Tables turned

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?

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

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

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

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

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

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

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

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

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

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

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

Sleep, glorious sleep

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

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

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

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

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

SurgeXperiences 305: This Is Africa

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




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

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




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



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



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

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



KevinMD talks about operating on patients with situs inversus.




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




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

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

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

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

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

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

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




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





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

Thanx for coming!

SurgeXperiences 305

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

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

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

Looking forward to reading your articles!