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.