I had to see to him quickly. When I turned back I saw that my plate was empty. Damn! My boyfriend was now on the phone in the foyer. I went to check and, sure enough, he was eating my cheese roll! I tried to get it back, but he's much taller than I am and he held it out of my reach, but I was persistant. Then he just stuffed it all in his mouth!

Nice.

Gecko

2007-10-04T12:27:00.000-07:00

We have a resident gecko living in our new house. It lives high up on the wall just below the ceiling. At first I thought it was great. I thought it was cute. I even jokingly said to my boyfriend that I wonder if the suckers on its feet would make squishy noises when it walked. We laughed.

One evening I was home alone (my boyfriend has this tendency to work alot) when I heard a noise behind me. I turned around to see what it was but there was nothing there. Then I heard it again. I turned around, but again saw nothing. Then I heard it a third time and realised it was in fact a squishy noise. I turned to see the gecko sitting on the wall about half a metre across from where i was sitting and at my eye level. I had this eery sensation that it was watching me, but immediately thought I was being silly and dismissed the thought. But over the next couple of weeks, whenever I was alone, the gecko would come out and sit across from me. Eventually I got freaked out and chased it out onto the veranda. The next day I told my boyfriend that I'd chased the gecko out because it was stalking me. He laughed. (It was a nervous sort of laugh). I knew he thought I was crazy, but that gecko was definitely watching me.

Then, earlier this evening, I was once again sitting alone in the lounge when I saw a gecko on the wall. I wasn't sure if it was the same one (I call him Stan) so I watched him closely. It was running across the wall when it suddenly stopped and started making very strange noises. "What the hell?" I thought. Then his tail started twitching. Then his hind legs as well. I thought he was having a seizure, actually. I even considered giving him some Valium, but I didn't have any at my immediate disposal. Then, just as suddenly, it stopped. Next thing, something dropped from what I assume is its anus, but I was too afraid to go closer to investigate just in case he was actually a she and her spawn was about to hatch.

I don't think geckos are cute anymore.

Say what?

2007-09-27T09:45:00.000-07:00

In the setting that I work in, it is seldom that my patients and I speak the same language. This seems a bit strange when I sit and think about it, but I have become so used to it that it feels completely normal now. This hurdle can usually be easily overcome with the use of an interpreter, but even then there can still sometimes be a language barrier (problems usually arise due to differences in pronunciation). Where I work, interpreters take the patients' presenting complaints before they are seen by a doctor. And I have seen some strange interpretations of presenting complaints!
Here are just a few examples and my proposed management plans:

If a patient has had a "missed courage" (miscarriage) is it okay for me to tell her the story of the little engine who could?

If someone is "feeling noiseous" (feeling nauseous) should I advise them not to be a disruptive element?

If a patient is having "pain when pussing urine" (pain when passing urine) do I really have to do dipstix or an MCS? Isn't the pus evidence enough?

If a man has "haemorrhoids on the penis" (I don't know how they came up with that one!) does that mean he's homosexual?

And if you have to have a cough, isn't it better if you're "coughing a beat"? (coughing a bit). I, for one, would love to hear that!

Lastly, I once had a complaint that read ""shortage of blood while preeking". (What?) I have no idea! Nobody could figure this one out. Even the patient was shocked to find out she'd been preeking.

Lose weight now...

2007-09-08T00:32:00.000-07:00

I've been feeling very depressed about my weight lately as it's been picking up. This became evident when I started having difficulty fitting into one of my favourite pairs of pants. I decided to start watching my weight but to my dismay, the next time I wore these pants, they were so tight that I could not even close the buttons anymore! Now I became really depressed about it. But then the other day, I decided to wear a pair of pants I hadn't worn in a long time (out of desperation) - we had been away on a short holiday and I didn't have any other clean pants to wear to work. I was sure they would no longer fit me (I hadn't worn them since before I fell pregnant with my baby!). There's no way they'll fit I said to myself, but as I've already mentioned, I was desperate! So imagine my surprise when they fit me perfectly! Yes, it was then that I realised that my other pair of pants had been shrinking in the wash!!!

Trees are evil

2007-07-29T11:09:00.000-07:00

This is a photograph I took recently on a trip to the Blyde river canyon in Mpumalanga. It clearly illustrates one tree strangulating another.

Proof that trees are in fact evil.

Men don't get it

2007-07-21T23:56:00.001-07:00

Recently there was a series of print advertisements promoting insurance for women only (on the premise that women's insurance should be cheaper as they have better risk profiles than men). It hilighted certain bad qualities that men have. The picture above shows one of these ads. Very funny. Except if its true.

The picture above is of my bedroom. At least my boyfriend has only narrowly missed the basket!

Maybe he's trying ;)

My boyfriend is a blogaholic!

2007-07-15T11:22:00.000-07:00

My boyfriend is seriously a blogaholic!

Whenever he's home, he's on the net. If he's not posting on his own blog, he's reading other blogs, commenting on blogs, searching for new blogs, etc. But he's mostly obsessed with his own blog. He checks his comments and stats constantly. He's joined basically every blog stat counter site there is and he checks them on almost a minute to minute basis. Sometimes he just sits there staring at the stats screen waiting for them to change. It's unbelievable. And if we're not at home, he connects via his cell phone. It's ridiculous!

So I've decided to start a blog of my own. Who knows if it'll be any good, but i figure if i can't do anything about his addiction, i might as well see what's got him hooked.

So here goes...