The Good the Bad and the Ugly

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...

...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

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...

... 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

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

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

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...

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

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?

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

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

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?

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...

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

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

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!

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...