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

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.

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.