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.

Shocked

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

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

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

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

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!

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.